Citation Nr: 1318110 Decision Date: 06/04/13 Archive Date: 06/11/13 DOCKET NO. 07-36 365 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for neurological complications, claimed as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for visual impairment, claimed as secondary to service-connected diabetes mellitus. 3. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus with impotency. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to December 1968. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from a September 2006 decision of the RO that, in pertinent part, denied a disability rating in excess of 20 percent for service-connected diabetes mellitus with impotency; and denied service connection for visual impairment and for neurological complications. The Veteran timely appealed. In September 2007, the RO granted service connection for cardiovascular disability, and assigned an initial 10 percent evaluation, effective May 15, 2006. The Veteran submitted a notice of disagreement with the initial rating in November 2007. In a statement of the case issued in September 2008, the RO assigned initial 30 percent disability rating effective May 15, 2006; and assigned a 60 percent disability rating for post-operative coronary artery disease effective July 18, 2007. The matter was not perfected on appeal, and is no longer before the Board. In a May 2011 decision, the Board denied service connection for neurological complications, claimed as secondary to service-connected diabetes mellitus; and remanded the matters of an increased disability rating for diabetes mellitus with impotency, and of service connection for visual impairment. The Board is satisfied there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran appealed the May 2011 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2012 Joint Motion, the parties moved to vacate the Board decision in part, and remand the case to the Board. The Court granted the motion. Thereafter, the case was returned to the Board. In November 2012, VA's Appeals Management Center (AMC) granted service connection for peripheral vascular disease of each lower extremity, and assigned each an initial 100 percent evaluation effective May 15, 2006. As the record, to date, reflects no disagreement with either the initial ratings or the effective date assigned, it appears that the AMC's grant of service connection has resolved those matters, and they are no longer before the Board. The Court has recently held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board notes that the Veteran already has been awarded a TDIU. Hence, it is unnecessary to remand the matter for further action. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA file. FINDINGS OF FACT 1. Peripheral neuropathy of each lower extremity is related to service-connected diabetes mellitus. 2. Ocular disability of each eye, other than refractive error, was not present during active service or within the first post-service year, and is not otherwise related to service or to a service-connected disability. 3. The Veteran's diabetes mellitus with impotency has been treated with insulin and a restricted diet, but has not required restriction or regulation of activities. 4. For the period from July 21, 2011, the Veteran has exhibited mild incomplete paralysis of the sciatic nerve of each lower extremity; moderate or severe incomplete paralysis, or complete paralysis has not been demonstrated. CONCLUSIONS OF LAW 1. Peripheral neuropathy of each lower extremity is proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. Ocular disability of each eye, other than refractive error, was not incurred in or aggravated by service, is not proximately due to or the result of a service-connected disability, and may not be presumed to be related to service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for a disability rating in excess of 20 percent for diabetes mellitus with impotency have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.119, Diagnostic Code 7913 (2012). 4. The criteria for separate 10 percent disability evaluations for associated incomplete paralysis of the sciatic nerve of each lower extremity, for the period from July 21, 2011, are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.27, 4.40, 4.124a, Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). A decision by the United States Court of Appeals for the Federal Circuit has addressed the amount of notice required for increased rating claims, essentially stating that general notice is adequate and notice need not be tailored to each specific Veteran's case. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Through May 2006 and January 2007 letters, the RO notified the Veteran of elements of service connection and increased rating claims, and the evidence needed to establish each element. These documents served to provide notice of the information and evidence needed to substantiate the claims. In each letter, the RO specifically notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO or AMC has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims on appeal, reports of which are of record and are adequate for rating purposes. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Service Connection Service connection is awarded for disability that is the result of a disease or injury in active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). With respect to the showing of chronic disease, there must be a combination of sufficient manifestations to identify the disease entity and sufficient observation at the time, as distinguished from isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303 (2012). Here, there is no competent evidence of either neurological disability or optic nerve disease or injury in service or within the first post-service year. Rather, the Veteran contends that his neurological complications and visual impairment are secondary to his service-connected diabetes mellitus. Any disability which is proximately due to, or results from, another disease or injury for which service connection has been granted, shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2012). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b) (2012); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). A. Neurological Complications In April 2003, the Veteran's treating physician, James G. Joachim, M.D., reported that the Veteran was currently receiving care for non-insulin dependent diabetes mellitus associated with multiple vascular and neurological complications. During a July 2003 VA examination, the Veteran reported some numbness and tingling for the past six to seven months. Neurological examination at that time was normal. The report of a July 2006 VA examination reflects no neurologic disease. Examination revealed normal coordination, and neither motor loss nor sensory loss of any extremity. Deep tendon reflexes were 2+. VA treatment records, dated in September 2008, show an assessment of diabetes mellitus with neuropathy. A VA nurse practitioner noted that the Veteran had been approved for a vascular procedure, but had not yet been contacted; and that he still had some occasional rest pain, and pain in the right leg with walking. The report of a July 2011 VA examination reflects sensory polyneuropathy of each lower extremity below knee level. Detailed motor examination revealed active movement against full resistance of each extremity. Muscle tone was normal, and there was no muscle atrophy. The examiner opined that the Veteran's peripheral neuropathy was a complication of his diabetes mellitus. In support of the opinion, the examiner commented that the stocking pattern of sensory neuropathy in the lower legs below knee level bilaterally was consistent with diabetic peripheral neuropathy, although the Veteran's peripheral vascular disease was also a contributing factor. In Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006), the Federal Circuit Court indicated that, where lay evidence provided is competent and credible, the absence of contemporaneous medical documentation during service or since, such as in treatment records, does not preclude further evaluation as to the etiology of the claimed disorder. And the Veteran, even as a layman, is competent to proclaim that he suffered some numbness and tingling in his lower extremities. This is further corroborated by the April 2003 physician's statement, noting treatment for diabetes mellitus associated with multiple vascular and neurological complications. The Board finds the Veteran's lay statements concerning numbness and tingling are not only competent, but also are credible, to show current neurological complications. His lay statements, therefore, have probative value. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). The question remains, however, whether the current neurological complications are related to service or to a service-connected disability. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Here, the Board finds that the July 2011 examiner provided a thorough etiology opinion, associating the Veteran's peripheral neuropathy of each lower extremity with his diabetes mellitus. That opinion is factually accurate, fully articulated, and contains sound reasoning. Given the nature of the disability, the Veteran's credible lay statements, and post-service treatment records reflecting neurological complications, and the July 2011 favorable opinion, the Board finds that the Veteran's neurological complications are the result of disease or injury incurred in service. See Hodges v. West, 13 Vet. App. 287, as amended (2000). Accordingly, service connection is warranted for neurological complications of each of the Veteran's lower extremities. In reaching this decision, the Board has extended the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107. B. Visual Impairment Under 38 C.F.R. § 3.303(c), refractive error of the eye is not considered a disease or injury within the meaning of applicable legislation governing the awards of compensation benefits. As both myopia and presbyopia are refractive errors, these conditions are not "diseases" or "injuries" for purposes of service connection. See McNeely v. Principi, 3 Vet. App. 357, 364 (1992); Parker v. Derwinski, 1 Vet. App. 522 (1991); see also Dorland's Illustrated Medical Dictionary, 1094, 1349 (28th Edition, 1994). Service treatment records do not reflect any findings or complaints of eye disease or eye injury. A report of medical history at the time of the Veteran's separation examination in October 1968 reveals that the Veteran wore glasses for reading only. The report of a July 2003 VA examination reflects that the Veteran had large pinguecula on the nasal aspect that were greater than the temporal aspect of both eyes. All other anterior segment findings were nominal for each eye. Following ocular examination, the diagnoses included pinguecula of both eyes; myopia of both eyes; and presbyopia. No diabetic retinopathy or other retinal pathology for either eye was found. During a July 2006 VA examination, the Veteran reported no history of ocular injuries, disease, or surgery. He denied having any eye pain or visual symptoms, and denied using any eye treatment. Ocular examination revealed that his best-corrected visual acuity in the right eye at distance was 20/20, and at near was equivalent to 20/20; and in the left eye at distance was 20/40, and at near was equivalent to 20/20. The diagnosis was diabetes mellitus without ophthalmic sign. The examiner commented that there was no diabetic-caused visual impairment or disability. VA digital retinal imaging in October 2009 revealed no diabetic retinopathy of the right eye, and revealed mild nonproliferative diabetic retinopathy of the left eye. Records show that a comprehensive eye evaluation was recommended. During the follow-up VA clinical eye evaluation in March 2010, the Veteran reported that both eyes were doing well. Following ocular examination, the assessment was ametropia. The examiner found no evidence of diabetic retinopathy in each eye. Examination results were shown as normal-i.e., no retinopathy. The Veteran underwent a VA examination in July 2011. The examiner noted the Veteran's ocular history, and reported that the only significant ocular assessments were those of dry eyes and refractive errors; and that the refractive errors were correctable to 20/20 in each eye with eyeglasses. The Veteran reported no pain, no visual symptoms, no past ocular injuries, and no eye diseases or surgery. He currently was under no eye treatment. Following ocular examination, diagnoses included ametropia and presbyopia. The examiner opined that the Veteran had no visual impairment or disability related to diabetes mellitus or otherwise. The Board finds the VA opinions probative as they are definitive, based upon a complete review of the Veteran's entire claims file, and supported by detailed rationale. Accordingly, the opinions are found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Accordingly, the Board finds the VA opinions in July 2003, July 2006, and July 2011, as well as the comprehensive evaluation in March 2010, to be more probative than the October 2009 digital retinal imaging alone. The Board is within its province to weigh the Veteran's statements and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). As indicated above, refractive errors of the eye are not considered a disease or injury for purposes of service connection. While the Veteran contends that his visual impairment has worsened due to his diabetes mellitus, he is not shown to have the medical expertise to offer an opinion on such a complex medical question. He is not shown to be competent to render an opinion as to the nature of his underlying visual impairment, or to identify that a disability is related to his service-connected diabetes mellitus. In essence, the Board finds that the issue presented in the case is not one in which the Veteran's lay contentions can serve to support an award of service connection. In short, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection for visual impairment, secondary to diabetes mellitus. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Increased Rating Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where entitlement to compensation already has 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, 58 (1994). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of diabetes mellitus, impotency, and of numbness and tingling. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. Service connection has been established for diabetes mellitus with impotency. The RO has evaluated the Veteran's diabetes mellitus with impotency under 38 C.F.R. § 4.119, Diagnostic Code 7913, as 20 percent disabling. Pursuant to Diagnostic Code 7913, a 20 percent rating is assigned for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A rating of 40 percent is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent evaluation is for application when diabetes mellitus requires 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 evaluation 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 3 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). Pursuant to the parties' joint motion discussed above, service connection has now been awarded for neurological complications, as part and parcel of the Veteran's diabetes mellitus. Pursuant to Diagnostic Code 7913, Note (1)-pertaining to diabetes mellitus-complications such as impotency and peripheral neuropathy are rated as part of the diabetic process unless they are compensably disabling, in which case they are rated separately. Hence, the Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. The Board notes, however, that the Veteran's service-connected peripheral vascular disease of each lower extremity, diabetic nephropathy, and post-operative coronary artery disease have been evaluated separately; and are not for consideration in evaluating the Veteran's diabetes mellitus with impotency. 38 C.F.R. § 4.14. The report of a July 2003 VA examination reveals that the Veteran had erectile dysfunction for the past four-to-five years, and was treated with Viagra. Private treatment records, dated in July 2005, indicate that the Veteran's diabetes mellitus was poorly controlled; and that the Veteran was exercising, and was doing fairly well with his multiple severe medical problems, which have disabled him. VA treatment records, dated in March 2006, reflect that the Veteran was instructed to try to exercise at least 30 minutes, three times per week if possible; and that any increase in physical activity may be useful in controlling his blood pressure. In April 2006, the Veteran's treating physician indicated that treatment of the Veteran's diabetes mellitus required insulin, and that the Veteran had multiple complications. The complications noted included visual, neurological, cardiovascular, and peripheral vascular. In evaluating the severity of the Veteran's diabetes mellitus, the treating physician indicated on a form letter that the Veteran's diabetes mellitus required insulin, restricted diet, and regulation of activities. Although the treating physician was asked to "describe regulation of activities in the Remarks section," the treating physician only noted that the Veteran had "significant medical disability secondary to diabetes, triple vessel coronary artery disease, and chronic hypertension." The report of a July 2006 VA examination reflects that the Veteran had been diabetic for about 7 years; and that he was taken pills, but had to add insulin. His medical history reflects that the Veteran followed a restricted diet. Neurological examination in July 2006 was normal; neither motor nor sensory losses were detected. The examiner noted that the Veteran was able to mow his lawn with a riding mower, and use a weed eater. VA treatment records, dated in September 2008, show that the Veteran still had some occasional rest pain and pain in the right leg when walking. The diagnosis was diabetes mellitus with neuropathy. Records show that the Veteran was instructed on diabetic management and foot care. During a July 21, 2011 VA examination, the Veteran reported that he took his medications as prescribed; and that he checked his blood sugar only twice a month. VA records show that the Veteran had fairly good control of his diabetes mellitus between March 2009 and February 2011. The examiner noted that the Veteran had no episodes of hypoglycemia reactions or ketoacidosis; and that the Veteran was on a restricted diet, and was not restricted in his ability to perform strenuous activities. Neurological examination then revealed polyneuropathy below knee level of each lower extremity; sensory was decreased to pinprick and light touch of each lower extremity. Detailed motor examination revealed active movement against full resistance of each extremity. While the Veteran has indicated that he is restricted in performing activities, none of his treatment reports includes a recommendation that he regulate his activities in order to treat his diabetes mellitus, so as to warrant an increased evaluation. In this regard, the April 2006 description provided by the Veteran's treating physician primarily reveals that restrictions, if any, are related to his cardiovascular disabilities. The overall evidence supports a finding that the Veteran's diabetes mellitus with impotency requires insulin and a restricted diet; and is against a finding that the Veteran's diabetes mellitus with impotency requires regulation of activities. Hence, the preponderance of the evidence is against awarding an evaluation in excess of 20 percent. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21 (2012). As noted above, complications are rated as part of the diabetic process unless they are compensably disabling, in which case they are rated separately. Pursuant to Diagnostic Code 7522, a 20 percent disability rating is assigned for deformity of the penis, with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. The evidence reflects that the Veteran has erectile dysfunction, and that he receives special monthly compensation for loss of use of a creative organ. In this case, the Veteran's erectile dysfunction is noncompensable under Diagnostic Code 7522 because there is no deformity shown. Hence, a separate evaluation is not warranted. Likewise, the evidence reflects some sensory deficit, primarily in each lower extremity, associated with the Veteran's diabetes mellitus. Pursuant to Diagnostic Code 8520, a 10 percent evaluation is warranted for mild incomplete paralysis of the sciatic nerve of the lower extremity. A 20 percent evaluation is warranted for moderate incomplete paralysis of the sciatic nerve of the lower extremity. A 40 percent evaluation is warranted for moderately severe incomplete paralysis of the sciatic nerve of the lower extremity. A 60 percent evaluation is warranted for severe incomplete paralysis, with marked muscular atrophy, of the sciatic nerve of the lower extremity. An 80 percent evaluation is warranted for complete paralysis of the sciatic nerve of the lower extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8520. 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 the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Complete paralysis of the sciatic nerve is indicated where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. In this case, there have been no reports of loss of reflexes or muscle atrophy. No examiner has found significant neurological deficits at any time. Given the July 2011 examiner's findings of polyneuropathy below knee level and decreased sensory to pinprick and light touch, and resolving doubt in favor of the Veteran, separate 10 percent disability ratings are warranted for mild incomplete paralysis of the sciatic nerve of each lower extremity from the date of examination on July 21, 2011. 38 C.F.R. §§ 4.123, 4.124 (2012). There is no indication that incomplete paralysis of the sciatic nerve of each lower extremity is more than mild to warrant disability ratings in excess of 10 percent at any time. The consistent lack of significant objective findings weighs against granting separate ratings in excess of 10 percent for either lower extremity. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings is permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, prior to the July 2011 VA examination, the evidence does not reveal neurological complications that are compensably disabling. Finally, an extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluations assigned for the Veteran's service-connected diabetes mellitus with impotency and for neurological complications, are adequate in this case. While examiners have noted the severity of the Veteran's disabilities, any functional impairment is contemplated by the schedular criteria for diabetes mellitus and for neuropathy. Specifically, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected disabilities. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For the foregoing reasons, the Board finds that the preponderance of the evidence is against a disability rating in excess of 20 percent for diabetes mellitus with impotency; and, from July 21, 2011, is in favor of separate 10 percent disability evaluations for associated mild, incomplete paralysis of the sciatic nerve of each lower extremity. ORDER Service connection for peripheral neuropathy of each lower extremity is granted. Service connection for visual impairment secondary to diabetes mellitus, is denied. An increased evaluation in excess of 20 percent for diabetes mellitus with impotency is denied. Separate 10 percent disability ratings for associated mild, incomplete paralysis of the sciatic nerve of each lower extremity, for the period from July 21, 2011, are granted, subject to the pertinent legal authority governing the payment of monetary awards. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs