Citation Nr: 1318814 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 09-22 804 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a circulatory system disorder, claimed as secondary to service-connected Type II diabetes mellitus. 2. Entitlement to an evaluation above 10 percent for peripheral neuropathy of the right lower extremity prior to February 21, 2012. 3. Entitlement to an evaluation above 20 percent for peripheral neuropathy of the right lower extremity as of February 21, 2012. 4. Entitlement to an evaluation above 10 percent for peripheral neuropathy of the left lower extremity prior to February 21, 2012. 5. Entitlement to an evaluation above 20 percent for peripheral neuropathy of the left lower extremity as of February 21, 2012. 6. Entitlement to an evaluation above 30 percent for arterial hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus). 7. Entitlement to an evaluation above 20 percent for Type II diabetes mellitus. 8. Entitlement to an initial compensable disability rating for diabetic retinopathy. 9. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty from December 1969 to November 1971. He served in combat in the Republic of Vietnam and his military decorations include the Combat Infantryman Badge, the Bronze Star Medal, and the Air Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the San Juan, Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA) which, inter alia, granted the Veteran service connection and an initial noncompensable evaluation for diabetic retinopathy (effective November 1, 2007) and denied his claims for increased ratings for bilateral peripheral neuropathy of the lower extremities (each lower extremity rated 10 percent disabling), hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus and rated 30 percent disabling), Type II diabetes mellitus (rated 20 percent disabling), service connection for a circulatory system disorder, and a TDIU. In February 2012, the Board remanded the case to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further evidentiary and procedural development. Thereafter, in a December 2012 rating decision, the RO, inter alia, assigned a 20 percent evaluation for peripheral neuropathy of each lower extremity, effective February 21, 2012; confirmed the 30 percent evaluation assigned to hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus) and the 20 percent evaluation assigned for Type II diabetes mellitus; and confirmed the denials of service connection for a circulatory disorder and a TDIU. The case was returned to the Board in February 2013 and the Veteran now continues his appeal. FINDINGS OF FACT 1. The objective clinical evidence does not demonstrate that the Veteran has a diagnosis of a circulatory system disorder. 2. Prior to February 21, 2012, peripheral neuropathy of the right lower extremity was manifested by subjective pain and diminished external sensory perception of the affected limb, producing impairment that equated to not more than mild incomplete paralysis of the involved sciatic nerve. 3. As of February 21, 2012, peripheral neuropathy of the right lower extremity is manifested by subjective pain and diminished external sensory perception of the affected limb and loss of external hair, with electromyographic (EMG) findings of demyelination of the involved sciatic nerve, which restrict the Veteran from performing physical tasks associated with prolonged manual labor and produce impairment that equates to not more than moderate incomplete paralysis of the right sciatic nerve. 4. Prior to February 21, 2012, peripheral neuropathy of the left lower extremity was manifested by subjective pain and diminished external sensory perception of the affected limb, producing impairment that equated to not more than mild incomplete paralysis of the involved sciatic nerve. 5. As of February 21, 2012, peripheral neuropathy of the left lower extremity is manifested by subjective pain and diminished external sensory perception of the affected limb and loss of external hair, with EMG findings of demyelination of the involved sciatic nerve, which restrict the Veteran from performing physical tasks associated with prolonged manual labor and produce impairment that equates to not more than moderate incomplete paralysis of the left sciatic nerve. 6. Arterial hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus) is currently manifested by hypertension controlled with medication, with systolic readings consistently less than 160 and diastolic readings consistently less than 100, with positive diagnosis of kidney dysfunction and positive tests for recurring albumin protein in urine, but with noncompensable BUN and creatinine scores; arterial hypertension has no disabling impact by itself on the Veteran's capacity to perform physical work. 7. Type II diabetes mellitus is currently treated and controlled through insulin medication and a restricted diet, but does not require regulation of physical activities as part of its medical management. 8. Diabetic retinopathy is not presently manifested by any incapacitating episodes or by any impairment of visual acuity. 9. The Veteran is presently service-connected for peripheral neuropathy of the left upper extremity (rated 40 percent), peripheral neuropathy of the right upper extremity (rated 30 percent), arterial hypertension with microalbuminuria (rated 30 percent), Type II diabetes mellitus (rated 20 percent), peripheral neuropathy of the left lower extremity (rated 20 percent), peripheral neuropathy of the right lower extremity (rated 20 percent), diabetic neuropathy (rated noncompensable), and erectile dysfunction (rated noncompensable), which produce a combined disability rating of 90 percent. 10. The Veteran is precluded from securing and following a substantially gainful occupation by reason of the combined effects of his service-connected disabilities. CONCLUSIONS OF LAW 1. A circulatory system disorder was not incurred, nor is one presumed to have been incurred during active duty, and is not secondarily related to a service-connected disability. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). 2. The criteria for an evaluation above 10 percent for peripheral neuropathy of the right lower extremity prior to February 21, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 3. The criteria for an evaluation above 20 percent for peripheral neuropathy of the right lower extremity as of February 21, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 4. The criteria for an evaluation above 10 percent for peripheral neuropathy of the left lower extremity prior to February 21, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 5. The criteria for an evaluation above 20 percent for peripheral neuropathy of the left lower extremity as of February 21, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 6. The criteria for an evaluation above 30 percent for arterial hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus) have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.104, 4.115a, 4.115b (2012). 7. The criteria for an evaluation above 20 percent for Type II diabetes mellitus have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). 8. The criteria for a compensable evaluation for diabetic retinopathy have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.79, Diagnostic Code 6006 (2012). 9. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16(a), 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) and VA's duty to assist. With respect to the claims decided herein, the Board notes at the outset that, in accordance with the VCAA, VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Generally, the notice requirements of a claim have five elements: 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). VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). During the course of the appeal, § 3.159(b) was revised and the requirement that VA request that the claimant provide any evidence in his possession that pertains to the claim was removed from the regulation. The current claims that will be adjudicated on the merits were filed on November 1, 2007. A VCAA notice letter was dispatched to the Veteran in February 2008, prior to the July 2008 rating decision now on appeal. This letter addressed the issues on appeal and satisfied the above-described mandates, as well as the requirements that the Veteran be informed of how VA calculates degree of disability and assigns an effective date for the disability, as prescribed in Dingess v. Nicholson, 19 Vet. App. 473 (2006). As fully compliant notice preceded the initial adjudication of each of the Veteran's claims adjudicated herein, there is no timing of notice defect. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. With the exception of the claim for a compensable initial evaluation for diabetic retinopathy, as the other increased rating and TDIU claims on appeal stem from November 1, 2007, when the Veteran filed his claim for increased ratings for his service-connected disabilities at issue, the relevant time period and evidence that must be addressed in the adjudication of the claim encompasses the period from November 1, 2006 to the present, in order to allow the Board to consider the applicability of a staged rating. See 38 C.F.R. § 3.400(o)(2) (2012); Hart v. Mansfield, 21 Vet. App. 505 (2007). The pertinent time period for the claim for a compensable initial evaluation for diabetic retinopathy commences only on November 1, 2007, which is the date of the Veteran's original claim for VA compensation for this disability. 38 C.F.R. § 3.400(b)(2) (2012). In this regard, the Board observes that private, Social Security Administration (SSA), and VA clinical records for the period spanning 2007 to 2012, including reports of VA medical examinations of the disabilities at issue, dated in March 2008 and February 2012, have been obtained and associated with the claims file, or are otherwise viewable on the Virtual VA electronic information database. The Board has reviewed the aforementioned examination reports and notes that the Veteran's claims file was reviewed by the VA clinicians who performed them, and that these examiners provided adequate discussion of their clinical observations and rationales to support their individual findings and conclusions within the context of the Veteran's pertinent clinical history as contained within his claims file. The examinations are therefore deemed adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). With regard to claim of entitlement to service connection for a circulatory system disorder, the Board notes that the Veteran's service medical records and all pertinent post-service clinical records from private, VA and SSA sources have been obtained and associated with his claims file or are otherwise viewable on the Virtual VA electronic information database. He was provided with a VA medical examination in February 2012 addressing the claim and an opinion addressing the claimed disability and its relationship to service was duly obtained, based on a full review of his pertinent clinical history. The examination as it pertains to the service connection claim is therefore deemed adequate for VA adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). In a signed statement dated in December 2012, the Veteran and his representative affirmed that there was no further evidence to submit in support of his current appeal. The Veteran having been provided with adequate opportunity to submit or otherwise identify relevant evidence in support of these claims, the Board finds that the record does not need to be held open any longer, and that no further delay in the adjudication of this appeal with respect the issues decided herein is warranted. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of the claims decided herein, and thus no additional assistance or notification is required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (a.) Entitlement to service connection for a circulatory system disorder, claimed as secondary to service-connected Type II diabetes mellitus. At the outset, the Board notes that the Veteran is already service-connected for arterial hypertension. He is presently claiming entitlement to a circulatory system disorder other than hypertension (previously rated as renal involvement in diabetes mellitus), manifested by subjective complaints of upper extremity pain that is separate and apart from his service-connected bilateral peripheral neuropathy of his upper extremities. He contends that this claimed circulatory system disorder is secondarily related to his service-connected Type II diabetes mellitus. Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a). With chronic disability or disease shown as such in service (or manifested to at least a compensable degree within the one-year presumptive period following separation from service under 38 C.F.R. § 3.307 for cardiovascular-renal disease) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any notation of a circulatory system abnormality (other than the Veteran's service-connected hypertension) during service will permit service connection for a circulatory system disorder, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board notes at this juncture that service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). In this regard, the Board observes that the Veteran is presently service-connected for bilateral upper and lower extremity peripheral neuropathy, arterial hypertension (previously rated as renal involvement in diabetes mellitus), Type II diabetes mellitus, diabetic neuropathy, and erectile dysfunction. To establish direct service connection for a claimed disorder, there must be (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of the existence of a current disability is satisfied when a veteran has a disability at the time he files his claim for service connection or during the pendency of that claim. In a case where the claimed disability resolves during the pendency of the claim, VA must make consideration of whether the veteran is still entitled to compensation benefits for that period during which the claimed disability was extent. VA compensation may be paid for that period in which it was extent if service connection is warranted. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As relevant, the Veteran's service medical records show no objective clinical diagnosis of any cardiovascular abnormalities during active duty, with normal vascular system, blood pressure readings, and chest X-ray films on enlistment examination in October 1969, throughout military service, and on pre-separation examination in August 1971. The Veteran was discharged from active duty in November 1971. There are no post-service medical records demonstrating the presence of a chronic cardiovascular disease or disorder manifested to a compensable degree within the immediate first year following his separation from service. Other than arterial hypertension as a clinical manifestation of renal involvement associated with service-connected diabetes mellitus, for which the Veteran is already in receipt of VA compensation benefits, the pertinent medical evidence does not demonstrate that he has a current diagnosis of a circulatory system disorder, nor did he ever have one at any time during the pendency of the claim for the period commencing November 1, 2007. In this regard, the VA examination of February 2012 shows that on clinical investigation of the Veteran's subjective complaint of upper extremity pain, these symptoms are attributed to his service-connected bilateral peripheral neuropathy of his upper extremities. Otherwise, the examining clinician reported that there was no history of a circulatory disorder and no medical evidence of a current circulatory disorder based on his examination of the Veteran and a review of the Veteran's claims file; thusly, a medical nexus opinion does not proceed. The Board has considered the aforementioned evidence and finds that absent a current diagnosis of a circulatory system disorder or one that was manifested during the pendency of the claim (other than arterial hypertension, for which he is already receiving VA compensation), the Veteran's claim in this regard has failed to meet the essential first element of the test prescribed by the United States Court of Appeals for Veterans Claims (Court) in Hickson v. West, 12 Vet. App. 247, 253 (1999) and McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As such, there is no basis to allow his claim for VA compensation for a circulatory system disorder. Service connection for this claimed disability is therefore denied. Because the evidence in this case is not approximately balanced with respect to the merits of this specific claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As a lay person for practical purposes, the Veteran is competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, the specific issue in this case (i.e., the diagnosis and etiology of his alleged circulatory system disorder as a chronic disability and its relationship to his service-connected Type II diabetes mellitus) falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Circulatory system pathologies are not the type of disabling syndromes that are readily amenable to mere lay diagnosis or probative comment regarding their etiologies and relationships to other disabilities, as the evidence shows that cardiovascular testing and other specific findings are needed to properly assess and diagnose these disorders. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms of upper extremity pain, there is no indication that the Veteran is competent to clinically diagnose a circulatory system disorder on the basis of these self-perceived symptoms as separate and apart from his service-connected peripheral neuropathy, Type II diabetes mellitus, and arterial hypertension. The Veteran has not been shown to possess the requisite medical training, nor the clinical expertise or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in any medical discipline, much less evaluating circulatory system disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, his lay statements and opinions do not constitute competent medical evidence and lack probative value. Increased ratings - generally. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2012). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2012); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2012). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Based on the November 1, 2007 date of VA's receipt of the Veteran's application to reopen his claims for a rating increase and his original claim for service connection for diabetic retinopathy, the relevant temporal focus for the TDIU and the increased rating claims for bilateral lower extremity neuropathy, arterial hypertension with microalbuminuria, and Type II diabetes mellitus is from November 1, 2006, and the relevant temporal focus for the initial compensable rating claim for diabetic retinopathy is from November 1, 2007. See 38 C.F.R. § 3.400 (2012). (b.) Entitlement to an evaluation above 10 percent prior to February 21, 2012, and above 20 percent as of February 21, 2012, for peripheral neuropathy of the right and left lower extremity. The Veteran is service connected for bilateral peripheral neuropathy of his lower extremities. Each lower extremity is rated for impairment due to paralysis of the sciatic nerve under the criteria contained in 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012), which provides for the following evaluations: Complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement is possible of muscles below the knee, flexion of the knee is weakened or (very rarely) lost, rate as 80 percent disabling. Severe incomplete paralysis of the sciatic nerve with marked muscular atrophy, rate as 60 percent disabling. Moderately severe incomplete paralysis of the sciatic nerve, rate as 40 percent disabling. Moderate incomplete paralysis of the sciatic nerve, rate as 20 percent disabling. Mild incomplete paralysis of the sciatic nerve, rate as 10 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). The clinical evidence pertinent to the period from November 1, 2006 to February 20, 2012, includes SSA records and the report of a March 2008 VA neurological examination, which demonstrates that the Veteran's peripheral neuropathy of his right and left lower extremity is manifested by subjective complaints of pain and cramps, primarily in the plantar region of each lower extremity. Testing of the proximal and distal muscles of both the right and left lower extremity revealed 5/5 muscle strength and no objective motor function impairment. Sensory testing revealed decreased ability to sense vibration, pain, and light touch due to peripheral nerve impairment. Right and left knee and ankle reflexes were each 2+ with normal right plantar flexion and no evidence of muscle atrophy, abnormal muscle tone or bulk, or tremors, tics, or abnormal movements affecting the right lower extremity. No impairment of right o left lower extremity joint function due to peripheral neuropathy was demonstrated. The Veteran's gait and balance as it related to each of his lower extremities were normal. No paralysis was present, although neuritis and neuralgia affecting the both lower extremities were objectively demonstrated. Per his reported history, the Veteran had been previously employed as a manual laborer and was unemployed for less than one year at the time of the March 2008 VA examination, not due to retirement but because his worksite location was moved to distant location relative to the Veteran's residence. The examining clinician opined that the Veteran's peripheral neuropathy of his right and left lower extremities presented no effects on his capacity to perform his usual daily activities. As it relates to the Veteran's peripheral neuropathy of each lower extremity, the above evidence presents an overall disability picture of impairment due to neuritis and neuralgia that is analogous to mild incomplete paralysis of the sciatic nerve, although no actual paralysis is demonstrated. The primary manifestation of the disability is pain, mostly in the plantar region of each foot, with decreased sensory perception in each limb. However, no impairment of reflexes, gait, and balance, and no muscle atrophy or muscle tissue abnormality were shown. As such, the Board cannot concede that the overall disability picture more closely approximates the criteria for a 20 percent evaluation on the basis of moderate incomplete paralysis of the right or left sciatic nerve. Therefore, in view of the foregoing discussion, the claim for an evaluation greater than 10 percent for peripheral neuropathy of each lower extremity prior to February 21, 2012 must be denied. Because the evidence in this case is not approximately balanced with respect to the merits of this specific claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). With respect to the clinical evidence pertinent to the Veteran's peripheral neuropathy of his right and left lower extremities for the period from February 21, 2012, the report of a VA medical examination conducted on this date shows that this neurological disability was manifested by subjective complaints of increased symptoms since the prior medical assessment of March 2008, with constant moderate pain, numbness, paresthesias, and dyesthesias in each lower extremity. Reflexes and muscle tone and strength were 5/5 and normal on examination of each leg. Perception of light touch and vibration were decreased in both lower extremities, with loss of hair evident on physical examination. EMG study revealed objective evidence of a mixed sensory-motor demyelinating-axonal peripheral neuropathy that was consistent with diabetes mellitus. The examining clinician opined, in relevant part, that the Veteran's bilateral peripheral neuropathy of his lower extremities would limit his capacity to ambulate in a workplace environment and would prevent him from performing physical tasks associated with prolonged manual labor, including standing upright for prolonged periods, walking long distances, and climbing stairs constantly. He was, however, deemed capable of working a desk-type job in a sedentary capacity if also permitted to take several breaks from the desk during the workday to avoid excess muscle fatigability. In view of the foregoing discussion, the Board finds that the evidence relevant to the period commencing February 21, 2012, supports the assignment of the 20 percent presently assigned to each lower extremity to compensate the Veteran for peripheral neuropathy manifested by impairment that more closely approximates, but does not exceed that which is contemplated in the rating schedule for moderate paralysis of the sciatic nerve for each lower extremity. Assignment of a higher evaluation is not warranted as the current evidence does not demonstrate that the level of impairment of the sciatic nerve in each lower extremity meets or more closely approximates moderately severe paralysis. 38 C.F.R. § 4.7 (2012). As such, the claim for an evaluation higher than 20 percent for peripheral neuropathy of each lower extremity for the period commencing on February 21, 2012 must be denied. Because the evidence in this case is not approximately balanced with respect to the merits of this specific claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (c.) Entitlement to an evaluation above 30 percent for arterial hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus). The Veteran's service-connected arterial hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus) is ratable under the criteria for hypertension contained in 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012), or as renal dysfunction under 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7541 (2012). By history, this disability is presently assigned a 30 percent evaluation under Diagnostic Code 7541, which has been in effect since August 2001. Diagnostic Code 7101 for rating hypertension provides for a 10 percent rating for hypertension when the diastolic pressure is predominantly 100 or more, or the systolic pressure is predominantly 160 or more, and also in those cases where the individual has a history of diastolic pressure predominantly 100 or more and requires continuous medication for control. A 20 percent evaluation is assigned for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent evaluation is assigned for diastolic pressure predominantly 120 or more. A 60 percent evaluation is assigned for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). Diagnostic Code 7541 for rating renal dysfunction associated with service-connected arterial hypertension with microalbuminuria provides for the assignment of a 30 percent evaluation for objective demonstration of constant urinary 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. A 60 percent evaluation is assigned for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent evaluation is assigned for persistent edema and albuminuria with blood urea nitrogen (BUN) of 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent evaluation is assigned when regular kidney dialysis is required, or renal dysfunction precluding more than sedentary activity due to 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 the cardiovascular system. 38 C.F.R. § 4.115a (2012). Clinical evidence pertinent to this claim shows that on VA examination in March 2008, the Veteran was positive for diagnoses of diabetes mellitus with hypertension and kidney disease. Hypertension was controlled with medication. His blood pressure measured no higher than 156/95 (systolic/diastolic). Urinalysis revealed the presence of albumin, with a creatinine level of 0.98 mg% and BUN of 15.6 mg%. No peripheral edema was detected and no red blood cells or hyaline and granular casts were present in the urine sample. The Veteran was unemployed since 2001 due to his work location being moved away to a distance that was not practically accessible to his residence. The report of a February 2012 VA examination shows that the Veteran was positive for diagnoses of diabetes mellitus with hypertension and kidney disease with recurring proteinuria. Hypertension was controlled with medication. His blood pressure measured no higher than 134/75 (systolic/diastolic). Urinalysis tests conducted in 2011 revealed no albumin present. No peripheral edema was detected and no red blood cells or hyaline and granular casts were present in the 2011 urine samples. The examining clinician who conducted the February 2012 evaluation opined that the Veteran's hypertension did not present him from obtaining and maintaining gainful employment requiring regular duty work. His hypertension did not affect his ability to work on either physically demanding or sedentary positions. Applying the facts of the case to the applicable rating schedule, the Board finds that the Veteran's arterial hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus) is manifested throughout the entire appellate period by clinical evidence of hypertension that is not more than 10 percent disabling under Diagnostic Code 7101 on the basis of his requiring medication to control it. None of the diastolic and systolic scores obtained during the period of this claim support assignment of more than a 10 percent evaluation under Diagnostic Code 7101. Although albumin protein is present in the Veteran's urine on analysis in March 2008, it was not present on testing in 2011. No edema and no red blood cells or hyaline and granular casts were present at any time during the pendency of the appeal. In view of the foregoing discussion, the Board finds no basis to assign an evaluation greater than the 30 percent evaluation currently assigned. Indeed, the clinical evidence does not even demonstrate that the criteria for a 30 percent evaluation under Diagnostic Code 7541 are currently met. However, although the Veteran's claim for an increased rating above 30 percent is denied, the Board will not find that a decrease of this 30 percent evaluation now in effect is warranted. Because the evidence in this case is not approximately balanced with respect to the issue of entitlement to a rating increase above 30 percent, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (d.) Entitlement to an evaluation above 20 percent for Type II diabetes mellitus. The Veteran's service-connected Type II diabetes mellitus is currently rated 20 percent disabling under the criteria contained in 38 C.F.R. § 4.119, Diagnostic Code 7913. A 20 percent evaluation contemplates diabetes mellitus requiring insulin and restricted diet; or oral hypoglycemic agent and restricted diet. The next higher rating of 40 percent requires insulin, restricted diet, and regulation of activities. 38 C.F.R. § 4.119, DC 7913 (2006). For the reasons set forth below, the Board finds that the criteria for a rating in excess of 20 percent have not been met in this case. SSA records show that this agency determined that the Veteran was eligible for SSA disability benefits as of June 2007 due to diabetes and peripheral neuropathy. However, SSA administrative decisions and regulations are not binding on VA or the Board. Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). In this regard, VA examination in March 2008 shows that the Veteran was on insulin and a restricted diet to control his diabetes mellitus, but that there was no restriction in his ability to perform strenuous physical activities. In this regard, his diabetes imposed no more than only mild effects on his usual daily activities and he reported that he engaged in an exercise routine that involved walking and using a stationary bicycle for at least 30 to 45 minutes daily. From this, the Board finds that there was no regulation of the Veteran's physical activities due solely to diabetes mellitus. At the time, he reported that he was a manual laborer but he was unemployed since 2001 because his primary job location moved to an impractical distance away from his residence. VA examination in February 2012 revealed nearly identical relevant findings as presented in the prior March 2008 examination, including a clinical determination that specifically found that the Veteran did not require regulation of his activities as part of medical management of his diabetes mellitus. Furthermore, the examining clinician opined that the Veteran's diabetes mellitus by itself did not prevent him from being able to obtain and maintain gainful employment requiring regular duty work and that he was capable of effective interacting with the general public in a position such as in sales or as a receptionist. Applying the facts of the case to the applicable rating schedule, the Board finds that the Veteran's Type II diabetes mellitus is manifested throughout the entire appellate period by impairment that does not meet the criteria for an evaluation greater than 20 percent under Diagnostic Code 7913. Although he requires insulin and a restricted diet to control his diabetes, the objective medical evidence does not demonstrate that he requires regulation of his physical activities as part of medical management of his diabetes mellitus, as contemplated in the criteria for a 40 percent evaluation under Diagnostic Code 7913. His claim for a rating increase above 20 percent for Type II diabetes mellitus must therefore be denied. Because the evidence in this case is not approximately balanced with respect to this issue, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (e.) Entitlement to an initial compensable disability rating for diabetic retinopathy. By rating decision on appeal, the Veteran was granted service connection and a noncompensable evaluation for diabetic retinopathy, effective November 1, 2007. He appeals the initial zero percent rating assigned, seeking an award of a compensable evaluation for this ophthalmological disability. Diabetic retinopathy is rated under the criteria contained in 38 C.F.R. § 4.79, Diagnostic Code 6006, which states that this ophthalmological disability is to be evaluated on the basis of either visual impairment due to retinopathy or incapacitating episodes, which results in a higher evaluation. The rating code provides for the assignment of a 10 percent evaluation for incapacitating episodes having a total duration of at least 1 week, but less than 2 weeks, during the past 12 months. Assignment of a 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months. Assignment of a 40 percent evaluation is warranted for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. Assignment of a 60 percent evaluation is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. As relevant, VA ophthalmological examinations performed in March 2008 and February 2012 objectively demonstrate that the Veteran was diagnosed with moderate non-proliferative diabetic retinopathy not manifested by ocular pain or incapacitating episodes. Additionally, diabetic macular edema of the right eye was diagnosed during the February 2012 VA eye examination. Loss of vision in each eye was determined to have been due to refractive error and senile cataracts. These were conclusively determined to be unrelated to service-connected diabetes mellitus and were not manifestations of diabetic retinopathy. The examining clinician opined that the Veteran's hypertensive retinopathy and non-proliferative retinopathy with macular edema did not affect his central vision at the time of the February 2012 examination, was not manifested by incapacitating episodes, and did not impact his ability to work. On basis of the above objective findings, the Board concludes that there is no basis to assign an initial compensable evaluation for the Veteran's service-connected diabetic retinopathy, as it was not manifested by any incapacitating episodes during the pendency of the claim and the eye examiners conclusively determined that the visual impairment that the Veteran experienced was not due to his service-connected diabetes mellitus but rather to mere refractive error and age-related cataracts. Therefore, the Veteran's appeal in this regard must be denied. Because the evidence in this case is not approximately balanced with regard to the merits of this specific issue, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (f.) Extraschedular consideration. A rating in excess of the assigned schedular evaluations for the Veteran's service-connected disabilities addressed herein on the merits may be granted when it is demonstrated that the particular disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. See Shipwash v. Brown, 8 Vet. App. 218, 277 (1995). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, 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 and frequent periods of hospitalization. Id. at 116. If this is the case, 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 for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that there is no evidence that the Veteran's service-connected bilateral peripheral neuropathy of his lower extremities, diabetic retinopathy, arterial hypertension with microalbuminuria (to include renal dysfunction), and Type II diabetes mellitus have presented such an unusual or exceptional disability picture at any time between November 1, 2006 to the present, so as to require consideration of an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b) (2012). In this case, the evidence of record does not indicate the Veteran is frequently hospitalized for any of these aforementioned service-connected disabilities. The criteria of the applicable rating schedules are deemed to adequately contemplate the Veteran's present level of impairment due to the disabilities at issue, as individually considered. As such, the Board cannot concede that the Veteran's bilateral peripheral neuropathy of his lower extremities, diabetic retinopathy, arterial hypertension with microalbuminuria (to include renal dysfunction), and Type II diabetes mellitus, each standing by itself, causes marked interference with his employment capacity. Higher ratings are available for each of the Veteran's disabilities, but for the reasons described in the above decision, higher ratings were denied in each case. For each disability the clinical evidence and medical opinions fail to show that the disability picture created by these disabilities, in isolation, is of an exceptional or unusual nature. Having reviewed the record with these mandates in mind, the Board finds that the schedular ratings presently assigned to these disabilities adequately reflects the state of their impairment for the period to which they are applied, and that there is no evidentiary basis for referral of the case for extraschedular consideration with regard to any of these issues. (g.) Entitlement to a TDIU. VA will grant a total rating for compensation purposes based on individual unemployability when the evidence shows that a veteran is precluded, by reason of service-connected disability, from obtaining and maintaining any form of gainful employment consistent with his or her education and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disability or disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. While the regulations do not provide a definition of "substantially gainful employment," VA Adjudication Procedure Manual, M21-1 MR, Part IV, Subpart ii, Chapter 2 (Dec. 13, 2005) (previously cited at M21-1, Part IV, paragraph 7.09), defines the term as that "at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides." In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a Veteran is entitled to TDIU is whether his service-connected disabilities alone are of sufficient severity to produce unemployability. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a) (2012). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a Veteran's favor. 38 C.F.R. § 4.3 (2012). The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). The Veteran is presently service-connected for peripheral neuropathy of the left upper extremity (rated 40 percent), peripheral neuropathy of the right upper extremity (rated 30 percent), arterial hypertension with microalbuminuria (rated 30 percent), Type II diabetes mellitus (rated 20 percent), peripheral neuropathy of the left lower extremity (rated 20 percent), peripheral neuropathy of the right lower extremity (rated 20 percent), diabetic neuropathy (rated noncompensable), and erectile dysfunction (rated noncompensable), which produce a combined disability rating of 90 percent under 38 C.F.R. § 4.25 (2012). Therefore, the Veteran has met the rating requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a). As relevant, the Board notes that the Veteran is presently 62 years old at the time of this writing. His DD 214 indicates that he has a 12-year public school education and a high school diploma. His medical records show that his vocation was as a manual laborer and indicate that he was employed up until 2001, when his employer relocated to a new location that was not a conveniently accessible commute from the Veteran's residence. The Board notes that SSA records associated with the Veteran's claims file show that the SSA has determined that the Veteran is disabled for purposes of SSA benefits due to diabetes mellitus and peripheral neuropathy as of June 2007. While this evidence is probative, SSA administrative decisions and regulations are nevertheless not binding on VA or the Board, although findings made by the SSA regarding the existence of a total and permanent disability and resulting unemployability are relevant to determining whether TDIU is applicable under VA laws and regulations and thus must be considered. Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). Although the VA examinations of March 2008 and February 2012 address the individual impact of each of the Veteran's service-connected disabilities on his employability and indicate that, as a separate and individual factor, none of these disabilities renders the Veteran unable to work in at least a sedentary capacity, the Board notes that no objective clinical assessment of the collective impact of all of the Veteran's service-connected disabilities on his capacity for employment has been presented in the record. However, notwithstanding this deficit, the Board finds it noteworthy that the Veteran is already deemed to be 90 percent disabled by the combined rating of all his service-connected disabilities and that furthermore the SSA has found him to be disabled from working due to his service-connected diabetes mellitus and syndromes related to diabetes. Significantly, the Veteran's vocational background is in manual labor and therefore it may be problematic for him to obtain employment in a sedentary position in today's job market, given his present education level and occupational experience. The evidence is therefore in relative equipoise regarding the question of whether or not the Veteran is individually unemployable as a result of the combined effects of his multiple service-connected disabilities. Resolving any doubt in this regard in favor of the Veteran, the Board concludes that he is unable to obtain and retain gainful employment due to his multiple service-connected disabilities operating in concert against him. His claim for a TDIU under the regulatory provisions of 38 C.F.R. § 4.16(a) is thusly granted. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). [Continued on Next Page] ORDER Service connection for a circulatory system disorder, to include as secondary to service-connected Type II diabetes mellitus, is denied. Entitlement to an evaluation above 10 percent for peripheral neuropathy of the right lower extremity prior to February 21, 2012 is denied. Entitlement to an evaluation above 20 percent for peripheral neuropathy of the right lower extremity as of February 21, 2012 is denied. Entitlement to an evaluation above 10 percent for peripheral neuropathy of the left lower extremity prior to February 21, 2012 is denied. Entitlement to an evaluation above 20 percent for peripheral neuropathy of the left lower extremity as of February 21, 2012 is denied. Entitlement to an evaluation above 30 percent for arterial hypertension with microalbuminuria (previously rated as renal involvement in diabetes mellitus) is denied. Entitlement to an evaluation above 20 percent for Type II diabetes mellitus is denied. Entitlement to an initial compensable disability rating for diabetic retinopathy is denied. Entitlement to a TDIU is granted. ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs