Citation Nr: 1322511 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 09-37 987 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 2. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 3. Entitlement to an increased evaluation for peripheral neuropathy of the left lower extremity, evaluated as 10 percent disabling prior to March 9, 2012, and as 20 percent disabling on and after March 9, 2012. 4. Entitlement to an increased evaluation for peripheral neuropathy of the right lower extremity, evaluated as 10 percent disabling prior to March 9, 2012, and as 20 percent disabling on and after March 9, 2012. 5. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty from November 1967 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The July 2008 rating decision denied ratings in excess of 10 percent for all four peripheral neuropathy claims and denied service connection for PTSD. In an October 2012 rating decision, the disability ratings for peripheral neuropathy of the right and left lower extremities were increased to 20 percent, effective March 9, 2012. In February 2010, the Veteran appeared at a personal hearing before a Decision Review Officer at the San Juan RO. A transcript of this hearing was prepared and associated with the claims file. In January 2012, the Board remanded this case for additional development, and the case has been returned for further appellate review. As discussed in the January 2012 remand, the Board has considered whether the issue of entitlement to service connection for PTSD should be read more broadly to include a general claim of entitlement to service connection for a psychiatric disability pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). The case at hand can be distinguished from Clemons, however, as that case concerned VA's failure to consider a claim of entitlement to service connection for a psychiatric disability other than the one specifically claimed, even though it was the psychiatric symptomatology for which the Veteran was seeking service connection. In the case at hand, however, VA has adjudicated a separate claim of entitlement to service connection for depression and anxiety. The Veteran was notified of the denial of this claim and of how to perfect an appeal, and he chose not to do so. Thus, unlike Clemons, this is not a case in which VA has ignored the issue of entitlement to service connection for a current psychiatric disability other than PTSD. Rather, it has been specifically denied by the RO, and the Veteran subsequently appealed only the claim for PTSD. The Board therefore finds that it does not have jurisdiction over the issue of entitlement to service connection for a psychiatric disability other than PTSD. FINDINGS OF FACT 1. The Veteran's peripheral neuropathy of the left upper extremity is manifested by symptoms that may be characterized as no more than mild, incomplete paralysis. 2. The Veteran's peripheral neuropathy of the right upper extremity is manifested by symptoms that may be characterized as no more than mild, incomplete paralysis. 3. Prior to March 9, 2012, the Veteran's peripheral neuropathy of the left lower extremity was manifested by symptoms that may be characterized as no more than mild, incomplete paralysis. 4. Prior to March 9, 2012, the Veteran's peripheral neuropathy of the right lower extremity was manifested by symptoms that may be characterized as no more than mild, incomplete paralysis. 5. On and after March 9, 2012, the Veteran's peripheral neuropathy of the left lower extremity is manifested by symptoms that may be characterized as no more than moderate, incomplete paralysis. 6. On and after March 9, 2012, the Veteran's peripheral neuropathy of the right lower extremity is manifested by symptoms that may be characterized as no more than moderate, incomplete paralysis. 7. Resolving reasonable doubt in favor of the Veteran, the Veteran has a diagnosis of PTSD which is the result of his combat service. CONCLUSIONS OF LAW 1. The criteria for the assignment of a disability rating in excess of 10 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8515 (2012). 2. The criteria for the assignment of a disability rating in excess of 10 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8515 (2012). 3. The criteria for the assignment of an increased rating for peripheral neuropathy of the left upper extremity, rated as 10 percent disabling prior to March 9, 2012, and as 20 percent disabling thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8520 (2012). 4. The criteria for the assignment of an increased rating for peripheral neuropathy of the right upper extremity, rated as 10 percent disabling prior to March 9, 2012, and as 20 percent disabling thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8520 (2012). 5. The criteria for service connection for PTSD have been met. 38 U.S.C.A. §§ 1110, 1154(b), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012)). In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2012)). The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Dingess, supra; Pelegrini, supra. The Board finds that the notification requirements of VCAA have been satisfied in this case. In this regard, the Board notes a December 2007 evidentiary development letter, which was issued prior to the initial adjudication of his claims in July 2008, in which the RO advised the appellant of the evidence needed to substantiate his increased rating claims. The appellant was advised in this letter of his and VA's responsibilities under VCAA, to include what evidence should be provided by him and what evidence should be provided by VA. This letter also advised the Veteran as to the type of evidence needed to substantiate both the disability rating and effective date elements of his claims, pursuant to the Court's holding in Dingess, supra. The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case. 38 U.S.C.A. §§ 5103 and 5103A. Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issues on appeal has been obtained and associated with the claims folder. In particular, the Board notes that the RO obtained the Veteran's VA medical records and his identified private medical records. The RO arranged for the Veteran to undergo VA examinations in February 2008 and April 2012. The Board finds that the resulting examination reports are adequate for the purpose of determining entitlement to increased ratings. The examiners elicited from the Veteran his history of complaints and symptoms, and the examination reports provide pertinent clinical findings detailing the results of the examinations to allow for effective evaluation of the Veteran's disabilities. For these reasons, the Board concludes that the examination reports in this case provide an adequate basis for a decision. The evidence of record provides sufficient information to adequately evaluate the claims. Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Ratings The Veteran has claimed entitlement to increased ratings for peripheral neuropathy of the bilateral upper and lower extremities. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7. Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. However, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Peripheral Neuropathy of the Bilateral Upper Extremities The Veteran is currently in receipt for two separate 10 percent disability ratings for peripheral neuropathy of the left and right upper extremities. These ratings have been assigned for paralysis of the median nerve pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). Under Diagnostic Code 8515, for either the dominant (major) or non-dominant (minor) hand, mild incomplete paralysis of the median nerve warrants a 10 percent evaluation. Moderate incomplete paralysis of the median nerve warrants a 30 percent evaluation for the major hand and 20 percent for the minor. Severe incomplete paralysis of the median nerve warrants a 50 percent evaluation for the major hand and 40 percent for the minor. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the place of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, inability to make a fist, and the index and middle finger remain extended; inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at the right angle to the palm; weakened flexion of the wrist; and pain with trophic disturbances warrants a 70 percent evaluation for the major hand and a 60 percent evaluation for the minor hand. 38 C.F.R. § 4.124a. Neuritis, either cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated at a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123 (2012). The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Neuralgia, either cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See 38 C.F.R. § 4.124 (2012). The term 'incomplete paralysis' with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at 'Diseases of the Peripheral Nerves' in 38 C.F.R. § 4.124a (2012). Turning to the evidence of record, the Veteran underwent VA examinations of the peripheral nerves in February 2008 and April 2012. The February 2008 VA examination report reflects that the Veteran described experiencing numbness and stiffness in his hands, which are worse when he wakes up in the morning. He reports that his symptoms have progressively worsened. He responds fairly to the medication he takes for his symptoms. Muscle strength was normal and there was no motor impairment. On sensory function examination, the Veteran's left and right upper extremity were normal to vibration and position sense, while each had decreased pain sensation and decreased light touch in the peripheral nerves of the distal extremities. Reflexes were normal. Muscle atrophy was not present. There was no abnormal muscle tone or bulk. There were no tremors, tics, or other abnormal movements. Joint function was not affected. It was noted that nerve dysfunction and neuralgia were present, while paralysis and neuritis were absent. The examiner noted that the pain from these disabilities had significant effects on the Veteran's occupation. There was moderate interference with chores, shopping, exercise, sports, recreation, traveling, bathing, and dressing. There was mild interference with feeding, toileting, and grooming. The examiner noted that there appeared to be no interval change in the Veteran's clinical findings on neurological examination, despite the Veteran's report that his symptoms have worsened. (The May 2006 VA examination report diagnosed mild sensorimotor peripheral neuropathy in the lower and upper extremities.) The April 2012 VA examination report notes a diagnosis of upper extremity peripheral neuropathy. It reflects that the Veteran reported experiencing burning, cramping, and decreased hand strength in the upper extremities. He is very stiff in the mornings. The Veteran reported that he experiences moderate constant pain in the upper extremities. He experiences severe intermittent pain in the upper right extremity. He also reported moderate paresthesias and/or dysesthesias in the upper extremities, as well as moderate numbness. Muscle strength was normal in bilateral elbow flexion and extension and pinch. He had less than normal strength in bilateral wrist flexion and extension and grip. Reflexes were normal. Light touch was normal in the shoulder areas and the inner and outer forearms, but it was decreased in both hands and in fingers on both hands. Position sense was normal. Vibration sense was decreased in both upper extremities. The Veteran did not have muscle atrophy. Based on the above, the examiner determined that the Veteran has mild incomplete paralysis of the left and right median nerves. The radial and ulnar nerves were found to be normal. It was noted that the Veteran cannot work at a job in which his protective touch reflexes are needed since he has decreased pinprick sensation and vibration distally. The examiner noted that there has been some interval change since the February 2008 VA examination, as there is decreased upper extremity vibration and decreased distal upper muscle strength. Based on the above, the Board finds that a rating in excess of 10 percent is not warranted at any point during this appeal, as the evidence of record most closely approximates mild incomplete paralysis. The February 2008 VA examination report clearly reflects that the Veteran's left and right upper extremity peripheral neuropathy is characterized by incomplete paralysis and is wholly sensory. The term "sensory" is defined as "pertaining to or subserving sensation." Dorland's Illustrated Medical Dictionary 1681 (30th ed. 2003). The February 2008 VA examination report reflects complaints of numbness, decreased pain sensation, decreased light touch, and stiffness. The record does not indicate that the Veteran's reported stiffness is related to his peripheral neuropathy. However, there was no muscle weakness, muscle atrophy, motor impairment, abnormal muscle tone or bulk, tremors, tics, or other abnormal movements, while vibration, position sense, reflexes, and joint function were normal. These findings suggest mild, rather than moderate, impairment. Indeed, the 2008 VA examiner indicated there was no significant change from the 2006 VA examination at which time mild peripheral neuropathy ("clinically present") was essentially diagnosed. The Board also finds that subsequent evidence, most notably the April 2012 VA examination report, does not justify the assignment of a rating in excess of 10 percent. As compared to the February 2008 examination, the April 2012 report suggests that the Veteran experiences increased pain in his upper right extremity, as he has indicated that he intermittently experiences severe pain. He described his paresthesias, dysesthesias, and numbness as moderate. Strength in his wrist flexion, wrist extension, and grip was less than normal. Otherwise, the findings are comparable to those of the February 2008 examination report. The Board notes that, despite any increase in weakness and noted interval change, the examiner nevertheless felt that the overall severity of the Veteran's paralysis of the left and right median nerves was mild and incomplete. The competent and credible lay evidence is outweighed by competent and credible medical evidence that evaluates the true extent of the neurological impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the actual type and degree of impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The Board finds that this evidence does not reflect an increase in the severity of the Veteran's peripheral neuropathy of the left and right upper extremities to warrant a finding of moderate incomplete paralysis and justify a 20 percent rating. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against these claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to ratings in excess of 10 percent for peripheral neuropathy of the left and right upper extremities is denied. B. Peripheral Neuropathy of the Bilateral Lower Extremities The Veteran has claimed entitlement to increased ratings for peripheral neuropathy of the left and right lower extremities. These disabilities have been rated as paralysis of the sciatic nerve pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). Each lower extremity has been assigned a 10 percent rating prior to March 9, 2012, and a 20 percent rating on and after March 9, 2012. Diagnostic Code 8520 assigns a 10 percent rating for mild incomplete paralysis, a 20 percent rating for moderate symptomatology, a 40 percent rating for moderately severe symptomatology, and a 60 percent rating for severe symptomatology. An 80 percent rating is assigned for complete paralysis, which is characterized by foot dangle and drop, no active movement possible of muscles below the knee, and flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. As noted above, words such as 'severe,' 'moderate,' and 'mild' are not defined in the Rating Schedule. The term 'incomplete paralysis' with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at 'Diseases of the Peripheral Nerves' in 38 C.F.R. § 4.124a (2012). The February 2008 VA examination report notes that the Veteran was diagnosed with mild sensorimotor peripheral neuropathy in the lower extremities. It was noted that the Veteran complained of burning pain in his soles and cramps in his thighs and calves. For the past four to six months, he had been experiencing burning pain running from the back of his right thigh down to his foot. He noted weakness in his knees with episodes of his knees giving way, resulting in falls. He complained of numbness and stiffness in his legs, which was worse in the morning. He responded fairly to medication. On physical examination, the Veteran's muscles were at full strength and there was no functional impairment. Sensory function testing of both lower extremities revealed decreased vibration. There was decreased pain in the right distal extremity and increased pain in the left distal extremity. Light touch was decreased in the distal extremities bilaterally. Position sense was normal. Reflexes were normal. There was no muscle atrophy, abnormal muscle tone or bulk, or tremors, tics, or other abnormal movements. Joint function was not affected by nerve disorder, and gait and balance were normal. The examiner diagnosed lower extremity peripheral neuropathy. There was neuralgia, but there was no paralysis or neuritis. There were significant effects on the Veteran's occupation due to pain. There was moderate interference with chores, shopping, exercise, sports, recreation, traveling, bathing, and dressing. There was mild interference with feeding, toileting, and grooming. The examiner noted that there appeared to be no interval change in the Veteran's clinical findings on neurological examination, despite the Veteran's report that his symptoms have worsened. A March 2012 private nerve conduction study of the Veteran's lower extremities notes that there is electrodiagnostic evidence of a moderate generalized peripheral neuropathy. The April 2012 VA examination report diagnoses lower extremity peripheral neuropathy. It was noted that the Veteran complained of pain in the legs and burning pain and cramps on both legs, mostly in plantar feet. He complained of legs giving way and losing strength. He complained of morning stiffness. The Veteran reported constant moderate pain on the lower extremities. He reported severe paresthesias and/or dysesthesias and moderate numbness. On muscle testing, knee flexion and extension were full, while ankle plantar flexion and dorsiflexion were less than normal strength. Reflexes were normal. Light touch was normal in the bilateral knees, thighs, ankles, and lower legs, while it was decreased in the bilateral feet and toes. Position sense was normal. Vibration sensation was decreased. There was no muscle atrophy. The examiner opined that the Veteran had normal bilateral sciatic and femoral nerves. The March 2012 nerve conduction study was abnormal in the left and right lower extremities, with moderate generalized peripheral neuropathy. The examiner opined that the Veteran's peripheral neuropathy impacts his ability to work, as he needs to work at sedentary type jobs since his standing tolerance is diminished. The examiner noted that there has been some interval change in the Veteran's lower peripheral neuropathy in that there was been some deterioration in his peripheral neuropathy in the form of decreased distal lower extremity muscle strength. Based on the above, the Board finds that ratings in excess of 10 percent are not warranted prior to March 9, 2012, and that ratings in excess of 20 percent are not warranted on and after March 9, 2012. With respect to the first period, the Board finds that the Veteran's bilateral lower extremity peripheral neuropathy is characterized by incomplete paralysis and is wholly sensory. The February 2008 VA examination report reflects complaints of numbness, decreased pain sensation, weakness, decreased light touch, and stiffness. The record does not indicate that the Veteran's reported stiffness is related to his peripheral neuropathy, and there was no muscle weakness on examination. Furthermore, there was no muscle atrophy, motor impairment, abnormal muscle tone or bulk, or tremors, tics, or other abnormal movements, while vibration, reflexes, joint function, gait, and balance were normal. These findings suggest mild, rather than moderate, impairment. Indeed, the 2008 VA examiner indicated there was no significant change from the 2006 VA examination at which time mild peripheral neuropathy was diagnosed. The Board also finds that ratings in excess of 20 percent are not warranted from March 2012. The Board notes that the March 2012 private nerve conduction study on which this rating was based characterizes the Veteran's peripheral neuropathy as "moderate." These ratings contemplate the Veteran's complaints of pain, burning, cramps, paresthesias, dysesthesias, and numbness, as well as the decreased light touch in the Veteran's feet and toes and decreased vibration sensation. The normal reflexes; normal light touch in the knees, thighs, ankles, and lower legs; normal position sense; and absence of muscle atrophy support the Board's conclusion that the Veteran's peripheral neuropathy of the bilateral lower extremities is not moderately severe. The competent and credible lay evidence is outweighed by competent and credible medical evidence that evaluates the true extent of the neurological impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the actual type and degree of impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against these claims, the doctrine is not for application. Gilbert, supra. Accordingly, entitlement to increased ratings for peripheral neuropathy of the left and right lower extremities, each evaluated as 10 percent disabling prior to March 9, 2012, and as 20 percent disabling thereafter, must be denied. C. Extraschedular Evaluations and TDIU In reaching this conclusion, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disabilities at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities are inadequate. Second, if the schedular evaluations do not contemplate the Veteran's level of disability and symptomatology and are found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected peripheral neuropathy of the left and right upper and lower extremities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. Specifically, the Board finds that the rating criteria of Diagnostic Codes 8515 and 8520 for the Veteran's service-connected peripheral neuropathy adequately contemplate the impairment that is demonstrated in the evidence of record, as they consist of overall estimates of the level of severity of the disabilities at issue rather than of a limited set of criteria concerning specific symptomatology. The Veteran's complained of symptoms are not exceptional or unusual features of the disability. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Finally, the Board also recognizes that the Court of Appeals for Veterans Claims has clarified that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities exists as part of a claim for an increase (whether in an original claim or as part of a claim for increased rating). Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). While the Veteran has certainly contended that his peripheral neuropathy and PTSD disabilities interfere with his work, he has not specifically contended that these disabilities render him unemployable and the evidence does not otherwise suggest that this is the case. For these reasons, the Board finds that a claim for TDIU has neither been raised by the Veteran nor by the record. III. Service Connection The Veteran has also claimed entitlement to service connection for PTSD. Generally, service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2012). Generally, the evidence necessary to establish the occurrence of a stressor during service to support a claim of entitlement to service connection for PTSD will vary depending on whether a veteran "engaged in combat with the enemy." See Gaines v. West, 11 Vet. App. 353, 358 (1998); Hayes v. Brown, 5 Vet. App. 60, 66 (1993). Service department evidence that the veteran engaged in combat or that a veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2012). The Veteran's DD Form 214 reflects that he has combat service. The Veteran's claimed stressors are related to his combat service. Therefore, the occurrence of his described combat-related stressors is conceded and no further stressor verification attempts are required. As for whether the Veteran has PTSD that meets the DSM-IV criteria, the record contains favorable and unfavorable medical evidence. The Board must therefore weigh the credibility and probative value of these opinions. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The record contains examination reports from February 2008 and June 2011 VA examiners, both of whom determined that the Veteran did not meet the criteria for a diagnosis of PTSD and they provided rationales for their conclusions. The record also contains evidence of Axis I PTSD diagnoses based on the Veteran's combat service from the Veteran's treating VA mental health examiners, testimony from a psychiatrist at the February 2010 RO hearing in which he indicated that the Veteran had PTSD, and treatment records from the The Vet Center that showed the Veteran was seen for PTSD. Also, an October 2011 letter from a Vet Center clinical social worker concluded that the Veteran met the criteria for a diagnosis of PTSD based on his traumatic war experiences and current psychiatric manifestations. In light of the conflicting medical evidence, the Board remanded for a new comprehensive exam and specifically instructed that the examiner "consider and discuss the conflicting medical evidence of record, to include, but not limited to the evidence noted above." The resulting unfavorable April 2012 VA opinion does not discuss the conflicting medical evidence of record. Upon further review, the Board finds that at this juncture, in light of competent and credible medical evidence in favor of finding that the Veteran has PTSD and competent and credible medical evidence against finding that the Veteran has PTSD, reasonable doubt should be resolved in favor of the Veteran. Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990); 38 C.F.R. § 3.102 (2012). Accordingly, the Board finds that the Veteran is diagnosed with PTSD in accordance with the DSM-IV, that the claimed in-service stressors are related to his combat service, and that there is medical evidence linking his current PTSD symptomatology to his in-service stressors. Service connection for PTSD therefore is warranted. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to an increased evaluation for peripheral neuropathy of the left lower extremity, evaluated as 10 percent disabling prior to March 9, 2012, and as 20 percent disabling on and after March 9, 2012, is denied Entitlement to an increased evaluation for peripheral neuropathy of the right lower extremity, evaluated as 10 percent disabling prior to March 9, 2012, and as 20 percent disabling on and after March 9, 2012, is denied. Entitlement to service connection for PTSD is granted. ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs