Citation Nr: 1330643 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 09-11 763 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES Entitlement to an evaluation in excess of 20 percent for diabetes mellitus with peripheral neuropathy. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from February 1970 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office in Indianapolis, Indiana (RO). In pertinent part of that rating decision, the RO denied the benefit sought on appeal. In February 2013, the Board remanded the increased rating claim for diabetes mellitus to the RO (via the Appeals Management Center (AMC)) for additional development, to include obtaining outstanding records of private and VA treatment and providing the Veteran with a new VA examination to evaluated the severity of his diabetes mellitus and any secondary complications. The Board also instructed the RO/AMC to readjudicate the issue for an increased rating for diabetes mellitus, to include consideration of separate compensable evaluation for complications from diabetes mellitus. A review of the record shows that there has been compliance with the Board's remand directives, and no further action is required and the matter may now be adjudicated. See Stegall v. West, 11 Vet. App. 268 (1998). The Board is cognizant that a claim for increased evaluation includes a claim for a finding of TDIU where there are allegations of worsening disability and related unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). Although a freestanding claim for TDIU was previously denied in a May 2006 and in a May 2010 rating decisions and neither rating decision was appealed, the Veteran has again raised the issue in the context of his claims for increased evaluation in an October 2010 VA Form 21-527, Income Net Worth and Employment Statement. The Veteran stated that he was no longer able to work, in part, because of diabetes mellitus disability. The Board notes, however, that a 100 percent combined schedular rating has been granted, effective June 10, 2010. Although this rating does not preclude a simultaneous TDIU rating, the Veteran is already in receipt of special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s) effective from June 10, 2010. See, e.g., Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (a TDIU rating could serve as the "total" service-connected disability, if the TDIU entitlement was solely predicated upon a single disability for the purpose of considering entitlement to SMC as provided in § 1114(s)). The issue of TDIU is not before the Board. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file has been considered in conjunction with this decision. FINDINGS OF FACT 1. The Veteran's diabetes mellitus is manifested by insulin dependence and a restricted diet, but without required restriction of his activities. 2. The evidence shows that the Veteran has erectile dysfunction and peripheral neuropathy in the lower extremities manifested by no more than slight incomplete paralysis, and diabetic nephropathy associated with his diabetes mellitus, but the preponderance of the competent evidence is against a finding that any separate compensable evaluation is warranted. CONCLUSION OF LAW The schedular criteria for an initial disability rating higher than 20 percent for service-connected type II diabetes mellitus have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.119, Diagnostic Code 7913 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim. VA will inform the Veteran of the type of information and evidence that VA will seek to provide, and of the type of information and evidence, the claimant is expected to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to the claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). These VCAA notice requirements apply to all elements of a claim for service connection, so VA must specifically provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, VA sent letters to the Veteran in November 2007 that addressed the notice elements concerning his claim. The letter informed the Veteran of what evidence is required to substantiate the claim, and apprised the Veteran as to his and VA's respective duties for obtaining evidence. VA also informed the Veteran how it determines the disability rating and the effective date for the award of benefits if service connection is to be awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In addition to its duty to notify, or inform, the Veteran with regard to his claim, VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and records of pertinent medical treatment since service, and providing the Veteran a medical examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, VA has made reasonable efforts to obtain any available pertinent records as well as all relevant records adequately identified by the Veteran. During the period under appeal, VA has provided the Veteran with examinations in December 2007, October 2009, March 2010, July 2012, and April 2013 to determine the severity of his diabetes mellitus and/or associated disabilities. The examinations are fully adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. See Bernard v. Brown, 4 Vet. App. 384 (1993). For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify and its duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103; 38 C.F.R. §§ 3.159(b), 20.1102; Pelegrini, supra; Quartuccio v. Principi, 16 Vet. App. 183 (2002). 2. Increased Rating The Veteran seeks a higher evaluation for his disability due to diabetes mellitus. His disability is currently rated as 20 percent disabling. Disability evaluations are determined by the application of the facts presented to a schedule of ratings that is based on the average impairment of earning capacity caused by a given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. When evaluating the severity of a disability, VA will consider the entire history of the disability including records of social impairment. See 38 C.F.R. § 4.126(a); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetes mellitus is rated under 38 C.F.R. § 4.119, Diagnostic Code 7913. A rating of 20 percent is assigned for diabetes mellitus requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted for diabetes mellitus is warranted when the condition requires insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus that requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requires more than one daily insulin injection, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength, or complications that would be compensable if separately evaluated. Id. It is noted that complications of diabetes mellitus separately are to be evaluated separately, unless they are used to support a 100 percent rating. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Any reasonable doubt will be resolved in favor of granting the veteran's claim. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. § 3.102. In this case, the Veteran seeks an evaluation in excess of 20 percent for his diabetes mellitus. He asserts that his disability is more severe than the criteria associated with the currently assigned evaluation. The Veteran has not been awarded separate evaluations for any disability associated with his diabetes mellitus. The Veteran filed his increased rating claim for diabetes mellitus in August 2007. In the year prior to his claim, the Veteran was hospitalized twice in October 2006 to treat episodes of hypertriglycemia and associated pancreatitis, which stabilized after treatment with regulated diet and medication, including insulin. See VA and private treatment records dated in October 2006, which show he was hospitalized from October 2, 2006 to October 8, 2006 and from October 12, 2006 to October 16, 2006. The Veteran was hospitalized again in May 2007 for hyperglycemia and treated with insulin. See VA and private treatment records dated in May 2007. A review of the record shows that during the period under appeal VA has examined the Veteran regarding his diabetes mellitus on five separate occasions. The record also contains copies of his VA and private treatment records. The Veteran underwent his first VA examination in conjunction with his claim in December 2007. The VA examination report shows that the Veteran's treatment involved insulin and a restricted diet. There was no medical history of ketoacidosis and hypoglycemia, but the Veteran was hospitalized in 2007 because of his diabetes mellitus disability. The Veteran also reported having hypertension and he complained of erectile dysfunction. The Veteran reported that he walks every day and that he sees his diabetic provider once every three months. Laboratory results revealed evaluated fasting blood sugar and his urinalysis reflected traces of protein. It was felt that the Veteran's diabetes mellitus was poorly controlled. The examiner opined that it was at least as likely as not that the Veteran's peripheral neuropathy and erectile dysfunction were related to his diabetes mellitus based on a review of the medical literature. There are also reports of contemporary VA neurologic and hypertension examinations. The VA neurologic examination report shows subjective complaints of burning sensation in his feet and objective findings of increased sensation in his right foot, but no evidence of paralysis or neuritis. The examiner stated that it was impossible to tell specifically what nerve was involved. The examiner concluded that the Veteran's peripheral neuropathy was at least as likely as not related to his diabetes mellitus. The VA hypertension examination report shows the Veteran reported a history of hypertension since 1995, for which he takes medication. The VA examiner opined that the Veteran's hypertension was less likely than not related to his diabetes mellitus as his creatinine was normal (1 mg/dL) and he has hyperlipidemia. Subsequent VA and private treatment records to show that the Veteran sought treatment for his diabetes mellitus. A January 2008 VA treatment record notes show that the Veteran complained of bilateral paratheasisa in his lower extremities. It was noted that the Veteran still experienced hyperglycemia and his medication was increased. He continued to follow a restricted diet. By May 2008, it was felt that the Veteran's diabetes mellitus was well controlled. VA treatment records dated in March 2009 and August 2009 shows that the Veteran's treating VA medical provider informed him that he did not have any restriction of activities due to his insulin-dependence. In October 2009, the Veteran underwent another VA diabetes mellitus examination in order to evaluate the severity of his disability. The examination report shows that the Veteran has been diagnosed with diabetes mellitus since 1995 and he treats his condition with oral medication and insulin as well as a restricted diet. He did not require restriction of strenuous activities. The Veteran denied any episodes of ketoacidosis or hypoglycemia reactions. He was treated for elevated blood sugar and associated pancreatitis in 2006. He also reported having problems with erectile dysfunction since the 1970's. Clinical examination revealed normal neurologic evaluation in the lower extremities and the VA examiner opined that the bilateral carpal tunnel syndrome was not associated with the Veteran's diabetes mellitus. The VA examiner concluded that the Veteran's hypertension was a complication of his diabetes mellitus based on the onset of his hypertension in 2006 in relation to the onset of his diabetes mellitus in 1995. The examiner noted that there was no evidence of vision impairment, kidney disease, or other diabetic conditions. In March 2010, the Veteran was afforded a VA general medical examination in conjunction with his claim for TDIU. The examination report shows that the Veteran reported that he had peripheral neuropathy in his upper and lower extremities since 2009. He complained of constant ache in his legs and he had a history of carpal tunnel syndrome surgery. He takes Gabapetin, which he feels helps with the numbness in his hands. The Veteran also having experienced erectile dysfunction since the early 1970's, which he asserts has gradual worsened over the years. Clinical evaluation no genitourinary or neurologic abnormalities. A March 2011 correspondence from Dr. C. A. G to the Veteran's employer shows that the Veteran required work restrictions, where his "permitted activity is walking or standing only occasionally, occasional lifting of 10 pounds maximum and/or carrying articles like small tools." Although Dr. G. did not specifically identify the Veteran's diabetes mellitus as requiring these restricted work activities, he did not that the Veteran was an insulin dependent, type II diabetic and he requires frequent breaks for management of his insulin. The Veteran underwent another VA examination in conjunction with his claim in July 2012. In that examination report, the examiner noted that the Veteran's diabetes mellitus was managed by restricted diet and treated with oral hypoglycemic agent and insulin. The examiner noted that there was no indication that the Veteran's diabetes mellitus resulted in regulation of his activities as part of his medical management of his condition. He visited his diabetic care provider less than two times per month and there was no history of hospitalization due to his diabetes mellitus in the past year. The Veteran denied any urinary problems associated with his diabetes mellitus. The VA examiner noted that a review of the medical evidence showed that the Veteran had diagnoses of diabetic peripheral neuropathy, erectile dysfunction, coronary artery disease (CAD), and hypertension, which were known complications of diabetes mellitus. The examiner opined that the Veteran's erectile dysfunction was likely caused by his diabetes mellitus as his prostrate hypertrophy was well under control by medication. Subsequent VA treatment records continue to show that the Veteran sought treatment for his diabetes mellitus. A December 2012 VA treatment records show that the Veteran's diabetes mellitus required insulin and his treating medical provider encouraged the Veteran to diet and to engage in regular exercise. In April 2013, the Veteran underwent his most recent VA examination to evaluate the severity of his diabetes mellitus and any associated complications. In that examination report, the examiner noted that the Veteran treated his diabetes mellitus with oral agents and insulin injections. It was also noted that the Veteran reported he followed a restricted diet and he saw his diabetic care provider less than two times a month. He denied requiring hospitalization in the past year because of his diabetes mellitus disability. There was no evidence of retinopathy on examination. The VA examiner noted that a review of the medical evidence showed that the Veteran had diagnoses of diabetic peripheral neuropathy, diabetic nephropathy, erectile dysfunction, coronary artery disease (CAD), and hypertension, which were known complications of diabetes mellitus. However, based on further review of the claims folder and the findings from clinical evaluation, the VA examiner opined that it was less likely than not that the Veteran's hypertension and erectile dysfunction were associated with his diabetes mellitus. The examiner noted that the Veteran's hypertension had existed well before any changes have been noted in his kidney function tests and his blood pressure has been well controlled with medications. The examiner also noted that the Veteran's erectile dysfunction existed well before he developed diabetes mellitus. The April 2013 VA examiner also concluded that clinical examination did not show findings of symptomatic peripheral neuropathy in the lower extremities. During the clinical examination, the Veteran denied symptoms of pain, paresthesia, and numbness in his lower extremities. Neurologic evaluation revealed normal reflexes, muscle strength, position sensation and vibration. It was noted that bilateral carpal tunnel symptoms, but the examiner felt that this was not associated with his diabetes mellitus as the symptoms resulted from compression of the medial nerve at the wrist and not demyelinization of the tendon sheath. Moreover, the examiner observed that there was no evidence numbness, loss of vibration or sensation in the stoking or glove distribution in any of the Veteran's extremities that would be expected as the result of diabetic peripheral neuropathy. The examiner concluded that the Veteran was asymptomatic in his lower extremities. With regard to diabetic nephropathy, the April 2013 VA examination report shows that the Veteran's renal dysfunction is manifested by recurring albuminuria, but his hypertension was not associated with his kidney dysfunction. He has history of calculi over ten years ago and he had no history of urinary or kidney infection. Laboratory studies revealed BUN of 18 mg/dL, creatinine of 1.1 mg/dL and positive finding for proteinurina. It was also noted that a March 2013 VA laboratory results for spot test were positive for microalbumin in the urine. Based on a review of the foregoing, the Board finds that disability due to the Veteran's diabetes mellitus does not support the criteria for an evaluation in excess of 20 percent under Diagnostic Code 7913 for the entire period under appeal. 38 C.F.R. § 4.119, Diagnostic Code 7913. Throughout the entire period under appeal, the medical evidence of record clearly shows that the Veteran's diabetes mellitus requires insulin and restricted diet. Such symptomatology does not support an evaluation in excess of 20 percent. The Board acknowledges the March 2011 private medical statement indicates that the Veteran required regulation of his activities at work because of his diabetes mellitus. However, Dr. G. did not specifically state that the work activity restrictions were because of diabetes mellitus disability. He only noted that the Veteran needed to take breaks for management of his insulin. Moreover, none the VA treatment records subsequent to the March 2011 statement show that the Veteran's diabetes mellitus required restriction of his activities. Rather, the July 2012 and April 2013 VA examination reports show that the Veteran denied that his activities were restricted because of his diabetes mellitus disability. There is no medical finding for the "avoidance of strenuous occupational and recreational activities" because of symptomatology related to his diabetes mellitus at any point during the period under appeal. See 38 C.F.R. § 4.119, Diagnostic Code 7913; see also Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007). Although the Veteran had at least one hospitalization for hyperglycemia in May 2007, prior to the date of his claim, his symptomatology stabilized with the induction and regulation of his insulin in-take. See VA treatment records dated in 2007 and 2008. The Veteran has denied any episodes of ketoacidosis or hypoglycemia, and he has not required any subsequent hospitalization for his diabetes mellitus disability. Further, none of the VA or private treatment records reflects that the Veteran was hospitalized because of episodes of ketoacidosis or hypoglycemic reactions. Accordingly, there is no evidence that shows the Veteran's diabetes mellitus disability has resulted in episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. Therefore, the Board concludes that the Veteran's disability due to diabetes mellitus satisfies the criteria for a 40 percent evaluation, and not the next higher evaluation. See 38 C.F.R. § 4.119, Diagnostic Code 7913. The Board has considered the Veteran's statements regarding his restricted activities due to his diabetes mellitus contained in his February 2006 Substantive Appeal. As a layperson, the Veteran does not possess the training and expertise to competently render a probative opinion on whether his diabetes requires regulation of activities as contemplated by the regulations, something the Court has determined to be a medical matter. See Bostain v. West, 11 Vet. App. 124, 127 (1998). None of the VA treatment records or subsequent VA examination reports show that the Veteran's diabetes mellitus disability has required a regulation of his activities or has resulted in episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider that would warrant a higher rating. See 38 C.F.R. § 4.119, Diagnostic Code 7913. An evaluation in excess of 20 percent for diabetes mellitus is not warranted. Id. Next, the Board will consider whether the evidence shows that the Veteran any other conditions as complications of his diabetes mellitus disability that warrant a separate compensable rating under the purview of Note 1. See 38 C.F.R. § 4.119. The Board notes that the Veteran has raised a claim of clear and unmistakable error (CUE) to the RO's February 2008 denial of a separate compensable evaluation for peripheral neuropathy in the lower extremities, which was upheld in an unappealed September 2010 rating decision. The Board acknowledges that the Veteran did not appeal the September 2010 decision; however, given the nature of the Veteran's increased rating claim for diabetes mellitus disability and any complications there form, the Board finds that question of whether a separate compensable rating is warranted for peripheral neuropathy in the lower extremities is part and parcel to the diabetes mellitus disability claim on appeal. Here, a separate compensable rating is not warranted for peripheral neuropathy in the lower extremities. The Board acknowledges the Veteran's previous subjective complaints of pain, burning sensation, and numbness in his lower extremities throughout the period under appeal prior to his April 2013 VA examination, when he denied any such symptomatology. Regardless, the evidence of record does not show that peripheral neuropathy in the lower extremities warrants a compensable evaluation at any point during the period under appeal. See 38 C.F.R. § 4.124a Diagnostic Code 8520 (compensable evaluation requires mild symptomatology). The December 2007 VA examination report shows evidence of increased sensation in his right foot, and not decreased sensation, and the examiner found no evidence of paralysis or neuritis on clinical examination. Neurologic evaluation was normal in October 2009 and in March 2010. Moreover, the April 2013 VA examination report shows that the Veteran's lower extremities were asymptomatic. The evidence of record does not support the criteria for a separate compensable evaluation. See 38 C.F.R. § 4.124a Diagnostic Code 8520. Also, the evidence of record shows that the Veteran's bilateral carpal tunnel syndrome is not associated with his diabetes mellitus. See October 2009 and April 2013 VA examination reports. The Board notes that record contains conflicting medical opinions on whether Veteran's erectile dysfunction is a complication of his diabetes mellitus disability. See July 2012 VA examination report in comparison with April 2013 VA examination report. In any event, even if attributable to diabetes mellitus, a separate evaluation is only appropriate where the disability is compensable in degree. In this case, there is no showing of penile deformity such as to warrant a compensable rating. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. Also, the Veteran has already been awarded special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s), which already includes consideration of his diabetes mellitus disability. As such, a separate award of SMC, rate-K, for loss of creative organs, would be inappropriate and constitute as pyramiding since the Veteran has already awarded SMC based in part on his diabetes mellitus disability. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In addition, the evidence of record shows that the Veteran has diabetic nephropathy as a complication of his diabetes mellitus. See April 2013 VA examination report. Under Diagnostic Code 7541, renal involvement in diabetes mellitus will be rated as renal dysfunction. See 38 C.F.R. § 4.115b. Under 38 C.F.R. § 4.115a, renal dysfunction will be awarded a noncompensable (zero percent) disability rating where the Veteran has albumin and cases with a history of acute nephritis; or, hypertension noncompensable under diagnostic code 7101. A 30 percent rating is warranted where the Veteran has albumin constant 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 rating is warranted where the Veteran has 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 rating is warranted where the Veteran has persistent edema and albuminuria with BUN 40 to 80 mg% or, creatinine 4 to 8mg%, or; generalized poor health characterized by lethargy, weakness, anorexia weight loss, or limitation of exertion. A 100 percent rating is warranted where the Veteran required regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80 mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Under Diagnostic Code 7101 for hypertension, a compensable evaluation is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Higher evaluations are warranted for increased symptomatology. 38 C.F.R. § 4.104, Code 7101. As noted above, the April 2013 VA examination report shows that the Veteran suffers from diabetic nephropathy manifested by recurring proteinuria but without evidence of casts or a history of nephritis, or hyaline and granular casts or red blood cells. Nor is there evidence of constant albuminuria with some edema, or definite decrease in kidney function. In addition, the evidence does not show that the Veteran has persistent edema and albuminuria with BUN 40 to 80 mg% or creatinine 4 to 8 mg%, and the Veteran has denied experiencing lethargy, weakness, anorexia, weight loss, or limitation of exertion. Although the evidence shows the Veteran has been diagnosed with hypertension, the weight of the competent evidence is against the Veteran's assertion that his hypertension is associated with diabetes mellitus disability and associated kidney disability. Both the December 2007 and April 2013 VA examiners opined that the Veteran's hypertension was less likely than not associated with his diabetes mellitus, and the April 2013 VA examiner specifically concluded that the Veteran's hypertension was separate from his kidney disability. The Board acknowledges the October 2009 VA examiner's opinion that the Veteran's hypertension was a complication of his diabetes mellitus based on the onset of his hypertension in 2006 in relation to the onset of his diabetes mellitus in 1995. However, this medical opinion appears to solely based on the Veteran's reported history at the time of that examination, which completely contradicts his previous and subsequent reports that reflect the onset of his hypertension was in 1995 prior to his diagnosis of diabetes mellitus in 2006. Accordingly, the Board finds that the Veteran's statements regarding his medical history regarding the onset of his conditions are not credible, the Board, in turn, finds that the October 2009 VA examiners' opinion is not credible or persuasive and is entitled to no probative value as it is based on the Veteran's reported history. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Veteran's assertions as that his hypertension is a complication of his diabetes mellitus and kidney disorder are afforded little probative weight in the absence of evidence that the Veteran has medical training that can provide the expertise to render opinions about medical matters. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Where the determinative issue involves a medical opinion, there must be competent medical evidence to the effect that the claim is plausible. Notably, the Veteran's lay assertions of medical etiology do not constitute competent medical evidence. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) . Rather, the Board finds medical conclusion by the December 2007 and April 2013 VA examiners are highly probative on this question. Based on the foregoing, the Board finds that the criteria for a separate compensable disability rating is also not warranted for diabetic nephropathy. See 38 C.F.R. § 4.115(a) and (b), Diagnostic Code 7541. In this regard, compensable disability rating is not warranted because, as noted, there is no lay or medical evidence of constant or recurring albumin with hyaline and granular casts or red blood cells, constant albuminuria with some edema, or definite decrease in kidney function. Nor is there evidence that the Veteran experiences persistent edema and albuminuria with BUN between 40 and 80 mg, creatinine between 4 to 8 mg, or generalized poor health. The evidence is also against a finding that the Veteran's hypertension is associated with his diabetes mellitus and secondary kidney disability. The evidence fails to establish any additional complications for which separate compensable rating are warranted. A separate compensable rating is not warranted for any bladder or bowel impairment. While the examination reports show the Veteran complained of bowel and bladder problems, there is no objective evidence of such impairments or problems found on examination. Accordingly, no diagnoses of such impairments or problems were rendered and associated with his diabetes mellitus at any point during the period under appeal. See 38 C.F.R. §§ 4.114, 4.115a. In summary, and based on the foregoing, the Board finds that the preponderance of the evidence is against the assignment of an evaluation in excess of 20 percent for service-connected diabetes mellitus. See 38 C.F.R. § 4.114, Diagnostic Code 7913. The preponderance of the evidence is against the award of separate compensable disability ratings. 38 C.F.R. § 4.114, Diagnostic Code 7913, Note (1). In making this determination, all reasonable doubt has been resolved in favor of the Veteran. See Gilbert, supra. Other Considerations The Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. § 3.321(b)(1) is warranted for the Veteran's diabetes mellitus disability at any time during the current appeal. That provision provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, a veteran may be awarded a rating higher than that encompassed by the schedular criteria, as shown by evidence reflecting that the disability at issue causes marked interference with employment or has in the past or continues to require frequent periods of hospitalization, thereby rendering impractical the use of the regular schedular standards. Id. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disorder are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describes the Veteran's disability level and symptomatology associated with diabetes mellitus, and it is observed higher evaluations are available for more severe symptoms than currently shown by the evidence. Thus, the Veteran's diabetes mellitus disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, the Board concludes that referral for extraschedular consideration for the service-connected disability on appeal is not warranted. ORDER Entitlement to an evaluation in excess of 20 percent for diabetes mellitus is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs