Citation Nr: 1337328 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 07-30 814 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Fargo, North Dakota THE ISSUES 1. Entitlement to an increased rating for peripheral neuropathy of the right upper extremity. 2. Entitlement to an increased rating for peripheral neuropathy of the left upper extremity. 3. Entitlement to a higher initial rating for diabetic nephropathy. 4. Entitlement to service connection for a heart murmur, to include as secondary to a service-connected disorder. REPRESENTATION Appellant (Veteran) represented by: The American Legion ATTORNEY FOR THE BOARD Christopher McEntee, Counsel INTRODUCTION The Veteran had active military service from July 1971 to May 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2006 and February 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Fargo, North Dakota. In June 2011, the Board remanded this matter for additional development and medical inquiry. The claims are again before the Board and will be decided below. The Board has reviewed the Veteran's entire claims file, to include documents of record in his virtual VA folder. No relevant evidence has been included in the claims file since the most recent supplemental statement of the case (SSOC) dated in October 2012. 38 C.F.R. §§ 19.31, 20.1304(c) (2013). The record raises several issues that have not been adjudicated by the Agency of Original Jurisdiction (AOJ). First, the record indicates that service connection for a muscular disability may be warranted for symptoms associated with service-connected peripheral neuropathy of the upper extremities. Second, the record indicates that the Veteran is interested in increased ratings for the service-connected peripheral neuropathy of the lower extremities. Third, the record indicates that the Veteran is interested in a separate service connection finding for disability related to the ulnar nerve, in addition to the median nerve disability which forms the basis for evaluating the Veteran's service-connected peripheral neuropathy of the upper extremities. Fourth, in a September 2013 statement of record from the Veteran's representative, claims for earlier effective dates for heart, hand, and hypertension disorders are raised. The Board does not have jurisdiction over these issues because they have not been adjudicated by the AOJ. The issues are therefore referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The evidence of record does not preponderate against the Veteran's assertion that, since June 7, 2005, the peripheral neuropathy in his right upper extremity has caused severe incomplete paralysis. 2. The evidence of record does not preponderate against the Veteran's assertion that, since June 7, 2005, the peripheral neuropathy in his left upper extremity has caused severe incomplete paralysis. 3. The preponderance of the evidence of record demonstrates that the Veteran has not experienced during the appeal period complete paralysis in his upper extremities. 4. From June 7, 2006 to July 9, 2008, the evidence of record did not indicate that the Veteran's nephropathy caused renal dysfunction with evidence of persistent edema and albuminuria with BUN [blood urea nitrogen] 40 to 80mg%, creatinine of 4 to 8mg%, or generalized poor health. 5. Heart murmur, in and of itself, is a symptom and not a disease entity for purposes of VA compensation benefits. CONCLUSIONS OF LAW 1. From June 7, 2005 to July 14, 2008, the criteria for a 50 percent rating, for the Veteran's service-connected peripheral neuropathy in the right upper extremity, had been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). 2. The criteria for a rating in excess of 50 percent, for the Veteran's service-connected peripheral neuropathy in the right upper extremity, have not been met since July 14, 2008. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). 3. From June 7, 2005 to July 14, 2008, the criteria for a 40 percent rating, for the Veteran's service-connected peripheral neuropathy in the left upper extremity, had been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). 4. The criteria for a rating in excess of 40 percent, for the Veteran's service-connected peripheral neuropathy in the left upper extremity, have not been met since July 14, 2008. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). 5. From June 7, 2006 to July 9, 2008, the criteria for a rating in excess of 60 percent, for the Veteran's service-connected nephropathy with hypertension, had not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.115, 4.115a, 4.115b, Diagnostic Code 7541 (2013). 6. The criteria for service connection for heart murmur have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA applies to these claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In this matter, the RO provided the Veteran with notification letters in July 2006 and December 2007 which notified the Veteran regarding what information and evidence is needed to substantiate claims for service connection and increased rating, how disability ratings and effective dates are determined, and what information and evidence must be submitted by the Veteran and what evidence VA would obtain. Further, full notification was provided prior to the rating decisions on appeal. The Board also finds the Veteran has been afforded adequate assistance in response to his claims. The Veteran's service treatment records (STRs) are on file, as are private and VA medical treatment records pertaining to his disorders. Records from the Social Security Administration (SSA) have been included in the claims file. Moreover, the Veteran has been provided with VA examinations into his claims during the appeal period. He underwent VA compensation examination in July 2006, November 2007, November 2008, May 2009, and September 2012. The reports of record address his disorders adequately. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claims. The Board is also unaware of any such evidence. Accordingly, the Board will address the claims for increased rating in this matter. II. The Claims for Higher Ratings The Veteran seeks higher disability ratings for his service-connected upper extremity peripheral neuropathy, and his service-connected nephropathy with hypertension. Each of these disorders has been service connected based on the Veteran's service-connected diabetes mellitus type 2 (diabetes). 38 C.F.R. § 3.310. In March 2004, the Veteran claimed service connection for peripheral neuropathy, which the RO granted in an unappealed May 2004 rating decision. The disorder in the right upper extremity was rated 30 percent disabling effective March 1, 2004, while the disorder in the left upper extremity was rated as 10 percent disabling effective March 1, 2004. On June 7, 2006, the RO received the Veteran's claim for increased rating for right and left upper extremity peripheral neuropathy. In the September 2006 rating decision on appeal, the RO continued the 30 percent rating for the right upper extremity, and increased to 20 percent, effective June 7, 2006, the rating for the left upper extremity. During the pendency of the appeal, in a November 2008 rating decision, the Veteran was assigned 50 percent rating for the peripheral neuropathy of the right upper extremity and a 40 percent rating for peripheral neuropathy of the left upper extremity, both effective July 14, 2008. The Veteran continues to seek higher disability ratings during the appeal period. AB v. Brown, 6 Vet. App. 35, 38 (1993). As such, the Board will consider whether higher ratings have been warranted from June 7, 2005 (one year prior to the date of the Veteran's claim for increased rating) at any time during the appeal period. Hart v. Mansfield, 21 Vet. App. 505 (2007); 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. On June 7, 2006, the Veteran also filed an original claim to service connection for diabetic nephropathy, which the RO granted in the September 2006 rating decision on appeal. The RO assigned a noncompensable rating effective December 8, 1998, and a 30 percent rating effective March 25, 2003. During the pendency of the appeal, by a November 2008 rating decision, the Veteran was granted a 60 percent rating, effective July 9, 2008. Then, in an October 2012 rating decision, an evaluation of 60 percent was assigned effective March 25, 2003, and an evaluation of 100 percent was assigned effective July 9, 2008. See AB, supra. For this claim, the Board will consider whether a higher initial rating has been warranted from the date of claim for service connection on June 7, 2006. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In contrast to the RO's decision to rate the Veteran's disorder effective December 8, 1998 - over 7 years prior to his June 2006 original claim for service connection - the Board is limited to rating the Veteran's disorder from the date of his claim. Controlling authority forbids the assignment of an effective date prior to June 7, 2006. Under 38 U.S.C.A. § 5110, it is provide that the effective date of an award based on an original claim shall not be earlier than the date of receipt of the application for service connection. Further, under 38 C.F.R. § 3.400, it is provided that the effective date of an evaluation and award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is the later. Hence, an assessment of the appropriate initial rating for nephropathy should address evidence of record dated from June 7, 2006 to the present. Ratings for service-connected disabilities are determined by comparing the symptoms the Veteran is presently experiencing with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based as far as practical on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. A claimant's specific occupation is not for consideration under the Rating Schedule. Separate diagnostic codes identify the various disabilities. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower evaluation will be assigned. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. In Alemany v. Brown, 9 Vet. App. 518 (1996), the United States Court of Appeals for Veterans Claims (Court) found that in light of the benefit of the doubt provisions of 38 U.S.C.A. § 5107(b), an accurate determination of etiology is not a condition precedent to granting service connection; nor is "definite etiology" or "obvious etiology." The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive 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). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). The Board will address the Veteran's claims separately below. Upper Extremity Peripheral Neuropathy The Veteran's upper extremity peripheral neuropathy has been rated under Diagnostic Code (DC) 8515 of 38 C.F.R. § 4.124a. Under DC 8515, paralysis of the median nerve is rated. For mild incomplete paralysis a 10 percent rating is warranted in either the major or minor extremity. For moderate incomplete paralysis in the minor extremity, a 20 percent rating is warranted, while a 30 percent rating is warranted for moderate incomplete paralysis in the major extremity. For severe incomplete paralysis of the minor extremity a 40 percent rating is warranted while a 50 percent rating is warranted for severe incomplete paralysis of the major extremity. The right arm is the Veteran's major upper extremity. 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. See Note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. Id. Complete paralysis will be evaluated as 70 percent for the major limb, and 60 percent for the minor limb, for such symptoms as the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. The Veteran's upper extremity peripheral neuropathy has been subject to several staged ratings during the appeal period (i.e., since June 2005). In assessing whether higher ratings are due here, the Board has reviewed private and VA treatment records dated between 2005 and 2012, SSA records included in the claims file pursuant to the Board's June 2011 remand, VA examination reports dated in July 2006, November 2007, and November 2008, and lay statements from the Veteran, from his spouse, and from his former employer. This evidence does not preponderate against the Veteran's claim that he has experienced severe incomplete paralysis in each upper extremity during the appeal period. In assessing the claims, the Board will separately address the evidence of record dated from June 7, 2005 to July 14, 2008, on which date the Veteran was awarded 50 and 40 percent ratings for severe incomplete paralysis. The Board will then address evidence dated during the entire appeal period from June 7, 2005 in determining whether a rating for complete paralysis has been warranted here. A. June 7, 2005 to July 14, 2008 Between June 7, 2005 and July 14, 2008, the Veteran's peripheral neuropathy was rated as either mild or moderate (i.e., 10, 20, or 30 percent ratings). 38 C.F.R. § 4.124(a), DC 8515. Regarding the relevant evidence during this period, the Board initially notes that it has considered the findings of an April 2004 VA examination. Though this exam is dated prior to the beginning of the appeal period, the Board nevertheless regards its findings as valuable in assessing the state of the Veteran's peripheral neuropathy in June 2005. This is due to the fact that, first, the private and VA treatment records dated around June 2005 are mainly silent regarding the nature of the upper extremity peripheral neuropathy and, second, the July 2006 VA report, which is dated during the appeal period, refers to relevant findings in the April 2004 VA report. In the April 2004 VA report, the examiner noted a numbness and loss of strength in both hands. He noted the Veteran's report that "he can sometimes cut or otherwise injure his fingers ... and not feel or notice anything." He noted the Veteran's inability to clip his fingernails due to hand weakness, and that writing had become difficult, and that he often dropped things. On examination, the examiner noted a "loss of sensation" with the "ulnar and median nerve distribution" of both hands. The examiner noted evidence of muscle atrophy bilaterally, and weakness on range of motion testing. Moreover, in addressing peripheral neuropathy of the upper extremities, the examiner noted "early dupuytrens contractures" on the hands. Findings indicating serious symptoms were reinforced by a VA treatment record dated in March 2006, which noted that the Veteran "clearly has progressive large fiber neuropathy in his hands." The July 2006 VA examiner noted the Veteran's complaints that his arm and hand weakness disable him from writing and playing golf. The examiner noted the Veteran's complaints of weakness, numbness, and aching symptoms. On examination, the examiner noted no wounds, edema, or ulcerations, noted intact sharp light touch sensation, intact vibratory sensation, and noted no palpable tenderness. The examiner noted ability to perform the "finger-thumb loop opposing the left and the right thumbs with ipsilateral second through fifth distal phalanx." He noted the Veteran's bilateral ability to pick up a dime, paper clip, and a 5 mm button. He noted no evidence of pain, excess fatigability, incoordination, or additional loss of function following exercises conducted pursuant to the examination. Moreover, the examiner noted that the Veteran was able to form a fist with each hand. However, the examiner noted "classical puckering of the skin overlaying the palmar surface" on the left hand, indicating "early Dupuytren's contracture." Moreover, the examiner noted subdued bilateral grip strength in each hand and, bilaterally, "obvious muscle wasting of the thenar and hypothenar eminences ... with early interosseous muscle atrophy dorsally[.]" The November 2007 VA examiner reviewed the history noted above, and reported the Veteran's complaints of progressive worsening, with continual sensitivity and aching, of "very weak" hand grasp strength, of "increasingly difficult" fine manipulation of objects, of recurring daily dropping of objects, of deformed muscle mass in the hands, and of an inhibited ability to write or type. On examination, the examiner entered findings similar to the July 2006 VA examiner, noting intact sharp light touch sensation, intact vibratory sensation, no palpable tenderness, and no discoloration. The examiner noted ability to perform the finger-thumb loop opposing the left and the right thumb with ipsilateral second through fifth distal phalanx. He noted the Veteran's bilateral ability to pick up a dime, paper clip, and a 5 mm button. He noted no costovertebral angle tenderness. He noted no evidence of pain, excess fatigability, incoordination, or additional loss of function following exercises conducted pursuant to the examination. The examiner noted intact capillary refill, and that all fingers move on command. However, the examiner also noted that position sense was not intact to any of the fingertips. He noted weak grip strength on each hand, and an ability to only form "a loose fist" on each hand. He noted "obvious muscle wasting" on both hands, "classical puckering" from the Dupuytren's contracture, edema, and ulnar deviation. A VA treatment record dated in July 2008 notes "mild to moderate neuropathic pain in his hands" while VA treatment records dated in December 2007, April 2008, June 2008, and July 2008 note treating physicians' observations of increasing disability, "marked" hand weakness and "marked" muscle atrophy, "extensive muscle wasting particularly in the hands," "severe" neuropathy, and inability to perform daily tasks due to muscle wasting. Finally, in assessing whether higher ratings were due between June 7, 2005 and July 14, 2008, the Board has reviewed the lay evidence of record from the Veteran, his spouse, and his employer. The Board finds little probative value in a July 2008 letter of record from an employer, who indicates that the Veteran has experienced difficulty at work related to his service-connected diabetes. The employer did not provide specific information regarding limitations associated with the Veteran's upper extremities. The Board does find probative value in statements of record from the Veteran, and from his spouse. The Veteran clearly communicates that he has experienced severe disability due to his upper extremity peripheral neuropathy. In his June 2006 claim for increased rating, and in July 2008 documents associated with a claim for SSA benefits, he described hand pain following use of his hand, "losing strength" in his hands and dropping objects "due to neurological reasons." In July 2006, the Veteran's spouse described the Veteran's "losing strength in both of his hands" and the "reduced muscle mass" in the hands which "makes it difficult for him to perform simple tasks around the house and even to cut his fingernails." She also noted the Veteran's complaints of pain after using his hands, and that he "drops objects such as keys, plates, papers, etc. without a reason." As laypersons are competent to attest to manifest disability with the hands, which can be observed by the person experiencing the disability and by a person looking at the functional problems associated with the disability, the lay descriptions of the Veteran's hand difficulties are of probative value. Further, the Board has found no reason to doubt the credibility of the Veteran's statements, and those of his spouse. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Based on the evidence of record just reviewed, the Board finds ratings for severe incomplete paralysis in each upper extremity warranted from June 7, 2005, one year prior to the claims for increased rating. 38 U.S.C.A. § 3.400. Though certain medical findings noted in the evidence dated between June 2005 and July 2008 indicate mild to moderate disability, certain other medical findings demonstrate clear objective evidence that the Veteran's bilateral disability has, as likely as not, caused severe impairment. In other words, the Board cannot conclude that, between June 2005 and July 2008, the lay and medical evidence does not document severe impairment. Indeed, this evidence consistently shows "severe" neuropathy, "obvious," "marked," and "extensive" muscle "wasting," "marked" hand grip weakness, a lack of sensation, dropping of objects, progressive large fiber neuropathy, classical puckering of the hand skin, Dupuytren's contracture, deformed muscle mass in the hands, inhibited ability to write or type, an inability to form a tight fist, and inability to perform daily tasks due to muscle atrophy. Hence, with regard to the right upper extremity, the Board finds a 50 percent rating rather than a 30 percent rating, warranted between June 7, 2005 and July 14, 2008. With regard to the left upper extremity, the Board finds a 40 percent rating warranted between June 7, 2005 and July 14, 2008, rather than the 10 and 20 percent ratings that were assigned during this period. B. From June 7, 2005 However, the preponderance of the evidence of record is against the Veteran's claim that higher ratings are due during the appeal period - i.e., ratings in excess of 50 percent for the right arm and 40 percent for the left arm are not warranted at any time from June 7, 2005. That is because, though the evidence dated from June 7, 2005 to the present continues to demonstrate severe incomplete paralysis, thus warranting 50 and 40 percent disability ratings, none of the evidence indicates that the Veteran has had complete paralysis in his upper extremities. As the evidence reviewed above demonstrates, the Veteran's upper extremities cannot be described as completely paralyzed. Indeed, each of the VA examiner's who assessed the Veteran's upper extremities prior to July 14, 2008 (in July 2006 and November 2007) noted substantial range of motion and use in the hands. Each examiner noted intact sensation, the ability to perform the "finger-thumb loop" testing, the ability to grasp and pick up small items such as a dime, paper clip, and a 5 mm button, and the lack of pain, excess fatigability, incoordination, or additional loss of function following testing. Moreover, regarding the issue of complete paralysis, the Board finds significant the November 2007 examiner's findings that the Veteran demonstrated intact capillary refill in his hands, and that his fingers moved on command. The evidence dated since July 14, 2008 continues to document severe symptoms but as with the earlier evidence, the evidence from July 14, 2008 documents an absence of "complete" paralysis. Initially, the Board notes that neither the Veteran nor his representative has ever claimed complete paralysis in the hands. Indeed, the representative expressly argued in April 2011 and September 2013 statements of record - that ratings for severe incomplete paralysis have been warranted in this matter. Further, in an August 2008 statement submitted to SSA, the Veteran's spouse noted the Veteran's hand pain following "extended use of his hands, i.e. writing or grasping tools or utensils[.]" She further noted that, though the Veteran experienced pain, he was "able to do all normal activities he always did around the house." A November 2008 VA examiner noted the Veteran's ability to use a keyboard, presence of 50 percent of his grip strength and upper extremity strength, the ability to form a fist, albeit a loose one, successful finger-thumb loop testing, and an ability to pick up a dime, paper clip, and button. The examiner noted pain on repetitive testing, but also noted an absence of excess fatigability, incoordination, and additional loss of function following testing. The examiner noted diminished light-touch sensitivity but also noted intact "circulation and motion" in both hands, and that all fingers moved on command. VA treatment records dated from July 2008 to September 2012 are either negative for symptoms related to upper extremity peripheral neuropathy or, as indicated earlier, note symptoms indicative of severe incomplete paralysis rather than complete paralysis. Certain records have even indicated that the Veteran has continued to actively use his upper extremities. A January 2010 VA treatment record indicated that the Veteran was still capable of playing golf - he expressed reservations regarding foot surgery because he did not want it to affect his golf game. Also, June through September 2012 VA treatment records, which reflect medical inquiry into cranial neuropathies related either to cerebrovascular disease or lung cancer, indicate that the Veteran had recently noticed "that he was having difficulties coordinating his right upper extremity when throwing a ball." After noting hand muscle atrophy and a tremor, this examiner otherwise noted full finger extension and flexion, normal upper extremity reflexes, full upper extremity muscle strength, and normal muscle tone. In sum, the lay and medical evidence of record indicates that, from June 7, 2005 to July 14, 2008, the Veteran manifested severe incomplete paralysis in each upper extremity, thereby warranting the assignment of 50 and 40 percent ratings for the right and the left upper extremity, respectively. At no time during the appeal period has the Veteran manifested complete paralysis, however. Hence, ratings in excess of 50 and 40 percent are not warranted at any time during the appeal period. 38 C.F.R. § 4.124a , DC 8515. The Board has looked at alternative DCs to determine whether an increased rating would be warranted here under another code. In particular, the Board looked closely at DCs 8514, and 8516 through 8518, which address nerve disorders originating in the upper extremity area. But a rating in excess of the 50 and 40 percent ratings would be unauthorized under these codes for the severe incomplete paralysis demonstrated here. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a rating higher than that already assigned, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102 , 4.3; Gilbert, supra. Nephropathy with Hypertension The Veteran's diabetic nephropathy with hypertension has been rated under DC 7541 of 38 C.F.R. § 4.115b. This provision addresses "renal involvement" or diagnoses associated with diabetes, and notes that the disorder at issue should be rated for its predominant symptom, renal dysfunction, under 38 C.F.R. § 4.115a. Ratings of 0, 30, 60, 80, and 100 percent are provided under 38 C.F.R. § 4.115a. The Veteran has been rated as 60 percent disabled from the date of his service connection claim on June 7, 2006 to July 9, 2008, and then as 100 percent thereafter. As such, the inquiry here will be limited to whether a schedular rating of either 80 or 100 percent was warranted between June 7, 2006 and July 9, 2008. An 80 percent rating is warranted for renal dysfunction with evidence of persistent edema and albuminuria with BUN [blood urea nitrogen] 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 warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. In cases involving diabetic nephropathy with hypertension, the Board notes the provisions of 38 C.F.R. § 4.115, which address nephritis that originates from hypertension, and provide that "separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis on account of the close interrelationships of cardiovascular disabilities." The provision states that separate ratings would be permitted in cases where a kidney is absent, or where the claimant requires "regular dialysis." In assessing whether an 80 or a 100 percent rating was warranted here between June 7, 2006 and July 9, 2008, the Board has reviewed private and VA treatment records dated between 2006 and 2008, SSA records, VA examination reports dated in July 2006 and November 2007, and lay statements from the Veteran and his spouse. The Board has also reviewed a September 2012 VA examination report because it includes commentary regarding the nature of the Veteran's disorder from June 2006 to July 2008. Based on this evidence, the Board finds that a higher initial rating (i.e., 80 percent) is unwarranted between June 7, 2006 and July 9, 2008. As will be detailed further below, the criteria for an 80 percent rating have not been met during the applicable period. Though the Veteran's many health problems have caused him generalized poor health, the evidence does not indicate that his nephropathy causes his generalized poor health. Moreover, the criteria for an 80 percent rating under 38 C.F.R. § 4.115a, particularly those addressing laboratory test results, are not indicated here - the evidence has not indicated persistent edema and albuminuria with BUN 40 to 80mg%, or creatinine 4 to 8mg%. The July 2006 VA examiner noted the Veteran's complaints of fatigue and physical limitations, but indicated that the Veteran attributed such to his foot problems and his diabetes. The examiner noted that the Veteran had had diabetic neuropathy since 1998, based on positive urine microalbumin screening. The examiner also detailed blood and urine testing dated between July 2006 and 1992, none of which details the criteria noted for a schedular rating of 80 percent here - i.e., albuminuria with BUN 40 to 80mg% or creatinine 4 to 8mg%. An August 2006 VA treatment record noted "chronic kidney failure" and "chronic kidney disease, Stage III" but did not provide additional information relevant to rating for renal dysfunction. The November 2007 VA examiner stated that the Veteran's treating nephrologist estimated a 50% renal function loss. The examiner noted no evidence of uremia, nausea, vomiting, unusual headaches, anorexia, reduced appetite, weight loss, lethargy, dietary restrictions, or dialysis usage. The Veteran reported occasional urine dribbling but no leakage or incontinence, and no known current residuals of the nephropathy. The examiner indicated current treatment consisting of medication and "attempts at more optimal blood pressure control" which the examiner noted was "suboptimally controlled recently[.]" The examiner also detailed multiple laboratory testing results from August 2006 to October 2007, none of which indicates albuminuria with BUN 40 to 80mg% or creatinine 4 to 8mg%. VA treatment records dated between October 2006 and July 9, 2008 detail treatment and evaluation by the Veteran's treating VA nephrologist. Certain of these records state that the Veteran has "severe diabetic nephropathy" and "chronic kidney disease" while a November 2007 record states "diabetic nephropathy with normal or near normal kidney function." This report also notes an October 2006 ultrasound which indicated normal renal function. The records also indicate that the Veteran reported minimal edema, fatigue related to medication used for cardiovascular disorders, no nausea, vomiting, or "other uremic symptoms." The records indicated no anorexia and stable weight. In the records, the physician noted "pertinent" laboratory results, none of which approximated the requisite criteria for an 80 percent rating under § 4.115a of albuminuria with BUN 40 to 80mg% or creatinine 4 to 8mg%. The Board notes a July 8, 2008 note by the treating VA nephrologist who described the Veteran as "feeling better." The physician noted no uremic symptoms, and noted stable weight. He also noted creatinine at 1.4mg. He closed the note by stating that the Veteran's nephropathy had been "relatively stable for the past two years." But the next day, in a July 9, 2008 note by the treating nephrologist, the physician stated that the Veteran's kidney function had declined since 2003, but that it was difficult to "quantitate" the decline with certainty. The examiner commented that the Veteran's serum creatinine readings had been normal, but that they had recently worsened. Based on this note, the RO increased the Veteran's rating to 100 percent. Pursuant to the Board's June 2011 remand, the Veteran underwent a VA examination of his nephropathy in September 2012. These results are relevant because, in its June 2011 remand, the Board requested medical commentary on the history of the Veteran's nephropathy. In determining whether a rating in excess of 60 percent has been warranted between June 2006 and July 2008, the Board has considered the September 2012 VA examiner's comments. In relevant part, the examiner stated that the Veteran's "renal status" had fluctuated over time, "but is now not progressive and has not been progressive for a long time." The examiner further indicated that the Veteran's prior kidney difficulties stemmed from "his persistent lack of compliance to diabetic directions." The examiner opined that the "nephropathy with hypertension condition exhibits amazingly stable renal function in the face of very poor diabetic control or compliance. There is certainly minimal renal disease progression now for 3 years." The examiner also characterized the progression of the disorder as "minimal" since 1998 despite the Veteran's "poor self control of his diabetes." Lastly, though the Board finds that the Veteran is not competent to comment on the etiology and nature of an internal disorder such as nephrology, the Board finds it of significance that neither he nor his representative has argued for a rating in excess of 60 percent. In fact, in statements of record dated in July 2008 and November 2009, the Veteran and his representative indicated that a 60 percent rating would be appropriate for his disorder. In sum, the evidence of record dated between the Veteran's original claim for service connection on June 7, 2006, and the effective date of the assignment of a 100 percent evaluation on July 9, 2008, does not approximate the criteria for an increased initial rating during that period. The Veteran is clearly in generalized poor health as the result of his many complications from diabetes and, most recently, acute health concerns regarding cerebrovascular disease and lung cancer. The evidence does not indicate that the Veteran's nephropathy caused generalized poor health during the relevant period, however. Moreover, VA examination reports and treatment records indicated an absence of edema, and noted laboratory results which indicated albuminuria with BUN below 40 to 80mg%, and creatinine below 4 to 8mg%. Hence, a rating in excess of 60 percent between June 7, 2006 and July 9, 2009 is unwarranted. 38 C.F.R. § 4.115a. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher initial rating, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102 , 4.3. Extraschedular Consideration The Board must still consider whether the Veteran is entitled to an extraschedular rating under the provisions of 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337 (1996). 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 disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the Board finds that the disability picture presented by the Veteran's peripheral neuropathy and nephropathy are appropriately contemplated by the rating schedule, particularly the criteria for a 50 and 40 percent ratings under DC 8515, and 60 and 100 percent ratings under 38 C.F.R. § 4.115a. The Veteran's neurological and kidney symptoms are directly contemplated by the schedular criteria. Moreover, assignment for the higher ratings available under the code is clearly not warranted based on the evidence. Therefore, referral for consideration of an extraschedular evaluation is not warranted here. Thun. III. The Claim to Service Connection The Veteran claims service connection for a heart murmur. Private and VA medical evidence documents that the Veteran has had a heart murmur. A July 2006 VA compensation examination report noted a heart murmur as did a November 2006 private medical report. The Veteran has argued that the heart murmur had its onset during service, and that it is secondarily related to a service-connected disorder. In February 2008, the RO denied his claim. In March 2009, the RO granted service connection for heart disease, namely arteriosclerotic heart disease, acute myocardial infarction, status post coronary artery bypass grafting (twice previously). The RO found the heart disease and its residuals due to the Veteran's service connected diabetes. The RO has nevertheless continued its denial of service connection for a heart murmur, most recently in the October 2012 SSOC. Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). When a Veteran seeks service connection for a disability, due consideration shall be given to the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the Veteran served, the Veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154; 38 C.F.R. § 3.303(a). Service connection may be awarded where the evidence shows that a Veteran had a chronic condition in service or during an applicable presumptive period and still has the condition. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. Certain disorders such as arteriosclerosis are presumed to have been incurred in service if manifested to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. If there is no evidence of a chronic condition during service or during an applicable presumptive period, then a showing of continuity of symptomatology after service is required to support the claim. The U.S. Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in § 3.303(b) is limited to the chronic diseases listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for disease that is diagnosed after discharge from active service, when the evidence establishes that such disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence 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). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Under 38 C.F.R. § 3.310(a), service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In this matter, the Veteran's complaints of having a current heart murmur are supported by medical evidence. However, service connection is granted only for disability, not on the basis of the symptoms of a disability. Indeed, Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110, 1131. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran's heart disease is a current disorder which was eligible for service connection. By contrast, his heart murmur, in and of itself, is a symptom or finding and not a disease entity for purposes of compensation benefits. As such, the claim of service connection for a heart murmur cannot be established. In conclusion, the RO granted service connection for heart disease in March 2009. A separate service connection finding for a heart murmur is unwarranted, however. The murmur itself is a symptom rather than evidence of a current cardiovascular disorder. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against the service connection claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102 , 4.3. ORDER Entitlement to a higher disability rating of 50 percent, for the Veteran's peripheral neuropathy in his right upper extremity, is granted from June 7, 2005 to July 14, 2008, in accordance with regulations governing the payment of monetary awards. Entitlement to a rating in excess of 50 percent, for the Veteran's peripheral neuropathy in his right upper extremity, is denied. Entitlement to a higher disability rating of 40 percent, for the Veteran's peripheral neuropathy in his left upper extremity, is granted from June 7, 2005 to July 14, 2008, in accordance with regulations governing the payment of monetary awards. Entitlement to a rating in excess of 40 percent, for the Veteran's peripheral neuropathy in his left upper extremity, is denied. From June 7, 2006 to July 9, 2008, entitlement to an initial disability rating in excess of 60 percent, for the Veteran's nephropathy with hypertension, is denied. Service connection for a heart murmur is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs