Citation Nr: 1341965 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 10-02 341 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to a rating in excess of 30 percent for hypertension with proteinuria. 3. Entitlement to a rating in excess of 20 percent for nonproliferative diabetic retinopathy. 4. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity. 5. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. 6. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 7. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 8. Entitlement to a compensable rating for erectile dysfunction. 9. Entitlement to a compensable rating for pterygium. 10. Entitlement to service connection for an acquired psychiatric disability, other than posttraumatic stress disorder (PTSD). 11. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran had active military service from February 1969 to February 1971. This appeal comes to the Board of Veterans' Appeals (Board) from an April 2009 rating decision. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The evidence of record does not show that treatment of the Veteran's diabetes mellitus has required regulation of activities as defined by VA regulations or insulin use. 2. The evidence does not show that the Veteran's diabetic nephropathy has caused constant albuminuria with some edema; definite decrease in kidney function; diastolic blood pressure that is predominantly at least 120 or more; persistent edema and albuminuria with BUN 40 to 80mg%; creatinine 4 to 8mg%; generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion; renal dysfunction requiring regular dialysis, or precluding more than sedentary activity; or markedly decreased function of his kidney or other organ systems, especially cardiovascular. 3. Throughout the appeal period, the Veteran's diabetic retinopathy has been manifested by distant vision obtainable after best correction by glasses of 20/40 or better in both eyes, no abnormalities in muscle function, and no active pathology; to the extent the Veteran has visual field impairment as a result of his diabetic retinopathy it impacts no more than a quarter of the visual field; and his diabetic retinopathy has not caused any incapacitating episodes. 4. The evidence shows that the Veteran's peripheral neuropathy has been no more than mild in all four extremities throughout the course of his appeal. 5. The Veteran's erectile dysfunction is remediable by medication, he is not shown to have any penile deformity, and he is receiving special monthly compensation (SMC) for loss of a creative organ. 6. The Veteran's decreased visual acuity has been assigned a 20 percent evaluation and to assign an additional compensable rating for pterygium would constitute pyramiding; additionally, the Veteran's pterygium has not caused any scarring, disfigurement, or chronic conjunctivitis. 7. The evidence of record makes it less likely than not that the Veteran has met the DSM-IV definition of any Axis I psychiatric disability during the course of his appeal. 8. The Veteran's service-connected disabilities alone have not been shown to prevent him from obtaining or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. Criteria for a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.119, Diagnostic Code (DC) 7913 (2013). 2. Criteria for a rating in excess of 30 percent for hypertension with proteinuria have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, 4.115a, DCs 7101, 7541 (2013). 3. Criteria for a rating in excess of 20 percent for nonproliferative diabetic retinopathy have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.79, Diagnostic Code 6006 (2013). 4. The criteria for a rating in excess of 10 percent for peripheral neuropathy of any of the Veteran's four extremities have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8515, 8520 (2013). 5. Criteria for a compensable rating for erectile dysfunction have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.115b, DC 7522 (2013). 6. Criteria for a compensable rating for pterygium have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.79, DC 6034 (2013). 7. Criteria for service connection for an acquired psychiatric disability, other than PTSD, have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). 8. Criteria for a TDIU are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board will also assess whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. Diabetes mellitus A claim seeking TDIU in February 2009 was interpreted as a claim for an increased rating for his diabetes mellitus which is rated at 20 percent under 7913. Under Diagnostic Code 7913, a 20 percent rating is assigned when diabetes mellitus requires either insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is assigned when diabetes mellitus requires insulin, a restricted diet, and regulation of activities. A 60 percent rating is assigned for diabetes 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. Logically, a 60 percent rating cannot be assigned without a veteran meeting all of the criteria for a 40 percent rating. In January 2009, Dr. Ortiz wrote that the Veteran had elevated blood sugar levels that required daily oral hypoglycemic, restricted diet and regulation of activities; and the Veteran suggests that this opinion is sufficient to warrant a 40 percent rating. A 40 percent rating is assigned when diabetes mellitus requires insulin, a restricted diet, and regulation of activities. That is, all three components must be met. See Middleton v. Shinseki, 727 F.3d 1172, 1178 (2013) (if disability rating criteria are written in the conjunctive, "a veteran must demonstrate all of the required elements in order to be entitled to that higher evaluation" and 38 C.F.R. § 4.7 cannot be used to circumvent the need to demonstrate all required criteria). In this case, they are not. Regulation of activities is defined as "avoidance of strenuous occupational and recreational activities." Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). In order for a veteran to be entitled to a 40 percent disability rating for diabetes mellitus, medical evidence must be submitted showing that regulation of activities is required. Id. at 364. It is true that Dr. Ortiz stated in January 2009 that the Veteran's diabetes mellitus required daily oral hypoglycemic, restricted diet and regulation of activities; however, he did not provide any explanation as to how the Veteran's activities were actually restricted in any way. This simply cannot be considered to be medical evidence, as it is nothing more than a conclusory statement, and a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. See Miller v. West, 11 Vet. App. 345, 348 (1998). Here, VA treatment records were reviewed, but do not make any mention of any regulation of activities. As noted regulation of activities is significant because it contemplates a situation in which activities must be regulated to avoid hypoglycemic episodes. Yet, the Veteran's records do not show any history of hypoglycemic episodes, and he specifically denied having experienced any at his most recent VA examination. Nevertheless, given the suggestion by Dr. Ortiz that the Veteran's activities might have been ordered to be regulated, the Veteran was provided with two VA examinations. In February 2009, the examiner noted that the Veteran was taking Glyburide and following up with a diabetic diet. The Veteran denied any hospitalization, surgery, pancreatic trauma or neoplasm, or episodes of hypoglycemia reaction or ketoacidosis. The examiner observed that the Veteran had been instructed to follow a special diet, but found that he had not been, and was not, restricted in his ability to perform strenuous activity. The Veteran was provided with a second VA examination in April 2013. The examiner reviewed the claims file and examined the Veteran. The Veteran was noted to be prescribed oral hypoglycemic agents. However, the examiner specifically found that the Veteran did not require regulation of activities as part of his medical management of his diabetes mellitus. It was noted that for VA purposes, regulation of activities was defined as avoidance of strenuous occupational and recreational activities with the intention of avoiding hypoglycemic episodes. In reaching this conclusion, the examiner observed that the Veteran visited his diabetic care provider fewer than twice per month, that he had denied any hospitalization for episodes of either ketoacidosis or hypoglycemia, and that he had not experienced progressive, unintentional weight loss as a result of his diabetes mellitus. These two opinions are better grounded in the evidence of record, than is the single conclusory opinion from Dr. Ortiz that suggests that regulation of activities had been ordered; and because the VA examiners' assertions are found to be more probative, they are entitled to greater weight. As such, regulation of activities is not found to be required to treat the Veteran's service connected diabetes mellitus. Additionally, it is not actually shown that the Veteran requires insulin to treat his diabetes mellitus, the second of the three requirements for a rating in excess of 20 percent for diabetes mellitus. Rather, as noted, he is prescribed Glyburide, which is an oral hypoglycemic agent. While this satisfies the criteria for a 20 percent rating, it does not meet the criteria of "insulin" that is required for a 40 percent rating. See Middleton v. Shinseki, 727 F.3d at 1177-78 (2013) (the "insulin" treatment requirement of Diagnostic Code 7913 may not be satisfied by use of a different treatment, even one that causes the body to produce insulin). Even Dr. Ortiz did not suggest that the Veteran required insulin to treat his diabetes mellitus. In October 2013, the Veteran's representative wrote a statement, but did not present any argument as to why a higher schedular rating would be warranted for the Veteran's diabetes mellitus. As described, the evidence of record fails to show that a schedular rating in excess of 20 percent is warranted for the Veteran's diabetes mellitus, and his claim is denied. Diagnostic Code 7913 Note (1) directs that any compensable complications of diabetes mellitus should be evaluated separately, unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. In this case, the Veteran has been service connected for several disabilities in conjunction with his diabetes mellitus, including peripheral neuropathy of all four extremities, diabetic nephropathy with hypertension, diabetic retinopathy, and erectile dysfunction, all of which are being addressed in this decision. No additional disabilities, not previously adjudicated have been alleged to be secondary to the Veteran's diabetes mellitus; thus, no additional ratings, other than those considered in this decision, need be considered separately from the Veteran's diabetes mellitus. With regard to extraschedular consideration, the evidence fails to show anything unique or unusual about the Veteran's diabetes mellitus that would render the schedular criteria inadequate. Such a conclusion is supported by the fact that the schedular rating criteria for evaluating diabetes directs VA to separately rate any compensable residuals from the diabetes mellitus. In this case, the Veteran receives separate ratings for peripheral neuropathy of all four extremities, hypertension, erectile dysfunction, and diabetic retinopathy. The schedular rating criteria that are assigned for the Veteran's diabetes mellitus focus on the medication required to control the disease and whether control requires activity or diet modification. It is not shown that the Veteran experiences any symptoms from his diabetes mellitus that both cause an impairment and that have not already been separately rated. This would suggest that the Veteran's case of diabetes mellitus is not unique or unusual, and that the Veteran's disability level and symptomatology are reasonably described by the schedular rating criteria. Therefore, his disability picture is fully contemplated by the rating schedule, the assigned schedular evaluation is adequate, and referral for consideration of an extraschedular rating is not warranted. Hypertension with proteinuria A claim seeking TDIU that was received in February 2009 was interpreted as a claim for an increased rating for the Veteran's hypertension with proteinuria which is rated at 30 percent under 7101-7541. The Veteran is service connected for hypertension with proteinuria, which is a result of diabetic nephropathy. The regulations direct that when there is renal involvement in diabetes mellitus, the condition is to be rated as renal dysfunction. Pursuant to 38 C.F.R. § 4.115a (which covers Diagnostic Code 7541), diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. Where diagnostic codes refer the decision maker to these specific areas of dysfunction, only the predominant area of dysfunction shall be considered for rating purposes. Since the areas of dysfunction described below do not cover all symptoms resulting from genitourinary diseases, specific diagnoses may include a description of symptoms assigned to that diagnosis. Renal dysfunction is rated as follows: A 30 percent rating is assigned when there is albumin, either constant or recurring with hyaline and granular casts or red blood cells; or when there is transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. A 60 percent rating is assigned when there is constant albuminuria with some edema; when there is definite decrease in kidney function; or when hypertension meets at least the criteria of 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is assigned when there is persistent edema and albuminuria with BUN 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 rating is assigned when there is renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; BUN more than 80mg%; creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Essentially, there are three ways to obtain a 60 percent rating under Diagnostic Code 7541. First, it may be assigned when renal dysfunction causes constant albuminuria with some edema. Here, the Veteran reported at an April 2013 VA examination that his renal functioning had been stable with medical treatment. Additionally, no edema was noted at numerous VA treatment sessions, including June 2011, September 2011, March 2012, July 2012, October 2012, February 2013, or April 2013. As such, this criterion has not been met. Second, a 60 percent rating can be assigned when renal dysfunction causes definite decrease in kidney function. Here, this is not shown by the evidence. For example, at the Veteran's April 2013 VA examination, the examiner noted that renal functioning was stable, and found the Veteran did not have any signs or symptoms as a result of renal dysfunction. VA treatment records similarly fail to show any decrease in kidney functioning. As such, this criterion has not been met. Third, a 60 percent rating will be assigned when renal dysfunction causes hypertension that meets at least the criteria of a 40 percent rating under Diagnostic Code 7101. Under Diagnostic Code 7101, a 20 percent rating is assigned for hypertension when either diastolic pressure is predominantly 110 or more, or when systolic pressure is predominantly 200 or more. A 40 percent rating is assigned for hypertension when diastolic pressure is predominantly 120 or more. A 60 percent rating is assigned for hypertension when diastolic pressure is predominantly 130 or more. In January 2009, Dr. Ortiz wrote that the Veteran was on treatment for high blood pressure that was directly related to his diabetic condition, explaining that microvascular changes to his kidney as a result of diabetes had caused diabetic nephropathy. He added that the Veteran's blood pressure had not been well-controlled, noting that every time he underwent physical examination, his blood pressure was elevated. It is not disputed that the Veteran's blood pressure has routinely been elevated. However, to merit a 40 percent rating for hypertension under 7101, the diastolic pressure must be predominantly 120 or more. The following chart records a number of blood pressure readings for the Veteran during the course of his appeal: Date BLOOD PRESSURE Date BLOOD PRESSURE Date BLOOD PRESSURE February 2009 150/90; 140/90, 140/90, 140/90 March 2010 130/80 July 2012 132/75 September 2009 149/96 June 2011 126/74 October 2012 138/86 October 2009 119/77 September 2011 117/75 February 2013 144/80 December 2009 133/75 March 2012 137/81 April 2013 132/75 As is plainly evident, the Board was unable to find any instance during the course of the Veteran's appeal in which his diastolic pressure was 120 or higher, despite blood pressure testing being conducted on a number of occasions. While it is possible that the Board overlooked a blood pressure reading in the claims file or that a blood pressure reading was not recorded, the fact remains that diastolic pressure must be predominantly 120 or more. VA regulations do not define the term "predominantly." Notably, in promulgating the current version of DC 7101, VA acknowledged that blood pressure readings were variable and expressed a concern that an adjudicative decision could be based on "readings taken on a single, perhaps unrepresentative, day." 62 Fed. Reg. 65201, 65215 (Dec. 11, 1997). This speaks to a recognition that blood pressure readings vary from examination to examination so that each reading must be read in the context of the entire record. This policy fits with the term "predominant," which is synonymous with the term preponderate and is defined as "[h]aving greatest ascendancy, importance, influence, authority or force." WEBSTER'S II NEW COLLEGE DICTIONARY, p. 870 (1995). As such, even if an isolated diastolic reading were found to be in excess of 120, it would not support a higher rating. In October 2013, the Veteran's representative requested that an additional VA examination be provided to evaluate the Veteran's hypertension, arguing that no diastolic pressure was measured at his VA examination, and noting that the next higher schedular rating would require hypertension at least 40 percent disabling under Diagnostic Code 7101. The Board considered this argument, but ultimately concludes that the examination was adequate and finds that an additional examination is not necessary for the following reason. The VA examination that was provided addressed the factors needed to rate the Veteran's claim, aside from specifically addressing his hypertension. However, the regulations require diastolic pressure to be predominantly 120 or more to warrant a higher rating. To suggest that another examination is necessary simply to measure the Veteran's blood pressure appears to be unnecessary given the fact that the Veteran's blood pressure was recorded on numerous occasions throughout the course of his appeal. That is, even if another VA examination were to be provided which showed diastolic pressure in excess of 120, this would not be sufficient alone to justify a higher rating, as the use of the word "predominant" suggests that the rating schedule requires blood pressure readings on multiple occasions. This does not conclude the Board's analysis, as Diagnostic Code 7541 is successive in nature, not conjunctive, and therefore the schedular rating criteria for an 80 percent rating must also be considered. See Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). Under Diagnostic Code 7541, an 80 percent rating is assigned when there is persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. The Veteran was provided with a VA examination in April 2013 to evaluate his diabetic nephropathy. The examiner noted that the Veteran's BUN was 22 percent, which is considerably less than the 40-80 percent required for an 80 percent rating. Creatinine was 1.6 percent , which likewise is less than the 4-8 percent needed. The Veteran has also not been shown to have generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. In fact, the examiner stated that aside from hypertension, the Veteran did not experience any signs or symptoms due to renal dysfunction. Additionally, the evidence of record does not show, nor has it been alleged, that the Veteran has either required dialysis or experienced markedly decreased function of his kidney and/or other organ systems, and thus a 100 percent rating is not warranted. As such an increased schedular rating is denied. With regard to extraschedular consideration, the evidence fails to show anything unique or unusual about the Veteran's hypertension with proteinuria that would render the schedular criteria inadequate. The schedular rating that was assigned considered the diabetic nephropathy and its health consequences, including hypertension; including consideration of the severity of the hypertension itself. As such, the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology, and his disability picture is thus contemplated by the rating schedule. However, even if the criteria do not reasonably describe the claimant's disability level and symptomatology, it is not shown that the exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Here, the Veteran's diabetic nephropathy and resultant hypertension has not required hospitalization and it has not been shown to cause marked interference with employment. For example, at the VA examination of the Veteran's kidney functioning in April 2013, the examiner specifically found that the kidney disability did not impact his ability to work. Accordingly, referral for consideration of an extraschedular rating is not warranted. Nonproliferative diabetic retinopathy A claim seeking TDIU that was received in February 2009 was interpreted as a claim for an increased rating for the Veteran's diabetic retinopathy which is currently rated at 20 percent under 7913-6006. Because this claim was received after the rating criteria for diseases of the eye were amended, effective December 10, 2008, the current eye regulations apply to the adjudication of this issue. The evaluation of diabetic retinopathy is governed by 38 C.F.R. § 4.79, Diagnostic Code 6006, which directs that eye disabilities are to be rated on the basis of either visual impairment or on incapacitating episodes according to a General Rating Formula, whichever results in a higher rating. Under the General Rating Formula based on incapacitating episodes, the following ratings apply: a 10 percent rating is warranted for diabetic retinopathy with incapacitating episodes having a total duration of at least 1 week, but less than 2 weeks, during the previous 12 months; a 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the previous 12 months; a 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the previous 12 months. A 60 percent rating is warranted for retinopathy with incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. Id. A note to DC 6006 defines an incapacitating episode as a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. During the course of his appeal, the Veteran has undergone two VA eye examinations. However, incapacitating episodes have not been shown at either examination, and the examiner in April 2013 specifically stated that incapacitating episodes had not been present. Incapacitating episodes of visual impairment were similarly not shown in any VA treatment records, and have not been alleged by the Veteran himself or by his representative. As such, it is considered more favorable to rate the Veteran's claim based on visual impairment. The regulations direct that evaluation of visual impairment is to be rated based on the consideration of three factors: 1) impairment of visual acuity (excluding developmental errors of refraction), 2) visual field, and 3) muscle function. 38 C.F.R. § 4.75. However, examinations of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Visual Acuity 38 C.F.R. § 4.76 directs that an examination of visual acuity must include the central uncorrected and corrected visual acuity for distance and near vision using Smeller's test type or its equivalent. Central visual acuity is to be evaluated on the basis of corrected distance vision with central fixation, even if a central scotoma is present. However, when the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye (and the difference is not due to congenital or developmental refractive error), and either the poorer eye or both eyes are service connected, the visual acuity of the poorer eye is to be evaluated using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity. Here, the Veteran has had his visual acuity measured on two occasions (VA examinations in February 2009 and April 2013) during the course of his appeal. At the 2009 examination, the Veteran demonstrated corrected vision to 20/15 bilaterally. To warrant even a compensable rating under Diagnostic Code 6066, the vision in one eye must be at least 20/50. Here, it clearly was not. Similarly, at the VA examination in April 2013, the Veteran's vision was correctable to 20/20 bilaterally, which would also fail to warrant a compensable rating under Diagnostic Code 6066. Moreover, even if the Veteran did have greater visual impairment, the examiner explained that while the Veteran did have early changes that were consistent with diabetic retinopathy, the changes from the diabetic retinopathy itself did not affect his central vision. VA treatment records do not suggest a different conclusion and the Veteran has not specifically argued otherwise. As such, a rating in excess of 20 percent is not considered to be warranted based on visual impairment. Visual Field Examinations of visual fields will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Here, the examiner in April 2013 indicated that the Veteran had a visual impairment defect, although he did not specifically address whether it was caused by one of the Veteran's service connected eye disabilities. Nevertheless, as discussed below, the Veteran's visual fields impairment, even if assumed to be related to a service connected disability, does not warrant a rating in excess of 20 percent. To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, the regulations indicate that the visual acuity and visual field defect (expressed as a level of visual acuity) should be separately evaluated, and then combined under the provisions of § 4.25. 38 C.F.R. § 4.77(c). However, as discussed above, the Veteran's visual acuity does not warrant a compensable rating, and thus there is not a separate rating to combine in this instance. Under 38 C.F.R. § 4.79, Diagnostic Code 6081, a minimum 10 percent rating is assigned when a scotoma affects at least one-quarter of the visual field (quadrantanopsia) or with centrally located scotoma of any size. Alternatively, scotomas may be evaluated based on visual impairment due to scotoma, if that would result in a higher evaluation. At the VA examination in February 2009, a Goldmann perimetry test was noted to be within normal limits. At the April 2013 VA examination, the Veteran was noted to have a visual field defect using Goldmann's equivalent III/four extremities target. However, the examiner specifically found that the Veteran did not have the loss of a visual field (i.e. homonymous hemianopsia, or lows of temporal, nasal, inferior, or superior half of the visual field). He did have a scotoma that affected at least a quarter of his visual field bilaterally, but which did not cause legal blindness in either eye. The presence of a scotoma affecting at least a quarter of his visual field bilaterally would support a 10 percent rating for each eye, but the Veteran already receives a 20 percent rating for his diabetic retinopathy. 38 C.F.R. § 4.76a explains that the normal visual field extent at 8 principal meridians is (expressed in degrees): Temporally: 85, Down temporally: 85, Down: 65, Down nasally: 50, Nasally: 60, Up nasally: 55, Up: 45, Up temporally: 55. The combined sum is 500. To calculate the visual field, determine the average concentric contraction of the visual field of each eye by measuring the remaining visual field (in degrees) at each of eight principal meridians 45 degrees apart, adding them, and dividing the sum by eight. As noted, a Goldmann perimetry test was noted to be within normal limits at the February 2009 VA examination. In the right eye, the meridians were at approximately 55, 55, 42, 38, 35, 41, 55, and 62. This totals to 383. The average remaining field in the right eye was 383/8= 47.875. In the left eye, the meridians were at approximately 45, 35, 32, 38, 45, 55, 45, and 50. This totals to 345. The average remaining field in the left eye was 345/8= 43.125. The rating criteria dictates that when the remaining visual field is 46-60 degrees, a 10 percent rating is applied for unilateral or bilateral impairment; alternatively, each affected eye may be evaluated as 20/50. When the remaining visual field is 31-45 degrees, a 10 percent rating is applied for unilateral and a 30 percent rating is applied for bilateral; or alternatively each affected eye may be evaluated as 20/70. When the remaining visual field is 16-30 degrees, a 10 percent rating is applied for unilateral and a 50 percent rating is applied for bilateral; or alternatively each affected eye may be evaluated as 20/100. Here, because the right eye remaining field was 48, it would warrant either a 10 percent rating, or be rated as 20/50. The remaining field for the left eye was 43, so it would warrant either a 10 percent rating, or be rated as 20/70. Under 38 C.F.R. § 4.79, Diagnostic Code 6066, when vision in one eye is 20/70 and vision in the other eye is 20/50, a 20 percent rating is assigned. Alternatively, the separate 10 percent ratings for each eye could be combined to 20 percent. As such, the 2009 Goldmann test did not support a higher rating. On the Goldmann test in April 2013, the meridians in the right eye were at approximately 58, 45, 40, 40, 42, 45, 45, and 62. This totals to 377. The average remaining field in the right eye was 377/8= 47.125. However, a significant scotoma was noted in the Veteran's right eye which was not present in 2009. While the Veteran had some visual field beyond the scotoma, the scotoma essentially restricted his right eye visual field. As such, the Board concludes that it is more equitable to use the interior edge of the scotoma as the end of the visual field yield. This would yield meridians at approximately 50, 45, 40, 40, 42, 45, 45, and 50. This totals to 357. The average remaining field in the right eye was 357/8= 44.625. In the left eye, the meridians were at approximately 45, 45, 38, 58, 60, 72, 42, and 45. This totals to 405. The average remaining field in the left eye was 405/8= 50.625. However, as with his right eye, a significant scotoma was also noted in the Veteran's left eye which was not present in 2009. While the Veteran had some visual field beyond the scotoma, the scotoma essentially restricted his left eye visual field to the perimeter. Using the interior edge of the scotoma as the end of the visual field yields meridians at approximately 45, 45, 38, 58, 48, 40, 42, and 45. This totals to 361. The average remaining field is 361/8= 45.125 As such, because the right eye remaining field (accounting for the scotoma) was 45, it would warrant either a 10 percent rating, or be rated as 20/70. The remaining field for the left eye (accounting for the scotoma) was 50, so it would warrant either a 10 percent rating, or be rated as 20/50. Under 38 C.F.R. § 4.79, Diagnostic Code 6066, when vision in one eye is 20/70 and vision in the other eye is 20/50, a 10 percent rating is assigned. A 30 percent rating would be warranted for bilateral loss of the temporal half or the inferior half of the visual field, neither of which is shown to be present. Additionally, the examiner in April 2013 explained that while the Veteran had bilateral retinopathy, no present visual impairment was attributable to it, as the condition was not severe enough to cause visual acuity problems. As such, a rating in excess of 20 percent does not appear to be warranted based on visual field impairment, to include as due to a scotoma. Muscle Function Again, examinations of muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Muscle function was considered, but the examiner at the April 2013 VA examination specifically found that diplopia was not present in either of the Veteran's eyes, and muscle functioning of the eyes is evaluated based on the degree of diplopia. Additionally, the examiner explained that the Veteran's bilateral retinopathy was not severe enough to cause visual acuity problems. As such, the Board does not find that there is a problem with muscle function in either of the Veteran's eyes. In October 2013, the Veteran's representative wrote that he had no argument to add and suggested that a higher rating be granted. However, neither the Veteran, nor his representative has submitted any evidence that would support a schedular rating in excess of 20 percent for the Veteran's diabetic retinopathy. Therefore, the Veteran's claim is denied. With regard to extraschedular consideration, the evidence fails to show anything unique or unusual about the Veteran's diabetic retinopathy that would render the schedular criteria inadequate. The Veteran's main symptom is diminished visual acuity and a restricted visual field (including accounting for his bilateral scotomas), both of which are explicitly considered by the schedular rating criteria. As such, the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology, and his disability picture is thus contemplated by the rating schedule. Accordingly, the assigned schedular evaluation is adequate, and referral for consideration of an extraschedular rating is not warranted. Peripheral neuropathy of all four extremities The Veteran currently receives four separate 10 percent ratings for peripheral neuropathy of each of his extremities. A claim seeking TDIU that was received in February 2009 was interpreted as a claim for an increased rating for the Veteran's peripheral neuropathy which is currently rated under 38 C.F.R. § 4.124a, Diagnostic Codes 8515 (upper extremities) and 8520 (lower extremities). Under Diagnostic Code 8515 when there is incomplete paralysis of the median nerve in the major extremity, 10, 30, and 50 percent ratings are assigned for mild, moderate and severe impairment respectively. When there is incomplete paralysis of the median nerve in the minor extremity, 10, 20, and 40 percent ratings are assigned for mild, moderate and severe impairment respectively. A 70 percent rating is assigned on the major side and a 60 percent rating is assigned on the minor side if there is complete paralysis of the median nerve with 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; or pain with trophic disturbances. Under Diagnostic Code 8520 when there is incomplete paralysis of the sciatic nerve a 10 percent rating is assigned for mild impairment, a 20 percent rating is assigned for moderate impairment, a 40 percent rating is assigned for moderately severe impairment, and a 60 percent rating is assigned for severe impairment with marked muscular atrophy. An 80 percent rating is assigned for complete paralysis of the sciatic nerve where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a Words such as "mild", "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. In January 2009, Dr. Ortiz wrote that the Veteran had pins and needles type sensation in all four extremities. As such, the Veteran was scheduled for a VA examination to investigate the nature and severity of his peripheral neuropathy. In February 2009, the Veteran underwent a VA examination of his peripheral neuropathy. The onset of peripheral neuropathy reportedly occurred two years earlier with the Veteran experiencing stabbing pain in the tips of his fingers and a dull pain in his lower extremities, associated with numbness which was worse in the right lower extremity. The Veteran denied receiving any treatment for the condition. On motor testing, he demonstrated 5/5 strength in all four extremities. Sensory testing of the upper extremities showed normal vibration, decreased pain, normal position sense. Sensory testing of the lower extremities revealed decreased vibration. The Veteran's distal extremity was lost after seven seconds. The Veteran also had decreased light touch. Position sense was normal. There was no muscle atrophy or abnormal muscle tone or bulk. The nerve functioning did not affect any joint. The Veteran's gait and balance were normal. The examiner stated that the Veteran had mild sensory peripheral neuropathy of all four extremities. Paralysis was absent. VA treatment records from throughout the course of the Veteran's appeal (including records from June 2008, October 2009, December 2009, March 2010, June 2011, September 2011, March 2012, July 2012, and October 2012) consistently show no gross motor or sensory deficit. In October 2012, the Veteran's representative wrote that the Veteran should be assigned higher ratings for peripheral neuropathy in all four extremities, asserting that the 2009 VA examination had noted both loss of sensation and pain, which he believed was closer to a moderate level of disability. However, at a VA treatment session in February 2013, the Veteran was again found to have no gross motor and/or sensory deficit. Nevertheless, given the representative's argument, the Veteran was provided with a second VA examination of his peripheral neuropathy in April 2013. The examiner reviewed the claims file and examined the Veteran, noting that he did not experience constant pain in any extremity as a result of peripheral neuropathy, but did experience moderate intermittent pain in all four extremities. The Veteran had no paresthesis and/or dysesthesias in any extremity; experienced mild numbness in all four extremities; and demonstrated normal sensory testing (5/5) and deep tendon reflexes in all four extremities. Light touch was normal in the shoulders, forearms, and knees, but decreased in the hands/fingers, the ankle/lower leg, and the feet/toes; and vibration sensation was decreased in all four extremities. However, neither was not absent in any extremity. Position sense was normal. Additionally, neither atrophy nor trophic changes were seen on examination. The examiner diagnosed the Veteran with diabetic peripheral neuropathy in all four extremities, but found that his radial, median, ulnar, sciatic and femoral nerves were all normal bilaterally. The examiner had the opportunity to denote mild, moderate, or severe incomplete paralysis for any of the aforementioned nerves on the examination form, but again he specifically found that the nerves were normal. The examiner noted that the Veteran's peripheral neuropathy caused mild impairment in walking. Here, the Veteran's representative has suggested that a higher rating is warranted, but has not provided a sufficient basis to assign such a rating. The representative's argument was essentially that the Veteran experienced pain and numbness in his extremities. Similarly, Dr. Ortiz stated that the Veteran experienced pain and numbness. However, the fact that the Veteran's peripheral neuropathy is symptomatic is not in dispute, as it is these symptoms which support the compensable ratings that have been assigned for each of his extremities. Yet, neither the Veteran's representative, nor his private doctor, have pointed to evidence that would justify higher schedular ratings for any extremity; and the medical evidence similarly does not show that a higher schedular rating is warranted for any extremity. The fact that the 2013 VA examiner commented that the Veteran reported "moderate" pain does not mean that his disability is of a moderate degree to warrant a higher rating. Here, despite his complaints of pain, the VA treatment records consistently found no gross motor or sensory deficits, and the VA examiners who have had the opportunity to physically examine the Veteran found that his peripheral neuropathy was at most mild in effect. The Veteran is considered competent to identify symptoms he experiences in his extremities such as pain and numbness. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he has not identified any symptoms which were not considered and investigated by the two VA examiners. Yet, after full examinations of the Veteran, both examiners concluded that his peripheral neuropathy was no more than mild in severity in any extremity. The Board, having reviewed the evidence of record, concurs with the examiners' assessments. As such, increased schedular ratings are not warranted for any extremity based on impairment as a result of peripheral neuropathy. With regard to extraschedular consideration, the evidence fails to show anything unique or unusual about the Veteran's peripheral neuropathy that would render the schedular criteria inadequate. The Veteran's main symptoms are pain, tingling, numbness (essentially sensory impairment), as well as some periodic motor impairment. These are precisely the symptoms contemplated by the Diagnostic Codes for neurologic impairment. Moreover, the Diagnostic Codes for neurologic impairment use terms such as mild, moderate, and severe, etc, which provides the flexibility to take into account all of the symptoms attributed to the Veteran's neurologic impairment within the confines of the schedular ratings which are assigned. As such, the schedular ratings that are assigned reasonably describe the Veteran's disability level and symptomatology, and referral for consideration of an extraschedular rating is not warranted. Erectile dysfunction A claim seeking TDIU that was received in February 2009 was interpreted as a claim for an increased rating for the Veteran's erectile dysfunction which is currently rated as noncompensable under 38 C.F.R. § 4.115b, DC 7522, which provides a 20 percent rating only if there is deformity of the penis with loss of erectile power. DC 7522 also instructs that in cases such as this one, entitlement to SMC should also be considered. However, the Veteran has already been granted SMC for his erectile dysfunction; and his claims file is void of any indication of penis deformity, to include any such assertion by the Veteran. Accordingly, the criteria for a compensable rating for erectile dysfunction (independent of the SMC) have not been met. In October 2013, the Veteran's representative argued that because the Veteran's condition was rated by analogy, he did not have to show the appearance of a deformity to receive a compensable rating, citing to Vogan v. Shinseki, 24 Vet. App. 159, 161 (2010) (when a condition is not listed in the VA disability schedule, VA may undertake rating by analogy where the disability in question is analogous in terms of the functions affected, the anatomical localization, and the symptomatologies of the ailments). The representative also cited to a nonprecedential decision from April 2013 (Ellis v. Shinseki, 2013 WL 1777310 (2013)) to suggest that a compensable rating might be warranted for erectile dysfunction. The representative argued that a 20 percent rating was warranted. While Ellis is a nonprecedential decision, the Board has nevertheless reviewed it. It is noted that the Court in Ellis did not direct that a compensable rating be assigned, just that the Board discuss the evidence. As such, this case does not establish that a 20 percent rating must be, or even should be, assigned for erectile dysfunction. Moreover, the facts of the case in Ellis differ from this case. For example, while the Veteran in Ellis also had erectile dysfunction, his was of such severity that he was incapable of vaginal penetration, his erectile dysfunction did not respond to oral medication, and he had an absence of ejaculation. That is, factors which are not present in this Veteran's case. It is true that the Veteran uses medication to address the symptoms of his erectile dysfunction. However, with medication, the Veteran is capable both of intercourse and ejaculation, as specifically found by the February 2009 VA examination. Given the fact that the Veteran's erectile dysfunction is remediable by medication, that he is not shown to have any penile deformity, and the fact that he is already receiving special monthly compensation for loss of use of a creative organ, the Board concludes that a compensable schedular rating is not warranted for the Veteran's erectile dysfunction, and therefore his claim is denied. With regard to extraschedular consideration, the evidence fails to show anything unique or unusual about the Veteran's erectile dysfunction that would render the schedular criteria inadequate. The Veteran's main symptoms are addressed by prescribed medication which enables intercourse and ejaculation. Moreover, he receives special monthly compensation on account of loss of use of a creative organ. Symptoms simply have not been alleged that have not been taken into account by the schedular rating that has been assigned. As such, the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology, and his disability picture is thus contemplated by the rating schedule. Accordingly, the assigned schedular evaluation is adequate, and referral for consideration of an extraschedular rating is not warranted. Pterygium A claim seeking TDIU that was received in February 2009 was interpreted as a claim for an increased rating for the Veteran's pterygium, which is currently rated as noncompensable under 38 C.F.R. § 4.79, Diagnostic Code 6034, which directs that pterygium be evaluated based on visual impairment, disfigurement (diagnostic code 7800), conjunctivitis (diagnostic code 6018), etc., depending on the particular findings. In October 2013, the Veteran's representative wrote that a compensable rating was warranted for the Veteran's pterygium because his visual impairment was 20 percent. However, as discussed above, the Veteran already receives a 20 percent rating for visual impairment as a result of his diabetic retinopathy. This rating contemplated both diminished visual acuity and visual field impairment. As such, any visual impairment caused by the pterygium would be contemplated by the rating assigned, and to assign a higher rating would constitute pyramiding. See 38 C.F.R. § 4.14. The rating schedule indicates that other Diagnostic Codes should be considered. At the Veteran's VA examination in February 2009, it was noted that there was no recurrent pterygium in the Veteran's right eye. At his VA examination in April 2013, the Veteran complained of symptoms of burning and stinging in his right eye which the examiner explained was caused by the recurrent pterygium. However, the examiner found that there was no scarring or disfigurement of either eye. There has similarly been no suggestion in the lay statements, treatment records, or examination reports that the Veteran's pterygium has caused active chronic conjunctivitis. For example, at VA primary care checkups in June 2011, March 2012, July 2012, February 2013, and April 2013, the Veteran denied any eye pain or visual changes. As such, the Board concludes that a separate schedular rating for pterygium is not warranted. With regard to extraschedular consideration, the Veteran's main symptoms are pain and burning, neither of which are explicitly considered by the schedular rating criteria, which directs that consideration be given to the impact on visual acuity, on scarring, or on whether the condition results in chronic conjunctivitis. As such, the schedular rating criteria do not reasonably describe the Veteran's disability level and symptomatology. However, referral for extraschedular consideration is still not warranted, as the Veteran's disability picture does not exhibit any of the "governing norms" of an extraschedular rating. 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. Specifically, the Veteran has not been hospitalized during the course of his appeal for treatment of his pterygium, and it has not been shown to cause marked interference with employment. Specifically, at the April 2013 examination, the examiner opined that the Veteran's visual impairment did not impact his ability to work. As such, referral for extraschedular consideration is not warranted. II. Service Connection In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. The Veteran is seeking service connection for a psychiatric disability, but there is no allegation that he has ever been diagnosed with or treated for a psychoses. Therefore, the condition at issue is not a "chronic disease" listed under 38 C.F.R. § 3.309(a), therefore 38 C.F.R. § 3.303(b) does not apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran is seeking service connection for an acquired psychiatric disability, other than PTSD. It is noted that the Veteran's claim for service connection for PTSD was denied by a July 2011 rating decision, which the Veteran did not appeal, and which is final. In order to prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be present as a current disability, the claimed condition must be present at the time of the claim for benefits, as opposed to sometime in the distant past. Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998). The Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even if a disability subsequently resolves during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In January 2009, Dr. Ortiz wrote that the Veteran had a history of seven different medical conditions, including depression. He added that as a result of his daily stressors from Vietnam and his diabetic condition, the Veteran was limited in his activities of daily living which exacerbated his emotional problems, such that he could not handle stress or react appropriately to his physical and social environment. However, Dr. Ortiz did not provide any explanation or rationale for his suggestion that the Veteran had depression, nor did he explain how the Veteran's symptoms met the DSM-IV criteria of an Axis I psychiatric disability. This becomes relevant in that the Veteran's claims file is otherwise completely void of any finding by a medical professional that he met the criteria for an Axis I psychiatric disability at any time during the course of his appeal. VA treatment records do not show that any acquired psychiatric disability has been diagnosed. For example, at a September 2011 VA treatment session, a depression assessment was negative. Likewise, in February 2013, a depression screen was negative and the Veteran affirmatively stated that he was not feeling down, depressed or hopeless at all. The Veteran was also provided with two VA psychiatric examinations, but neither examiner found sufficient evidence to support an Axis I psychiatric diagnosis, despite thorough investigation. At the first VA examination in June 2011, the examiner concluded that the Veteran did not meet the criteria for an Axis I psychiatric diagnosis. The examiner explained that the symptoms that were reported by the Veteran were normal reactions to everyday life's stresses, adding that the Veteran's sleep was considered adequate for his age. In October 2012, the Veteran's representative wrote that there was no examination to determine if the Veteran had depression secondary to his service connected disabilities, and suggested that the 2011 VA examination was inadequate, because the examination had not determined whether the Veteran had depression. However, a review of the examination report notes that the examiner conducted a thorough examination with the Veteran, but simply found that he did not meet the criteria for any Axis I psychiatric disability. This would necessarily include depression. Likewise, a disease cannot be secondary to or aggravated by a service connected disability if the disease is not found to exist. Nevertheless, the RO acquiesced to the representative's request and provided a second VA psychiatric examination in April 2013. However, after reviewing the Veteran's claims file and medical records, and conducting a psychiatric evaluation, the second examiner also concluded that there was no evidence to fulfill the diagnostic criteria for any mental disorder at that time. As such, because a mental health disorder was not diagnosed, no opinion could be issued addressing the etiology of such a disorder. In October 2013, the Veteran's representative wrote that greater deference should be given to Dr. Ortiz's assertion in 2009 that the Veteran had a "history of depression." However, the statement does not show that the Veteran has ever actually been given an Axis I psychiatric diagnosis, just that he has experienced periodic thoughts of depression. It must also be noted that the exact wording of Dr. Ortiz's statement is a history of, which clearly does not indicate a current condition. Two mental health professionals have reviewed the Veteran's medical records and met with him, but neither medical professional found sufficient evidence to support the finding of a current Axis I psychiatric disability. While the Board may not ignore a medical opinion, it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases; rather, it is the Board's duty to assess the credibility and probative value of evidence, and, provided that it supplies an adequate statement of its reasons or bases, it may assign greater probative weight to one medical opinion than to another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Here, to the extent Dr. Ortiz's reference to a history of depression can be interpreted to suggest that the Veteran might have a current psychiatric disability, Dr. Ortiz never explained how the Veteran met any Axis I criteria to satisfy the definition of a psychiatric disability. Two subsequent in-depth psychiatric examinations were obtained, but neither found an Axis I disability to be present. These conclusions are supported by the Veteran's treatment records as well. Given that the VA examiners' conclusions appear to be better supported by the evidence of record, than is Dr. Ortiz's statement, they are found to be the most probative evidence. Given this finding, the evidence fails to establish the presence of a psychiatric disability at any time during the course of the Veteran's appeal; and, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, the Veteran's claim of entitlement to service connection for an acquired psychiatric disability, other than PTSD, is denied. TDIU The Veteran has filed a claim for a TDIU, alleging that he is unemployable as a result of his service connected disabilities. A TDIU may be assigned where the schedular rating is less than total when the disabled Veteran is, in the judgment of the Board, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, this shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent disability or more. 38 C.F.R. § 4.16(a). The Veteran is currently service connected for hypertension (rated at 30 percent); for diabetes mellitus (rated at 20 percent); for peripheral neuropathy of all four extremities (rated at 10 percent for each extremity); for diabetic retinopathy (rated at 20 percent); for pterygium of the right eye (rated as noncompensable); and for erectile dysfunction (rated as noncompensable). His combined disability rating is 70 percent including the addition of a bilateral factor. While he does not receive a single 40 percent disability rating, the Veteran receives multiple ratings for his diabetes mellitus and the associated complications (namely peripheral neuropathy of all four extremities, diabetes mellitus, hypertension, and diabetic retinopathy) which when combined result in a rating that is well in excess of 40 percent. See 38 C.F.R. § 4.25. As such, the Veteran's disabilities have satisfied the schedular criteria set forth in 38 C.F.R. § 4.16(a) for the duration of his appeal. However, meeting the schedular criteria does not result in an automatic grant of TDIU. It is undisputed that the Veteran has not worked during the course of his appeal. The issue is thus whether the Veteran's service-connected disabilities alone, or in combination, are of such severity as to render him unable to obtain or maintain substantially gainful employment. While the Veteran has not been provided with a VA opinion which contemplates all of his service connected disabilities and their combined impact on his employability, such is not required. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013) (In a TDIU determination, "VA's duty to assist does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities."). In January 2009, Dr. Ortiz wrote that the Veteran was unable to work due to his emotional and pathological problems. In February 2009, the Veteran wrote that he had tried to go to work but had not been able to on account of his diabetes related complications. He indicated that he had last worked fulltime in 2001 as a construction supervisor. At a VA diabetes examination in February 2009, the examiner noted that the Veteran was not employed, but found that his diabetes mellitus had only a mild impact on chores, shopping, exercise, recreation and traveling, and had no impact on feeding, bathing, dressing, toileting, grooming, or driving. It was noted that the Veteran was a supervisor in the past and that he had retired in 2001 after being eligible by age or duration of work. The Board acknowledges that a finding that the Veteran retired because of age in 2001 does not in and of itself mean that he is capable of obtaining and/or maintaining substantially gainful employment in 2013. However, by the same token, it does not serve as evidence that his diabetes mellitus precluded substantially gainful employment. A VA examiner in February 2009 indicated that the Veteran's erectile dysfunction did not affect his activities of daily living. At his peripheral neuropathy examination in February 2009, it was noted that the Veteran's peripheral neuropathy had mild impact on chores, shopping, exercise, sports, and traveling, and it had no impact on recreation, feeding, bathing, dressing, toileting, and grooming. It was noted that the Veteran had retired on account of medical problems, including his diabetes mellitus. At a VA psychiatric examination in June 2011, it was noted that the Veteran had retired and the cause was eligible by age or duration of work, and medical (physical problem). The Veteran reported that he was feeling sick and tired, and thought he had leukemia, along with the fact that he had already worked for 29 years. In April 2013, a VA examiner opined that the Veteran's eye conditions did not impact his ability to work. Another examiner opined that the Veteran's peripheral neuropathy did impact his ability to work, but only in that it caused mild impairment with walking. Another examiner opined that the Veteran's kidney condition (which caused his hypertension) did not impact his ability to work. At a diabetes VA examination in July 2013, the examiner opined that the Veteran's diabetes mellitus and complications did not impact his ability to work. The examiner explained that the diabetes mellitus and diabetic nephropathy did not interfere with his employability. Here, Dr. Ortiz suggested that the Veteran could not work on account of his medical problems, but his opinion is simply not persuasive in light of the objective findings. His opinion is one piece of evidence to be weighed along with all the other evidence, and, here, it is not persuasive. The Veteran has been examined on a number of occasions, but the examiners repeatedly found that the Veteran's service connected disabilities had limited to no impact on his ability to work. The Board has independently reviewed all of the statements from the medical professionals, including Dr. Ortiz, but concludes that they do not establish that the Veteran's service connected disabilities are of such severity as to render him unable to obtain or maintain substantially gainful employment. As such, the criteria for a TDIU have not been met, and the Veteran's claim is denied. [Continued on next page] ORDER A rating in excess of 20 percent for diabetes mellitus is denied. A rating in excess of 30 percent for hypertension with proteinuria is denied. A rating in excess of 20 percent for nonproliferative diabetic retinopathy is denied. A rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. A rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. A rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. A rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. A compensable rating for erectile dysfunction is denied. A compensable rating for pterygium is denied. Service connection for an acquired psychiatric disability, other than PTSD, is denied. A TDIU is denied. ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs