Citation Nr: 1601411 Decision Date: 01/13/16 Archive Date: 01/21/16 DOCKET NO. 14-20 457 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial rating evaluation higher than 30 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a rating evaluation higher than 40 percent for service-connected diabetes mellitus, type II. 3. Entitlement to a rating evaluation higher than 10 percent for service-connected peripheral neuropathy of the lower left extremity. 4. Entitlement to a rating evaluation higher than 10 percent for service-connected peripheral neuropathy of the lower right extremity. 5. Entitlement to a compensable rating evaluation for service-connected erectile dysfunction. 6. Entitlement to an effective date earlier than April 15, 2008, for the grant of special monthly compensation based on loss of use of a creative organ. 7. Entitlement to service connection for an eye condition. 8. Entitlement to service connection for a left foot condition, to include callouses and hammer toes. 9. Entitlement to service connection for a right foot condition, to include callouses and hammer toes. 10. Entitlement to service connection for a skin condition, to include as a result of exposure to herbicides. REPRESENTATION Appellant represented by: Pennsylvania Department of Military and Veterans Affairs ATTORNEY FOR THE BOARD R. Sauter, Associate Counsel INTRODUCTION The Veteran had active service from February 1966 to February 1968 and from January 2003 to May 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from June 2008 and August 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The issues of service connection for the left and right foot conditions and the skin condition are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire initial rating period on appeal, the Veteran's service-connected PTSD was manifested by no more than moderate symptoms or moderate difficulty in social or occupational functioning as a result of sleep disturbances and frequent thoughts of events in service. 2. For the entire appeal period, bilateral peripheral neuropathy of the lower extremities primarily consists of mild sensory impairment consisting of complaints of pain in each lower extremity. 3. The Veteran's diabetes does not result in episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. 4. The Veteran's erectile dysfunction results in loss of erectile power but no physical deformity of the penis. 5. There was no claim, formal or informal, of entitlement to special monthly compensation for loss of use of a creative organ filed before April 15, 2008. 6. The currently diagnosed eye condition was not incurred in service, is not related to a service-connected disability, and is not otherwise related to service CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for the award of a disability rating in excess of 10 percent, for right lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1-4.7, 4.120, 4.124, 4.124(a), Diagnostic Code 8521 (2015). 3. The criteria for the award of a disability rating in excess of 10 percent, for left lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1-4.7, 4.120, 4.124, 4.124(a), Diagnostic Code 8521 (2015). 4. The criteria for the award of a disability rating in excess of 40 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102. 3.159, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2015). 5. The criteria for a compensable rating for the erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.350, 4.3, 4.7, 4.14, 4.115b, Diagnostic Code 7522 (2015). 6. The criteria for an effective date earlier than April 15, 2008, for the grant of special monthly compensation based on loss of use of a creative organ have not been met. 38 U.S.C.A. §§ 1114(k), 5101, 5110, 7105; (West 2014); 38 C.F.R. § 3.151, 3.400, 3.350 (2015). 7. The criteria for service connection for an eye condition have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). As the PTSD claim concerns an initial rating and comes before the Board on appeal from the decision which also granted service connection, there can be no prejudice to the Veteran from any alleged failure to give adequate 38 U.S.C.A. § 5103(a) notice for the service connection claim. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement). Similarly, the question of the appropriate effective date to be assigned is also a downstream element of the award of service connection, and no further notice is required with regard to the earlier effective date claim. Hart v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). In claims for increased rating, the VCAA requires generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO issued a preadjudicatory notice letter dated in May 2013 to the Veteran which met the VCAA notice requirements. Regarding the service connection claims, the VCAA duty to notify initially was satisfied by way of a pre-adjudicatory letter the RO sent to the Veteran in May 2013. These letters informed of the evidence required to substantiate the claim and of the respective responsibilities in obtaining this supporting evidence, including advising of how disability ratings and effective dates are assigned. Thus, the appellant has received all required notice concerning the claim. VA also has a duty to assist a claimant in the development of a claim. This duty includes assisting in the procurement of service treatment records (STRs) and pertinent post-service treatment records (VA and private) and providing an examination when needed to assist in deciding the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished. The claims file contains the Veteran's STRs, VA medical treatment evidence, and the Veteran's statements. The Veteran underwent a VA examinations for his PTSD in June 2013 and September 2014. He underwent examinations for diabetes, peripheral neuropathy, and erectile dysfunction in May 2008, June 2013 and September 2014. He had a VA eye examination in June 2013. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations and opinions are adequate because they were performed by medical professionals, and were based on a review of the record and history and symptomatology from the Veteran and a thorough examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran has not identified, and the record does not otherwise suggest, any additional existing evidence that is necessary to decide this claim that has not been obtained and that is obtainable; therefore, no further notice or assistance with this claim is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). VA's duties to notify and assist with this claim have been satisfied. Increased Evaluations Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2014). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board must assess the credibility and weight of evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to the appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the appeal. Initial Rating for PTSD The Veteran seeks an increased evaluation for posttraumatic stress disorder (PTSD), currently rated as 30 percent disabling. The Veteran's service-connected PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the provisions for rating psychiatric disorders, a 30 percent disability evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating requires evidence of the following: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting; inability to establish and maintain effective relationships.) The criteria for a 100 percent rating are: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. At a June 2013 VA PTSD examination, the Veteran reported frequent intrusive thoughts about his friend and about his cousin who were killed in Vietnam while he was not. The examiner observed unremarkable psychomotor activity, thought process, and thought content; spontaneous speech; cooperative attitude toward examiner; appropriate affect, orientation, judgment, and attention, anxious mood; and no delusions. He has disturbed sleep and sleeps about 3-4 hours a night. The Veteran does not have obsessive/ritualistic behavior, panic attacks, or homicidal or suicidal thoughts. Memory was normal. He reported experiencing recurrent and intrusive distressing recollections of events in service, including images, thoughts, or perceptions, and recurrent distressing dreams of the event. He makes efforts to avoid activities, places, or people that arouse recollections of the trauma, and has a markedly diminished interest or participation in significant activities, with feelings of detachment or estrangement from others. He has difficulty falling or staying asleep, experiences irritability or outbursts of anger, and has difficulty concentrating. The examiner opined that the Veteran's symptoms fluctuate between mild and moderate, but are more mild than moderate. He was provided another examination in September 2014. The examiner summarized his level of occupational and social impairment as being manifested by an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. He reported that he currently lives with wife, of almost 40 years. He describes their relationship "up and down," citing frequent arguments. He reported a good relationship with his four children. He has been working part time as a boat detailer for the past years, and spends time with his co-workers. He reported that he gets along with most of his co-workers and bosses. He has not experienced any discipline issues at work and he has not missed days at work due to emotional issues. He reports that he enjoys work and his work environment. He goes to a regular dinner with other Veterans and he reported that he enjoys this activity. He enjoys hunting and spending time with his two grandchildren as well. He has not been participating in behavioral health services since the last examination in June 2013, and he is not taking any psychotropic medications. He reports that several of his friends from the military recently passed away, and he has subsequently been thinking more about his deployment to Vietnam and about his losses there. He has been having unwanted memories related to experiences in Vietnam, and he also reported somewhat disturbed sleep with frequent awakening throughout the night, loss of interest in activities he used to enjoy as well as feelings of "super alertness." He is irritable at home and has frequent arguments with his wife. The examiner remarked that his symptoms seem to affect him more so at home and less at work. He denied hallucinations, delusions, paranoia, obsessive-compulsive thinking/behaviors, experiencing episodes of hypomania or mania, or suicidal or homicidal ideation, intent or plan. He was alert, oriented and made good eye contact. Speech was of normal rate, rhythm and volume. Mood was generally euthymic and affect was full range and congruent with mood. Thought process was logical, coherent and goal-directed. Thought content was free of hallucinations, delusions and paranoia. There was no evidence of an underlying thought disorder noted during the session. The examiner opined that the Veteran's symptoms "do not appear to have intensified since the last C&P evaluation completed in 2013." The Veteran was offered a referral to behavioral health services, but declined, stating that he has support from his friends and family. He submitted a statement with his January 2012 service connection claim asserting that his symptoms included, "intrusive thoughts, avoidance, hyperarousal, survivor's guilt." He presented the following arguments with his August 2013 notice of disagreement as to the assigned rating for PTSD: "I am continuing to experience intrusive thoughts (recalling my combat stressors daily from both Wars that interfere with my daily living activities; avoidance behavior (not wanting to think about, discuss or receive counseling for my combat stressors and intentionally avoiding people that I don't know); hyperarousal (displays of anger without a reason to do so); and survivor's guilt (feeling that I could have done something to change the outcomes of what I experienced in Vietnam and Kuwait, especially in Vietnam, because I saw the dead bodies of some of the servicemen that I had gotten to know and service with). "I have continued to experience moderate to severe impairments in occupational, school, family relationships, judgment, moods and work-like settings, such as: a. severe panic attacks, at least 3 times a week and depression affecting my ability to function independently, appropriately and effectively; b. impaired judgment, when I am experiencing my panic attacks; c. repeated rituals that interfere with routine activities (dressing in military gear, being clean all of the time and trying my best to be friendly or to please everyone, whether I know them or not); d. disturbances of motivation and moods, when I am experiencing my panic attacks; e. moderate to severe difficulty in establishing and maintaining work and social relationships; f. sometimes I am unable to determine where I am or get disoriented while driving in familiar places; g. forgetting to complete tasks and difficulty in adjusting to stressful situations at work or work-like settings; h. display unprovoked anger, impaired impulse control or unprovoked irritability with displays of violence, when I think persons are trying to make fun of me or my military service; i. sometimes speaking about irrelevant information that has nothing to do with the subject that other persons and I were initially talking about." Evaluating the lay and medical evidence in light of the above rating criteria reflects that the Veteran's symptoms do not manifest with occupational and social impairment with reduced reliability and productivity. Rather, the records consistently show that he has good relationships with friends, family, and co-workers. He has reported arguing frequently with his wife, but never acting violently toward her or anyone else. He has never reported missing work due to PTSD symptoms, or having any altercations or other difficulties requiring disciplinary action at work. The examiners have consistently described the Veteran's speech as normal and always described his judgment and thinking as intact. He was never noted to have panic attacks or impairment of memory during any of the examinations. Nor do the symptoms the Veteran had during this period manifest with such frequency and severity that it more nearly approximated the criteria for a higher rating. The evidence reflects that during this period the Veteran complained of difficulty sleeping, intrusive thoughts of Vietnam, and irritability with his wife. The evidence also reflects that he has good relationships with his children and grandchildren, has maintained friendships with other veterans, and has good relationships with his co-workers and bosses. The Veteran contends that his PTSD symptoms are worse than those contemplated by the currently assigned rating. However, the clinical evidence of record does not support this contention. Although he claims that he experiences frequent panic attacks, the clinical evidence does not show that he meets the diagnostic criteria for panic attacks. He did not report experiencing panic attacks in any of his VA examinations. Further, although his statements regarding sleep disturbances and intrusive thoughts are competent and credible, the evidence of record does not support that such symptoms cause more than occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran's assertions have been considered, and it is acknowledged that the Veteran is competent to report that on which he has personal knowledge, i.e., what comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, as a layperson, he is not competent to assess the nature and severity of his PTSD, because that is a complex medical question requiring expertise in the field of mental health. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom in a claim for rheumatic heart disease). As such, the Board affords more probative value to the clinical evidence provided by medical professionals. The symptoms the Veteran reported to treating physicians and described in lay statements during this period fail to reflect a severity in occupational and social functioning akin to that contemplated by the higher 50, 70 and 100 percent evaluations. These ratings contemplate functioning so impaired that it results in symptoms such as illogical speech, an inability to function independently, an inability to control impulses, danger of hurting self or others, and an inability to perform activities of daily living. Although the Veteran has competently asserted that he experiences sleep disturbances and intrusive thoughts, the nature and severity of such symptoms do not warrant a higher rating. Accordingly, the Board does not find that the Veteran's symptoms were of such frequency, severity, and duration that they resulted in more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. As the Veteran does not have occupational and social impairment with reduced reliability and productivity, deficiencies in most areas, or total impairment, the Board finds that the criteria for a rating in excess of 30 percent rating are not met. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (holding that a veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration). As the preponderance of the evidence is against the Veteran's appeal of his 30 percent evaluation, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Staged ratings have been considered but are not supported by the record. Increased Rating for Diabetes Mellitus, Type II The Veteran seeks a disability rating in excess of 40 percent for diabetes mellitus, type 2. He asserts this service-connected disability has increased in severity, warranting a higher evaluation. Diabetes mellitus is evaluated under Diagnostic Code 7913, which awards an evaluation of 20 percent for diabetes requiring insulin and a restricted diet, or; oral hypoglycemic agent and a restricted diet. Diabetes controlled through insulin, restricted diet, and regulation of activities warrants an evaluation of 40 percent. An evaluation of 60 percent is warranted for diabetes requiring 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. An evaluation of 100 percent is warranted for diabetes that requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Because of the successive nature of the rating criteria for diabetes, e.g., the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the criteria listed in the 60 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Stated another way, if a component is not met at any one level, a veteran can only be rated at the level that did not require the missing component. Id. At a May 2008 VA examination, he reported a negative history of ketoacidosis or hypoglycemic reactions, or hospitalizations for ketoacidosis or hypoglycemic reactions. He follows a restricted diet and restricts activities. At the time of the examination, he was using oral hypoglycemic agents only, not insulin. He visits his diabetic care provider every three months. He denied any change in vision due to diabetic retinopathy. The Veteran was provided VA examinations in June 2013 and September 2014. Both examiners noted that the Veteran visits his diabetic care provider less than two times per month for episodes of ketoacidosis or hypoglycemia, and has not been hospitalized for episodes of episodes of ketoacidosis or hypoglycemic reactions in the past twelve months. He has not had progressive unintentional weight loss and loss of strength attributable to diabetes. As to the question of whether diabetes impacts the Veteran's ability to work, the VA examiner noted that the Veteran must avoid strenuous activity to avoid hypoglycemic episodes. Overall, after consideration of the totality of the record, the Board finds the preponderance of the evidence to be against the award of a disability rating in excess of 40 percent at any time during the pendency of the appeal. None of the records reflect that the Veteran experiences episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider; nor does the Veteran have any additional complications that would be compensable if separately evaluated. Accordingly, an increased evaluation is denied. Regarding other diabetes-related complications, the Veteran has already been granted separate disability ratings for peripheral neuropathy of the lower extremities, and special monthly compensation for loss of use of a creative organ due to erectile dysfunction. On multiple VA examinations, he has been found to be without diabetic retinopathy; thus, a separate compensable rating based on diabetic retinopathy is not warranted at the present time. In sum, the Board finds that a preponderance of the evidence is against a rating in excess of 40 percent for diabetes mellitus. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Increased Rating for Peripheral Neuropathy of the Right and Left Lower Extremities The Veteran contends that he is entitled to higher ratings for peripheral neuropathy of the right and left lower extremities. Under Diagnostic Code 8521, mild incomplete paralysis is rated as 10 percent disabling, moderate incomplete paralysis is rated as 20 percent disabling, and severe incomplete paralysis is rated as 30 percent disabling. 38 C.F.R. § 4.124a. 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 of 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. At a May 2008 VA examination, Veteran reported that peripheral neuropathy had its onset approximately six months ago. He reported initially having a burning sensation in the right leg noted more when getting up in the mornings periodically. He reported flare ups and periodic burning just below the right knee that occurs periodically. He denied tingling or numbness. The burning sensation only lasts two to three minutes at the most and goes away on its own currently. Overall, he reported that peripheral neuropathy is manifested by positive sensory abnormalities of occasional burning. He denied that peripheral neuropathy interferes with his daily activities. At the June 2013 VA examination, the Veteran was assessed as having moderate intermittent pain, moderate paresthesias, and moderate numbness of the lower extremities. Muscle strength testing and deep tendon reflexes were within normal limits. Sensation testing of the lower extremities for light touch was decreased bilaterally. Mild incomplete paralysis was found in the sciatic nerves, the external popliteal nerves, the musculocutaneous nerves, the anterior tibial nerves, the internal popliteal nerves, and the posterior tibial nerves. No paralysis was found in any of the other nerves. As to the questions of whether the nerve condition affects the Veteran's ability to work, the examiner remarked that the Veteran is intolerant of excessive, repetitive, or prolonged activity of the bilateral lower extremities; prolonged inactivity of the bilateral lower extremities; prolonged standing and walking. Additionally, the Veteran loses balance, stumbles, and falls more frequently. Upon examination in September 2014, the Veteran was again assessed as having moderate intermittent pain, moderate paresthesias, and moderate numbness of the lower extremities. Muscle strength testing and deep tendon reflexes were within normal limits. Sensation testing of the lower extremities for light touch was decreased bilaterally. Mild incomplete paralysis was found in the musculocutaneous nerves and the anterior tibial nerves. No paralysis was found in any of the other nerves. As to the questions of whether the nerve condition affects the Veteran's ability to work, the examiner remarked that the Veteran is intolerant of excessive, repetitive, or prolonged activity of the bilateral lower extremities; prolonged inactivity of the bilateral lower extremities; prolonged standing and walking. Additionally, the Veteran loses balance, stumbles, and falls more frequently. The Board finds that the Veteran's symptoms do not more nearly approximate the next higher, 20 percent rating evaluation. The medical evidence reflects that he has intermittent pain, which has a minimal impact on his ability to work and participate in activities of daily living. Additionally, his lay statements do not indicate that his symptoms are more than mild. For example, the June 2013 and September 2014 examiners noted that the Veteran stumbles and fall more frequently, but did not indicate that this poses a greater than normal risk in his current occupation as a boat detailer. The Veteran stated in May 2008 that his peripheral neuropathy did not interfere with his daily activities. In a June 2013 statement, he noted that peripheral neuropathy causes him to have an altered gait, but he did not assert that this interferes with his occupation or other activities of daily living. The September 2014 VA examiner found no objective evidence of altered gait. A higher, 20 percent rating is not warranted, because moderate and severe symptoms are not shown. The highly probative clinical evaluations generally reflect sensory impairment and do not show additional symptomatology, such as skin/trophic changes, impaired reflexes, or periods of paralysis. The rating criteria limit the findings of severity to moderate for sensory disturbance symptoms. Here, no more than mild symptomology is shown. 38 C.F.R. § 4.124(a). Consequently, a rating in excess of 10 percent is not warranted for either extremity. Id. The Board finds that a rating in excess of 10 percent for the lower extremities is not warranted. The evidence of record does not indicate that the Veteran has incomplete "moderate" or "severe" paralysis of the nerves. The evidence of record indicates that, although walking is impaired, the Veteran has the ability to feel and move his feet and legs; accordingly, paralysis is not present. Neurological symptoms consisting of sensory disturbances cannot be assessed as posing more than moderate incomplete paralysis. 38 C.F.R. § 4.124a. The clinical evidence detailed above shows that the Veteran's peripheral neuropathy symptoms generally consisted of mild sensory disturbances. The clinical evidence weighs against findings of impaired motor function, muscle atrophy, or skin changes in either lower extremity. The Board considers the clinical evidence to be most probative in determining whether additional symptoms such as muscle atrophy, trophic changes, and weakness, among others are present. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table) see Madden v. Brown, 125 F. 3d 1447, 1481 (Fed. Cir. 1997); (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence when weighing evidence). This is because the clinical findings were reported by unbiased medical professionals. Id. Given the limitations for peripheral neuropathy ratings based primarily on sensory disturbances, a finding of moderate or severe partial paralysis for peripheral neuropathy is not warranted. Id.; 38 C.F.R. § 4.124a, DC 8521. The preponderance of the evidence is against the claim for higher than 10 ratings for peripheral neuropathy. Therefore, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. §5107(b); 38 C.F.R. § 3.102. Increased Rating for Erectile Dysfunction The Veteran seeks a compensable rating for erectile dysfunction. Erectile dysfunction is not specifically listed in the rating schedule. Diagnostic Code 7522 provides that deformity of the penis with loss of erectile power is rated 20 percent disabling. This code also notes the adjudicator is to review for entitlement to special monthly compensation under 38 C.F.R. § 3.350. The evaluation of the same manifestations under multiple diagnostic codes, a practice known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. The Veteran has been awarded special monthly compensation under 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350(a)(1) for loss or loss of use of a creative organ. Based on the above, resolution of this appeal ultimately turns on whether the Veteran has deformity of his penis in addition to the loss of erectile power on account of his erectile dysfunction. VA outpatient medical treatment records do not indicate the Veteran has any physical deformity of the genitalia resulting from his erectile dysfunction. No physical deformity of the genitalia was found upon examination in May 2008, when he was first noted to have erectile dysfunction. He was provided VA examinations in June 2013 and September 2014. No physical deformity of the genitalia was found. He was noted to have a voiding dysfunction secondary to benign prostate hypertrophy, not erectile dysfunction. As such, evaluation of the Veteran's erectile dysfunction based on voiding dysfunction is not warranted at the present time. As the Veteran does not presently have a deformity of the penis aside from loss of power, an increased evaluation is not warranted. The preponderance of the evidence is against the award of a separate compensable rating under the diagnostic criteria for erectile dysfunction. As a preponderance of the evidence is against the award of an increased rating, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Extraschedular The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2014); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's service-connected disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required for any period on appeal. The schedular rating criteria specifically provide for disability ratings based on a combination of history and clinical findings. The problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. Additionally, he has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Thus, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The Veteran has not specifically argued, and the record does not otherwise reflect, that his disabilities render him totally unemployable. The most recent VA examinations from September 2014 show that he is currently employed as a boat detailer. Accordingly, a claim for TDIU has not been raised. Earlier Effective Date The Veteran contends he is entitled to an earlier effective date for his award of special monthly compensation for loss of use of a creative organ. Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a). The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or his representative, may be considered an informal claim. An informal claim must identify the benefit sought. If a formal claim is received within one year of an informal claim, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155. Under 38 C.F.R. 3.157(b), once a claim for compensation has been allowed, receipt of a VA outpatient or hospital examination or admission to a VA hospital pertaining to the service-connected disability will be accepted as an informal claim for increased benefits. See Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). The date on the VA outpatient or hospital examination report will be accepted as the date of claim. 38 C.F.R. 3.157(b). The Veteran's claim seeking service connection for erectile dysfunction was received on April 15, 2008. A review of the Veteran's claims file reveals no other applications or statements on the part of the Veteran filed prior to April 15, 2008 that can be interpreted as an informal claim for benefits concerning this issue. In a June 2008 rating decision, the Veteran was awarded service connection for erectile dysfunction as secondary to the service-connected diabetes. He was also awarded special monthly compensation based on the loss of use of a creative organ, effective April 15, 2008, the date that he filed an increased rating claim for diabetes. A May 2008 VA diabetes examination noted his diagnosis of erectile dysfunction secondary to diabetes. That examination notes that the Veteran was first prescribed medication to treat erectile dysfunction on January 3, 2007. No VA examination or hospital admission record pertaining to erectile dysfunction was received within one year of the formal claim. Nor was there any correspondence from the Veteran within one year of the formal claim, such that an informal claim could be inferred. Here, SMC was awarded based on loss of use of a creative organ at the same time that service connection was established for erectile dysfunction. SMC based on loss of use of a creative organ is awarded when it is "...the result of service-connected disability...." 38 U.S.C.A. § 1114(k) (West 2014). As noted above, the date entitlement arose with regard to erectile dysfunction was April 15, 2008. Accordingly, entitlement to an effective date prior to April 15, 2008 for the award of special monthly compensation for loss of use of a creative organ is not warranted. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule is inapplicable. See 38 U.S.C.A. § 5107(b). Service Connection Legal Authority In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). To prevail on the theory of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Service Connection for an Eye Condition The Veteran contends that he has a currently diagnosed eye condition that is due to service-connected diabetes, and thus secondary service connection is warranted. A June 2013 VA examination provided a diagnosis of open angle glaucoma and right eye cataracts. No retinopathy was found. The VA optometrist provided the opinion that neither eye condition is caused by or related to the service-connected diabetes, reasoning that the opinion was supported by a gonioscopy which found no neovascularity of the angles. The Board finds that service connection is not warranted for the currently diagnosed eye condition, as either directly related to service or to service-connected diabetes. The June 2013 VA examiner opined that the eye condition is not related diabetes. VA diabetes examinations of June 2013 and September 2014 did not reveal a diagnosis of diabetic retinopathy. The VA examinations are highly probative medical evidence. The VA examiners were informed of the relevant evidence, relied on accurate facts, and gave fully articulated opinions that were supported by sound reasoning. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board acknowledges the Veteran's contentions that his eye condition is related to his service-connected diabetes. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert, 21 Vet. App. at 462 (concerning rheumatic fever); Jandreau, at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); see 38 C.F.R. § 3.159(a)(2). As a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex eye condition. See Kahana, 24 Vet. App. at 437 (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). The etiology of the current eye condition is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. The Board does not find the Veteran competent to provide evidence of an etiological nexus between the eye condition and his service, or his service-connected diabetes. Accordingly, the preponderance of the evidence is against the claim for service connection for an eye condition, and there is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107(b). ORDER An initial rating in excess of 30 percent for service-connected PTSD is denied. A rating in excess of 40 percent for service-connected diabetes mellitus, type II is denied. A rating in excess of 10 percent for service-connected peripheral neuropathy of the lower left extremity is denied. A rating in excess of 10 percent for service-connected peripheral neuropathy of the lower right extremity is denied. A compensable rating evaluation for service-connected erectile dysfunction is denied. An effective date earlier than April 15, 2008, for the grant of special monthly compensation based on loss of use of a creative organ is denied. Service connection for an eye condition is denied. REMAND A preliminary review of the record reflects that further development is necessary. The record reflects that the Veteran served in Vietnam during his first period of service. He underwent a VA examination for skin diseases in October 1983, where the diagnoses were tinea cruris and tinea pedis. The examiner noted that the Veteran sought care for a skin condition approximately two years after service separation, from a Dr. "C." Although the October 1983 examination was for compensation purposes, no rating decision was ever issued in conjunction with that examination. He reported a history of skin diseases on his July 1984 report of medical history, taken at enlistment into the Army National Guard. He explained on the report that the skin problem was chronic dermatitis secondary to Agent Orange. He also endorsed skin diseases on his August 1992 report of medical history. Although recent VA treatment records do not show any treatment or complaints of a skin condition, the Veteran asserts that he currently experiences a skin condition which he treats with over the counter medications (See statement attached to August 2013 notice of disagreement, page 4). In light of his presumed exposure to herbicides in service, his competent reports of symptoms during service and current symptoms, the medical evidence noting complaints of skin problems shortly after separation, and the absence of any competent medical opinion as to the diagnosis and etiology of the current skin condition, the Board finds that a new examination must be provided. The Veteran asserts that his current bilateral foot condition had its onset during his second period of active duty service. His January 2003 report of medical examination shows normal feet prior to his deployment. No foot examination results were reported on his December 2004 post-deployment examination. VA treatment records as early as August 2005 reflect an ongoing diagnosis of hammertoes. In light of the lack of any foot examination upon separation, the presence of a current foot condition which was diagnosed less than one year after separation, and the Veteran's credible report of experiencing foot symptoms during service, the Board finds that a VA examination must be provided. Accordingly, these matters are REMANDED for the following action: 1. Contact the Veteran and ask him to specify all medical care providers, including any private facilities, who have treated him for his claimed conditions. The AOJ should then obtain and associate with the claims file any records identified by the Veteran that are not already associated with the claims file. The AOJ should specifically request complete treatment records from Dr. C. regarding the Veteran's skin condition. 2. After the above development has been completed, schedule the Veteran for a VA examination as to the etiology of any current skin disability. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should provide opinions as to whether it is as least as likely as not (50 percent probability or more) that any current skin condition had its onset in service, or is otherwise related to service, to include the Veteran's presumed exposure to Agent Orange. A complete rationale should accompany any opinion provided. 3. Schedule the Veteran for a VA examination as to the etiology of any current foot disability. All necessary tests should be conducted. The claims file must be sent to the examiner for review. The examiner should provide opinions as to whether it is as least as likely as not (50 percent probability or more) that any current foot disability had its onset in service, or is otherwise related to service. The examiner is asked to consider the Veteran's competent reports of experiencing foot symptoms in service, and not to rely on the absence of service treatment records documenting such symptoms. A complete rationale should accompany any opinion provided. 4. After completing the above, and any other development deemed necessary, readjudicate the issue on appeal. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ M. Tenner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs