Citation Nr: 1622927 Decision Date: 06/08/16 Archive Date: 06/21/16 DOCKET NO. 06-14 394A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to an initial rating in excess of 40 percent for peripheral neuropathy of the right lower extremity, to include a separate rating prior to January 24, 2011. 3. Entitlement to an initial rating in excess of 40 percent for peripheral neuropathy of the left lower extremity, to include a separate rating prior to January 24, 2011. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from March 1966 to February 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from July 2005 and May 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. FINDINGS OF FACT 1. Manifestations of the Veteran's diabetes mellitus include poorly controlled blood sugar levels that require treatment, with an oral hypoglycemic agent; insulin injections; and a restricted diet, without regulation of occupational or recreational activities by a medical professional. 2. The Veteran's diabetic complications of diabetic retinopathy and erectile dysfunction do not manifest to a compensable level. 3. Prior to June 3, 2006, manifestations of the Veteran's peripheral neuropathy include occasional burning and tingling in the bilateral lower extremities, without objective evidence of neurological impairment that most nearly approximate mild incomplete paralysis of the sciatic nerves. 4. From June 3, 2006 to December 2, 2008, manifestations of the Veteran's peripheral neuropathy include decreased sensation in the bilateral lower extremities that most nearly approximate moderate incomplete paralysis of the sciatic nerves. 5. From December 3, 2008 to December 12, 2012, manifestations of the Veteran's peripheral neuropathy include decreased sensation and reflexes in the bilateral lower extremities leading to ambulation and balance deficiencies that most nearly approximate moderately severe incomplete paralysis of the sciatic nerves. 6. From December 13, 2012, manifestations of the Veteran's peripheral neuropathy include decreased sensation and reflexes in the bilateral lower extremities leading to ambulation and balance deficiencies that most nearly approximate severe incomplete paralysis of the sciatic nerves. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.79, 4.115b, 4.119, Diagnostic Codes 6006, 7522, 7913 (2015). 2. The criteria for a separate rating of 10 percent, but no more, for peripheral neuropathy of the right lower extremity prior to June 3, 2006 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 3. The criteria for a separate rating of 10 percent, but no more, for peripheral neuropathy of the left lower extremity prior to June 3, 2006 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 4. The criteria for a rating of 20 percent, but no more, for peripheral neuropathy of the right lower extremity from June 3, 2006 to December 2, 2008 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 5. The criteria for a rating of 20 percent, but no more, for peripheral neuropathy of the left lower extremity from June 3, 2006 to December 2, 2008 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 6. The criteria for a rating of 40 percent, but no more, for peripheral neuropathy of the right lower extremity from December 3, 2008 to December 12, 2012 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 7. The criteria for a rating of 40 percent, but no more, for peripheral neuropathy of the left lower extremity from December 3, 2008 to December 12, 2012 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 8. The criteria for a rating of 60 percent, but no more, for peripheral neuropathy of the right lower extremity from December 13, 2012 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 9. The criteria for a rating of 60 percent, but no more, for peripheral neuropathy of the left lower extremity from December 13, 2012 are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Diabetes Mellitus Entitlement to service connection for diabetes mellitus was awarded in the July 2005 rating decision on appeal, with an initial 20 percent evaluation assigned effective March 17, 2005. Thereafter, an effective date of March 17, 2004, for service connection for diabetes mellitus was granted in a May 2007 rating decision. The Veteran's diabetes mellitus is therefore rated as 20 percent disabling throughout the claims period from March 17, 2004. Service connection was also awarded for retinopathy and erectile dysfunction as diabetic complications in a July 2006 rating decision, with noncompensable evaluations assigned effective January 18, 2006. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2015). The Veteran's diabetes mellitus is rated under Diagnostic Code 7913 pertaining to diabetes mellitus. 38 C.F.R. § 4.119, Diagnostic Code7913. Diagnostic Code 7913 provides that when diabetes mellitus requires insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet, a 20 percent evaluation is merited. Id. When insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) are required, it is evaluated as 40 percent disabling. Id. Diabetes mellitus 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 rated, is rated 60 percent disabling. Id. Diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions, requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. Note (1) following the rating criteria provides that compensable complications of diabetes mellitus are rated separately unless they are used to support a total disability rating. Id. at Note (1). The criteria for ratings higher than 20 percent for diabetes mellitus are conjunctive not disjunctive-i.e., there must be insulin dependence and restricted diet and regulation of activities. "Regulation of activities" is defined by Diagnostic Code 7913 as the "avoidance of strenuous occupational and recreational activities." Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). After review of the evidence of record, the Board finds that the Veteran's diabetes mellitus does not meet the criteria associated with an increased evaluation. Although the record establishes that the Veteran's diabetes mellitus is treated with an oral hypoglycemic agent, insulin, and a restricted diet, the evidence does not establish regulation of activities. Private and VA treatment records do not document any instance where the Veteran's diabetic care providers advised him to avoid strenuous occupational and recreational activities due to diabetes mellitus. In fact, his VA primary care physician, endocrinologist, and nutritionist regularly advised the Veteran to exercise throughout the claims period and have encouraged, rather than restricted, strenuous recreational activities. Additionally, VA examiners in June 2005, June 2006, and December 2012 found that the Veteran's diabetes mellitus was managed by medication and a restricted diet. The June 2006 VA examiner also specifically noted that the Veteran's diabetes mellitus did not require regulation of activities. The Board has considered the Veteran's lay statements and testimony. He testified during a March 2016 hearing before the Board that he had difficulty exercising and walking and used a cane. He also testified that his ambulation was affected by diabetes mellitus and he frequently fell. The Veteran's statements are competent evidence to report symptoms that he experiences, such as an unsteady gait and frequent falls, but his opinion as to whether exercise would cause complications and risks associated with the control of his diabetes mellitus, and thereby such exercise should be regulated, cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). The competent evidence establishes that the Veteran's occupational and recreational activities have not been restricted at any time during the claims period due to diabetes mellitus. The record also does not establish that the Veteran's disability meets the criteria associated with an increased rating under Diagnostic Code 7913. The Veteran has consistently denied experiencing episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization. Review of VA treatment records also demonstrates that he has not visited his diabetic care provider twice a month. The Veteran's diabetes mellitus requires more than one daily injection of insulin, as included in the criteria for a 100 percent rating under Diagnostic Code 7913, but does not manifest symptoms of the severity contemplated by a total schedular rating. At no time during the claims period has the Veteran required regulation of activities or hospitalization due to diabetes mellitus, and rather than manifest progressive loss of weight, his treating physicians have consistently counseled him to lose weight to improve his health. In short, while the Veteran may manifest some of the criteria associated with a schedular rating in excess of 20 percent, as noted above, the criteria for ratings in excess of 20 percent for diabetes mellitus are conjunctive not disjunctive. Thus, an increased rating under Diagnostic Code 7913 is not warranted. The note following Diagnostic Code 7913 provides that compensable complications of diabetes mellitus are rated separately unless they are used to support a total disability rating. 38 C.F.R. § 4.119, Diagnostic Code 7913. The Veteran's service-connected diabetes mellitus includes complications of bilateral retinopathy and erectile dysfunction. While diabetic retinopathy was diagnosed upon VA examinations in June 2006 and December 2011, has not been identified during eye examinations performed during the claims period at the VA Medical Center. Additionally, the June 2006 VA examiner found that the Veteran's retinopathy did not have any significant effects on functioning and the December 2011 VA examiner concluded there was no associated decrease in visual acuity or other visual impairment. Retinopathy is rated under Diagnostic Code 6006 based on the frequency and duration of incapacitating episodes of acute symptoms requiring bed rest prescribed by a physician. 38 C.F.R. § 4.79. As the Veteran has not experienced any such incapacitating episodes during the claims period and the condition has not manifested to a compensable level, a separate evaluation is not warranted. The Veteran's erectile dysfunction has also not manifested to a compensable level. Erectile dysfunction is not specifically listed in the Rating Schedule and is rated by analogy to deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. This diagnostic code provides a 20 percent rating. Although the Veteran experiences erectile dysfunction due to diabetes mellitus, there is no evidence he manifests any physical deformity of the penis. VA examinations performed in June 2006 and December 2012 indicate a normal penis, and his erectile dysfunction was treated with medication provided through VA. Special monthly compensation from VA based on the loss of use of a reproductive organ has been granted due to the Veteran's service-connected erectile dysfunction. As his erectile dysfunction is not accompanied by any deformity, a separate compensable rating is not warranted. Finally, while there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected diabetes mellitus, the evidence shows no distinct periods of time during the appeal period when the Veteran's service-connected diabetes mellitus varies to such an extent that a rating greater or less than the initial 20 percent assigned in the July 2005 rating decision is warranted. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Peripheral Neuropathy of the Lower Extremities Service connection was granted for diabetes mellitus in the July 2005 rating decision on appeal. At that time, the disability was characterized as "diabetes mellitus with symptoms of peripheral neuropathy." The July 2005 rating decision referenced the Veteran's complaints of occasional burning and tingling in the bilateral lower extremities, but determined that a separate compensable rating was not warranted for the diagnosed peripheral neuropathy, as there was no objective medical evidence of nerve impairment. The Veteran's diabetes mellitus and associated peripheral neuropathy of the bilateral lower extremities were therefore rated together and assigned a single 20 percent evaluation effective March 17, 2005. An earlier effective date of March 17, 2004 for the award of service connection was later assigned in a May 2007 rating decision. In May 2015, a rating decision assigned separate 40 percent evaluations for peripheral neuropathy of each lower extremity effective from January 24, 2011. The Veteran contends that separate ratings should be assigned prior to January 24, 2011 as his diabetes mellitus manifested peripheral neuropathy since at least 2005. He also contends that increased ratings are warranted as each leg is productive of severe neurological impairment associated with peripheral neuropathy. Disability involving a neurological disorder is ordinarily rated in proportion to the impairment of motor, sensory, or mental function. When the involvement is wholly sensory, the rating should be for the mild, or, at most, the moderate degree. 38 C.F.R. §§ 4.120, 4.124a. The Veteran's peripheral neuropathy of the bilateral lower extremities is currently assigned separate 40 percent ratings for each leg under Diagnostic Code 8520 pertaining to paralysis of the sciatic nerve. Diagnostic Code 8520 provides for a 10 percent rating for mild incomplete paralysis of the sciatic nerve, a 20 percent rating for moderate incomplete paralysis, a 40 percent rating for moderately-severe incomplete paralysis, and a 60 percent rating for severe incomplete paralysis, with marked muscular atrophy. A maximum 80 percent rating is assigned with complete sciatic nerve paralysis when the foot dangles and drops, no active movement is possible of the muscles below the knee, flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board finds that staged separate ratings are warranted for the Veteran's peripheral neuropathy of the bilateral lower extremities throughout the claims period, i.e. effective from March 17, 2004. See Fenderson at 126. Prior to June 3, 2006, separate 10 percent ratings are appropriate for peripheral neuropathy of each lower extremity for mild incomplete paralysis of the sciatic nerve. From June 3, 2006 to December 2, 2008, higher 20 percent ratings are warranted for moderate incomplete paralysis, and 40 percent ratings are warranted for the period from December 3, 2008 to December 12, 2012, for moderately-severe incomplete paralysis. From December 13, 2012, manifestations of the Veteran's lower extremity peripheral neuropathy are severe incomplete paralysis, and 60 percent ratings are assigned under Diagnostic Code 8520. During the period prior to June 3, 2006, the Veteran's peripheral neuropathy was productive of occasional burning and tingling of the bilateral lower extremities without objective medical evidence of nerve dysfunction. The Veteran complained of "some occasional burning and tingling in the lower extremities" at a June 2005 VA examination. Neurological examination at that time was normal with intact sensation and no motor deficits. Similarly, the Veteran did not manifest any neurological abnormalities of the lower extremities during a December 2005 new patient evaluation at VA or a follow-up visit in April 2006. The Veteran's statements are competent evidence to report symptoms of burning pain and tingling in his lower extremities, but there is no competent medical evidence of neurological dysfunction during the period prior to June 3, 2006. Accordingly, separate 10 percent ratings are warranted during this period for mild incomplete paralysis of the bilateral sciatic nerves. The Veteran's peripheral neuropathy of the lower extremities was moderate during the period from June 3, 2006 to December 2, 2008, and therefore 20 percent ratings are warranted. Upon VA examination in June 2006, the Veteran reported symptoms similar to those noted at the June 2005 VA examination, but neurological testing showed decreased sensation in the feet. The Veteran was provided medication for neuropathy at VA in December 2006 and sensation was absent in the feet during a January 2007 podiatry consultation. His VA endocrinologist also estimated a 65 percent loss of sensation in the feet in July 2008. The June 2006 VA examiner found that there was no motor or reflex impairment associated with lower extremity peripheral neuropathy and VA treatment records do not document abnormalities other than the sensory loss noted above. The Board therefore finds the peripheral neuropathy was moderate during the period from June 3, 2006 to December 2, 2008, and separate ratings of 20 percent, but no more, are appropriate. See 38 C.F.R. §4.124a (when nerve impairment is wholly sensory, the rating should be at most for the moderate degree). From December 3, 2008 to December 12, 2012, an increased 40 percent rating for each leg is warranted for moderately-severe peripheral neuropathy. The Veteran's neuropathy was characterized as "significant" by private physicians at the Mayo Clinic in December 2008 and February 2009 and diminished reflexes were found during the February 2009 private examination. Lower extremity reflexes were also absent at a January 2012 VA neurological consultation and diminished sensation was shown below the knee during this period. The Veteran reported experiencing repeated falls beginning in December 2008, and his gait abnormality was attributed to lower extremity neuropathy by private doctor at that time. A VA neurologist also determined that the Veteran had continued navigation difficulty due to peripheral neuropathy in October 2012. Despite these findings, VA treatment records establish that the Veteran had several nonservice-connected conditions that also affected his ambulation and balance during this period, including vascular changes in the legs and an expanding left occipital meningioma. Furthermore, objective testing is consistent with moderately-severe incomplete paralysis. A VA nerve conduction study performed in January 2011 demonstrated lower extremity peripheral neuropathy moderate to severe in severity with motor and sensory involvement. The Board therefore finds that 40 percent ratings are warranted from December 3, 2008 to December 12, 2012, but not higher, as the lower extremity peripheral neuropathy most nearly approximates moderately severe incomplete paralysis of the sciatic nerves. Finally, during the period beginning December 13, 2012, the Veteran's peripheral neuropathy warrants a 60 percent evaluation for each lower extremity for severe incomplete paralysis of the sciatic nerves. Upon VA examination in December 2012, the Veteran was found to manifest severe numbness of the bilateral feet along with symptoms of constant pain and paresthesias. Strength and reflexes of the lower extremities were reduced and the Veteran was unable to walk more than 100 yards due to pain in his feet. He was also unable to feel the ground due to the absent sensation in his feet and toes. The Veteran's balance was described as "precarious" during a January 2013 prosthetics consultation at VA and he was provided an increased dose of nerve pain medication by his VA primary care provider in May 2015. The Veteran also testified at the March 2016 hearing that he experienced extreme pain, numbness, and discomfort in his lower extremities. While there are no findings of marked muscular atrophy in the record, with consideration of the functional impairment associated with the disability, the Board finds that the Veteran's peripheral neuropathy of the bilateral lower extremities most nearly approximates severe incomplete paralysis during the period beginning December 13, 2012. The Board has considered whether maximum 80 percent evaluations are appropriate during this period, but finds that the Veteran's disability does not show complete paralysis. There are no indications of foot drop and the Veteran had normal sensation of the bilateral knees and thighs during the December 2012 VA examination. In fact, the VA examiner characterized the neurological disability as incomplete paralysis that was only moderately-severe in degree. The Veteran's ability to ambulate and balance was also worsened by his nonservice-connected meningioma during this period; he reported experiencing dizziness, light-headedness, and falling due to the brain tumor at VA in September 2014. He underwent a resection of the meningioma at a private hospital in February 2015 following a seizure and while he testified in March 2016 he still experienced problems with falling, he also testified he had advancing vascular deficiencies in his legs including blood clots. Thus, complete paralysis of either lower extremity due to the service-connected peripheral neuropathy has not been shown. In sum, the Board finds that prior to June 3, 2006, 10 percent ratings are warranted with increased 20 percent ratings assigned from June 3, 2006 to December 2, 2008. During the period from December 3, 2008 to December 12, 2012, 40 percent ratings are warranted, while 60 percent ratings, but no more, are assigned for the period beginning December 13, 2012. To this extent, the claims for increased and separate ratings for peripheral neuropathy of the lower extremities are granted. Other Considerations Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2015). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2015). 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned ratings inadequate. The Veteran's service-connected diabetes mellitus and peripheral neuropathy of the lower extremities are evaluated under disorders of the endocrine system and neurological disorders, the criteria which are found by the Board to specifically contemplate the severity of the disabilities. Id. Manifestations of the Veteran's diabetes mellitus include impairment to blood sugar control necessitating treatment with insulin and a restricted diet. The Veteran also experiences erectile dysfunction and diabetic retinopathy that are noncompensable in severity as a result of his diabetes mellitus. His peripheral neuropathy of the lower extremities manifests a varying degree of nerve impairment resulting in a loss of sensation, motor deficits, and ambulation and balance problems. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by the ratings assigned herein. Higher evaluations are possible for diabetes mellitus and peripheral neuropathy, but the medical evidence demonstrates that those manifestations are not present in this case, as discussed in detail in the analysis above. The current disability evaluations reasonably describe the Veteran's disability level and symptomatology with regard to his service-connected diabetes mellitus and lower extremity peripheral neuropathy. The Board has also considered whether an award of a total disability rating due to individual employability resulting from service-connected disability (TDIU) is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009); see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case, the Veteran has not claimed that he is unemployable due to service-connected diabetes mellitus and/or peripheral neuropathy. The record establishes that he was employed as a corrections officer until July 13, 2009 when he was terminated due to physical restrictions associated with a nonservice-connected left ankle fracture incurred at work in December 2008. The Veteran experiences some functional impairment due to his diabetes mellitus and peripheral neuropathy, but he is also in receipt of a total schedular rating from October 25, 2011 and a claim for TDIU was most recently adjudicated by the originating agency in an August 2014 rating decision and February 2016 statement of the case. Thus, remanding a claim for TDIU is not required. Finally, in reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the assignment of any ratings higher than those currently assigned, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial rating in excess of 20 percent for diabetes mellitus is denied. A separate rating of 10 percent, but no more, for peripheral neuropathy of the right lower extremity from March 17, 2004 to June 2, 2006 is granted, subject to the laws and regulations governing the payment of monetary benefits. A separate rating of 10 percent, but no more, for peripheral neuropathy of the left lower extremity from March 17, 2004 to June 2, 2006, is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating of 20 percent, but no more, for peripheral neuropathy of the right lower extremity from June 3, 2006 to December 2, 2008, is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating of 20 percent, but no more, for peripheral neuropathy of the left lower extremity from June 3, 2006 to December 2, 2008, is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating of 40 percent, but no more, for peripheral neuropathy of the right lower extremity from December 3, 2008 to December 12, 2012, is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating of 40 percent, but no more, for peripheral neuropathy of the left lower extremity from December 3, 2008 to December 12, 2012, is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating of 60 percent, but no more, for peripheral neuropathy of the right lower extremity from December 13, 2012, is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating of 60 percent, but no more, for peripheral neuropathy of the left lower extremity beginning December 13, 2012 is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs