Citation Nr: 1609738 Decision Date: 03/10/16 Archive Date: 03/22/16 DOCKET NO. 03-02 521 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for an enlarged prostate. 2. Entitlement to service connection for erectile dysfunction (ED), including as secondary to service-connected disability. 3. Entitlement to service connection for a gastrointestinal disorder, claimed as gastroesophageal reflux disease (GERD), including as secondary to service-connected disability. 4. Entitlement to an increased rating for peripheral neuropathy of the right foot, rated 0 percent disabling prior to July 9, 2001, and 10 percent disabling from July 9, 2001. 5. Entitlement to an increased rating for peripheral neuropathy of the left foot, rated 0 percent disabling prior to July 9, 2001, and 10 percent disabling from July 9, 2001. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD L. Driever, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from September 1975 to September 1979. These claims come before the Board of Veterans' Appeals (Board) on appeal of October 2001 and December 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified in support of this appeal during hearings held at the RO in June 2003 and November 2007, before Decision Review Officers. (A friend was also present and sworn in, but did not testify.) During the course of this appeal, the Veteran also requested a hearing before the Board, but in December 2008, withdrew that request. The Board remanded these claims to the Agency of Original Jurisdiction (AOJ) for additional development in October 2011, May 2013 and July 2014. VA processed this appeal electronically, utilizing Virtual VA and Veterans Benefits Management System (VBMS), VA's paperless claims processing systems. Review of these claims therefore contemplates both electronic records. FINDINGS OF FACT 1. An enlarged prostate is not related to the Veteran's active service. 2. ED is not related to the Veteran's active service or a service-connected disability, including any medication taken therefor. 3. A gastrointestinal disorder, including GERD, is not related to the Veteran's active service or a service-connected disability, including any medication taken therefor. 4. Prior to July 9, 2001, peripheral neuropathy of the Veteran's right foot caused mild incomplete nerve paralysis. 5. Since July 9, 2001, peripheral neuropathy of the Veteran's right foot has caused mild incomplete nerve paralysis. 6. Prior to July 9, 2001, peripheral neuropathy of the Veteran's left foot caused mild incomplete nerve paralysis. 7. Since July 9, 2001, peripheral neuropathy of the Veteran's left foot has caused mild incomplete nerve paralysis. CONCLUSIONS OF LAW 1. A gastrointestinal disorder, including GERD, was not incurred in or aggravated by active service and is not proximately due to, the result of, or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2015). 2. An enlarged prostate was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 3. ED was not incurred in or aggravated by active service and is not proximately due to, the result of, or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2015). 4. The criteria for entitlement to a 10 percent rating for peripheral neuropathy of the right foot, prior to July 9, 2001, are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.123, 4.124a, Diagnostic Codes (DCs) 8520, 8522, 8620, 8622 (2015). 5. The criteria for entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right foot, from July 9, 2001, are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.123, 4.124a, DCs 8520, 8522, 8620, 8622 (2015). 6. The criteria for entitlement to a 10 percent rating for peripheral neuropathy of the left foot, prior to July 9, 2001, are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.123, 4.124a, DCs 8520, 8522, 8620, 8622 (2015). 7. The criteria for entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left foot, from July 9, 2001, are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1-4.10, 4.123, 4.124a, DCs 8520, 8522, 8620, 8622 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act (VCAA) Upon receipt of a complete or substantially complete application for benefits, VA is tasked with satisfying certain procedural requirements outlined in the VCAA of 2000 and its implementing regulations. 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(a) (2015). Specifically, VA must notify a claimant and his or her representative, if any, of the information and medical or lay evidence not of record that is necessary to substantiate the claim, which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103. VA must also assist a claimant in obtaining evidence necessary to substantiate a claim, including, in certain cases, by affording him or her a medical examination or obtaining a medical opinion. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b), (c). Here, the Veteran does not assert that VA violated its duty to notify or that there are any outstanding records VA should obtain on his behalf. Early in his appeal, he requested VA examinations in support of his claim, but since VA satisfied this request, he has not asserted that an additional examination is needed based on the inadequacy of any prior examination(s). No further notice or assistance is thus needed before discussing the etiology of the Veteran's prostate and gastrointestinal disorders and ED and the severity of his peripheral neuropathy. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (explaining that claimant has the burden of proof of showing there has been an error in developing his claim, but also beyond that, showing it is unduly prejudicial, meaning outcome determinative of his claim, i.e., more than harmless). II. Analysis The Veteran is in receipt of a 100 percent rating for service-connected disabilities, a total disability rating based on unemployability, and special monthly compensation. In a written statement dated November 2013, he indicated that he was satisfied with the 100 percent rating the AOJ assigned and withdrew his claim for service connection for a gallbladder disorder, which was then pending. He did not mention any of the claims then on appeal, which are at issue in this decision; therefore, the AOJ continued to process such claims. Since then, the Veteran and his representative too have submitted documents evidencing an intent to continue pursuit of these claims. A. Service Connection The Veteran seeks service connection for an enlarged prostate on a direct basis, as related to his active service, and for a gastrointestinal disorder and ED on both direct and secondary bases, the latter as related to the medication he takes for his service-connected disabilities. Service connection is granted on a direct basis for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303(a), 3.304 (2015). Establishing entitlement to service connection on a direct basis generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the injury or disease in service and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). Service connection is granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b) (2015). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The record in each case below does not warrant a grant of service connection, whether considered on a direct or secondary basis. 1. Enlarged Prostate According to the Veteran's February 2008 and February 2011 written statements, his prostate disorder, first diagnosed as benign prostatic hyperplasia (BPH) in 2007, initially manifested during service. He asserts that although this condition was not thought to be chronic until it required medication in 2007, it initially manifested during service as an enlarged prostate and prostatitis. First, post-service treatment records, including a report of a November 2006 digital rectal examination, a January 2012 treatment record, and the Veteran's medication lists, confirm that, at some point during the course of this appeal, the Veteran had an enlarged prostate and was treated for prostatitis. This evidence satisfies the current disability element of a service connection claim. Second, service treatment records dated in September 1978 establish that, during service, a provider noted that the Veteran had an enlarged, boggy and tender prostate and assessed prostatitis. Two weeks later, a provider characterized the prostatitis as acute and again noted an enlarged prostate. This evidence satisfies the in-service incurrence element of a service connection claim. The remainder of the evidence fails to satisfy the nexus element of a service connection claim. Between service and 2006, when a provider diagnosed BPH, the Veteran underwent testing that showed a normal prostate. Two medical professionals - both VA examiners - have discussed the etiology of the Veteran's prostate disorder. These examiners ruled out a relationship between any such disorder and the Veteran's period of active service. As discussed in the Board's July 2014 Remand, the opinion of the first VA examiner is premised on a faulty medical history and is therefore inadequate for consideration in support of this claim. Unfortunately, the unfavorable opinion of the most recent VA examiner (evaluated the Veteran in June 2015) is based on a consideration of the complete record and an accurate medical history and, as such, is adequate to decide this claim. According to that examiner, although the Veteran was treated for urethral discharge in 1977 and prostatitis secondary to an enlarged prostate in 1978, these conditions were acute, not ongoing. As of August 1979, when the Veteran underwent his final service examination, there was no evidence of urethritis or prostatitis. The examiner further pointed out that between 2000 and 2005, the Veteran had a normal prostate; it was not until 2006 that a provider diagnosed a prostate disorder, namely, BPH, requiring medication. The examiner explained that there was no evidence to suggest that this was a chronic condition until 2011, when it was listed as an active problem. The examiner explained that BPH most commonly results from hormonal changes attributed to the aging process and that by 70 years of age, 70 percent of American men have the condition. The examiner cited medical literature and concluded that the condition was not at least as likely as not related to the Veteran's active service. The Veteran has not submitted a medical opinion refuting that of the June 2015 VA examiner. His assertions thus represent the only evidence of record relating his BPH or any other prostate disorder to his period of active service, including the documented prostate findings. Although the Veteran is competent to report lay-observable discomfort in the area of his prostate or lay-observable urinary problems, which in some cases can be attributable to a prostate disorder, because he has no specialized training or expertise in medicine, he is not competent to offer an opinion as to the etiology of such problems. Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 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); Barr v. Nicholson, 21 Vet. App. 303 (2007) (layperson is competent to report disease with unique and readily identifiable features such as varicose veins); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Inasmuch as there is no competent evidence of record linking a prostate disorder, including one manifesting as an enlarged prostate, the Board concludes that such disability was not incurred in or aggravated by active service. The evidence in this case is not in relative equipoise; therefore, the benefit-of-the-doubt rule is inapplicable. 38 U.S.C.A. § 5107 (West 2014); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. ED According to the Veteran's February 2008 written statement, he has ED, for which he has been prescribed Viagra and Levitra. Allegedly he takes other medication, including anti-depressants, which caused him to develop this ED. Post-service treatment records dated since 1999, including medication lists, information from the Social Security Administration (SSA), and reports of VA examinations conducted in August 2013 and June 2015 confirm that the Veteran has ED. This evidence satisfies the current disability element of a service connection claim. This evidence fails to satisfy the in-service incurrence and nexus elements of a claim for service connection on a direct basis. It does not establish that the Veteran had ED or initially manifested symptoms of ED during active service. The Veteran never reported this condition during service and on separation examination conducted in August 1979, his genitourinary system and blood pressure readings (hypertension being a risk factor for ED) were noted to be normal. The Veteran does not allege and no medical professional has found that the ED is otherwise related to the Veteran's active service. Following discharge, the Veteran was service connected for multiple disabilities, including, in pertinent part, a mood disorder, hepatitis C and a lumbar spine disability. The question thus becomes whether the ED is related to a service-connected disability, including the medication taken for the mood disorder, as alleged. The two VA examiners noted above discussed this matter and both offered unfavorable opinions. Again, as discussed in the Board's July 2014 Remand, the opinion of the first VA examiner is inadequate as it is conclusory and not supported with rationale, including any discussion of the risk factors for ED. Unfortunately, the unfavorable June 2015 opinion of the other VA examiner is based on a consideration of the complete record and all risk factors and supported with rationale and, as such, is adequate to decide this claim. During the June 2015 examination, the Veteran reported that he began to experience ED in 1996, at about the same time he began using anti-hypertensive medication. The examiner acknowledged this reported history and also noted treatment records establishing that, in March 1999, the Veteran began taking sertraline to inhibit interferon/ribavirin-related depression while being treated for hepatitis C. The examiner further noted that the Veteran was diagnosed as early as 1998 with hypertension and in December 1999 with ED secondary to the use of Zoloft for depression. He pointed out that, in July 2001, another doctor found anti-hypertensive and anti-depressant medications affecting the Veteran's ability to maintain erections. The examiner further pointed out that, as of 2001, the Veteran had a 28-year history of ethanol and substance abuse; in 2004, a problem list included hyperglycemia and, in 2009, 2010 and 2012, respectively, problem lists included lumbar spine pain and sciatica, diabetes mellitus (DM) (reportedly first diagnosed in 2009) and hypogonadism. According to the examiner, because the Veteran began experiencing ED in conjunction with the use of investigational anti-hypertensive medication, several years prior to his use of sertraline to combat depression tied to hepatitis treatment, the anti-hypertensive medication represents the primary etiological cause of the ED. To determine whether there is a secondary cause of the ED, he listed multiple risks for developing ED, including, in part, DM, smoking, hypertension, anti-hypertensive medication, alcohol use, spine disease pain and medication to treat the pain, prostate surgery and altered hormone levels. The examiner noted that, by the time the Veteran was diagnosed with ED in 1999, he had used both tobacco and alcohol significantly in addition to using the anti-hypertensive medication. He also noted that ED is not a likely side effect of the drugs used to treat the Veteran's hepatitis C. The examiner then cited medical literature and concluded that the ED was not related to the Veteran's service-connected disability. He also concluded that the ED was not aggravated by any service-connected disability. He based this latter conclusion on evidence showing that the condition had somewhat improved; originally, the Veteran's ED hindered his ability to maintain erections but on examination, he reported being able to do so even without medication. For the same reasons noted above, the Veteran's assertions relating his ED to a service-connected disability are incompetent. Kahana v. Shinseki, 24 Vet. App. at 434; Jandreau v. Nicholson, 492 F.3d at 1372; Buchanan v. Nicholson, 451 F.3d at 1336; Barr v. Nicholson, 21 Vet. App. at 303; Davidson v. Shinseki, 581 F.3d at 1313. Inasmuch as there is no competent evidence of record linking ED to the Veteran's active service or a service-connected disability, the Board concludes that such disability was not incurred in or aggravated by active service and is not proximately due to, the result of, or aggravated by, such service. The evidence in this case is not in relative equipoise; therefore, the benefit-of-the-doubt rule is inapplicable. 3. Gastrointestinal Disorder According to written statements the Veteran submitted in May 2004 and December 2012 and his June 2003 and November 2007 hearing testimony, he has GERD, which initially manifested during service, after beginning treatment for hepatitis C. Allegedly, when he began using Interferon, he experienced frequent nausea and indigestion, which doctors treated. He continued to experience these symptoms after discontinuing the Interferon. He thus believes that, secondary to the medication he takes for his arthritis, his GERD persists. Post-service treatment records dated since 2000, including medication lists, information from the Social Security Administration (SSA), and reports of VA examinations conducted in April 2000, December 2007, July 2013 and June 2015 confirm that the Veteran has a gastrointestinal disorder, diagnosed as GERD, stomach function disorder and possible peptic acid syndrome. This evidence satisfies the current disability element of a service connection claim. Service treatment records establish that, during service, the Veteran was seen for gastrointestinal complaints. In June 1978, the Veteran presented complaining of stomach pain and right upper quadrant tenderness. The assessment was to rule out hepatitis and ulcer disease. Later in the month, a provider confirmed hepatitis, not ulcer disease. In July 1978, the Veteran presented claiming he had heartburn, right upper quadrant pain and malaise. A doctor noted dark urine and again attributed the complaints to viral hepatitis. In September 1978, a provider noted mild epigastric distress, abdominal rebound and hepatosplenomegaly attributable to hepatitis, for which the Veteran had received recent treatment. This evidence satisfies the in-service incurrence element of a service connection claim. The remainder of the evidence fails to satisfy the nexus element of a service connection claim, whether considered on a direct basis, in relation to the Veteran's service, or on a secondary basis, in relation to the Veteran's service-connected disabilities, including his hepatitis and lumbar spine disability. On separation examination conducted in August 1979, the Veteran did not report and the examiner did not note any gastrointestinal problems. Post-service, neither the Veteran nor any medical professional again mentioned these problems until May 1999, when the Veteran's doctor submitted a letter indicating that the Veteran was about to undergo long-term (6 months to a year) hepatitis treatment. This doctor indicated that the treatment consisted of Interferon injections and ribavirin, an anti-viral pill, and could result in multiple side-effects, including nausea. Treatment records during the hepatitis treatment reveal multiple complaints, which doctors attributed to the treatment, but none involving the gastrointestinal system. During a VA examination conducted in November 1999, the Veteran again reported multiple complaints, which the examiner attributed to hepatitis treatment, but none involving the gastrointestinal system. During that examination, the Veteran reported a history of right inguinal hernia surgery in 1976 or 1977 (later noted to have occurred in 1998) with no recurrence or residuals other than tenderness in the area of the surgery. In April 2000, one month after his hepatitis treatment ended, the Veteran underwent a VA digestive system examination. He reported that he experienced nausea and vomiting, but no diarrhea or constipation, when he was on Interferon treatment. His medication list at the time confirms that he was on ranitidine, used to treatment conditions causing too much acid. Thereafter, in 2001, the Veteran reported a history of heartburn and doctors began diagnosing gastrointestinal disorders, including a stomach function disorder that year and GERD in 2002, In 2002 and 2003, doctors prescribed Zantac and rabeprazole for these disorders. Since then, the Veteran has continued to receive treatment for gastrointestinal complaints, including additional medication such as omeprazole, has also been prescribed non-steroidal anti-inflammatories (NSAIDS) for arthritis, and has undergone multiple VA examinations of his digestive system. During a September 2003 examination, a VA examiner diagnosed possible peptic acid syndrome. Multiple medical professionals have discussed the etiology of the Veteran's variously diagnosed gastrointestinal disorders. As discussed in the Board's July 2014 Remand, however, all but one of these opinions are inadequate to decide this claim. During a September 2003 VA examination, the Veteran complained of heartburn secondary to his arthritis medicine, not Interferon. The VA examiner indicated that Interferon is not known to cause GERD and diagnosed peptic acid syndrome secondary to arthritis pills. He provided no rationale for this diagnosis. Similarly, in December 2007, another VA examiner found no relationship between the Veteran's GERD and hepatitis. He cited to medical literature but provided no rationale for his opinion and did not explain how the literature applied to the Veteran's case. Finally, in July 2013, a VA examiner ruled out a relationship between the Veteran's complaints of GERD and hiatal hernia and service based on a faulty premise, specifically, that testing and medication lists showed no evidence of such conditions. Unfortunately the opinion that remains, which is adequate to decide this claim, is unfavorable. According to that opinion, provided by a VA examination in July 2015, the Veteran's gastrointestinal disorder is not at least as likely as not related to the Veteran's active service or medication used to treat his hepatitis or arthritis. The examiner based this opinion on the following findings: (1) The Veteran reported that his gastrointestinal symptoms began in service and that he associated indigestion he had then with certain foods and drinks he consumed; (2) Heartburn is a nonspecific symptom, which is not unique to GERD; (3) Testing conducted in June 2015 revealed GERD without erosions or ulcerations; (4) Ethanol (alcohol) use lowers esophageal sphincter tone, inducing reflux symptoms of heartburn by altering gastric acid secretions, causing a gastric mucosal injury and interfering with gastric motility; (5) Ethanol can cause esophagitis and gastritis (peptic acid syndrome), which would explain the Veteran's symptoms and why testing in 2003 revealed no abnormalities; (6) Side effects of Interferon and ribavirin include nausea and diarrhea, not dyspeptic pain symptoms; (7) Treatment records establish the Veteran's ongoing use of NSAIDS; (8) There are multiple drugs known to cause GERD, but not NSAIDS; (9) NSAIDS use is associated with gastritis, dyspepsia and duodenal and gastric ulcers, not GERD; and (10) The Veteran's gastrointestinal symptoms primarily stem from the Veteran's GERD, not from dyspepsia. The opinion concluded by citing medical literature without elaboration. The Veteran has not submitted a medical opinion refuting that of the June 2015 VA examiner and his assertions to the contrary are incompetent. Kahana v. Shinseki, 24 Vet. App. at 434; Jandreau v. Nicholson, 492 F.3d at 1372; Buchanan v. Nicholson, 451 F.3d at 1336; Barr v. Nicholson, 21 Vet. App. at 303; Davidson v. Shinseki, 581 F.3d at 1313. Inasmuch as there is no competent evidence of record linking the Veteran's current gastrointestinal disability to the Veteran's active service, a service-connected disability, or the medication taken for service-connected disability, the Board concludes that such disability was not incurred in or aggravated by active service and is not proximately due to, the result of, or aggravated by, such service. The evidence in this case is not in relative equipoise; therefore, the benefit-of-the-doubt rule is inapplicable. B. Increased Ratings The Veteran seeks increased ratings for the peripheral neuropathy in both of his feet. In written statements he submitted in September 2001, June 2003, May 2004, July 2009, February 2010, February 2011 and December 2012, and during his July 2003 and November 2007 hearings, he asserted that he had been experiencing neuropathy symptoms in his feet since service. Allegedly, beginning in the early 2000s, his pain worsened, interfering with his sleep, and doctors told him he needed to avoid exposure to extreme heat and coldness and to find a job that did not require being on his feet 8 hours daily. He described his foot pain as burning, causing an inability to walk in the mornings and for prolonged periods of time, and indicated that when he sat, his feet began to tingle and go completely numb. He asserted that this condition caused limitation of motion, affected his ability to engage in activities of daily living, necessitated the use of medication and special shoes with special insoles and equated to incomplete paralysis of both legs below the knees. He claimed that the incomplete paralysis is moderately severe and that the assignment of a 20 percent rating for the peripheral neuropathy in each foot would satisfy his appeal. He argued that near-constant foot pain suggests more than mild impairment. In support of these claims, the Veteran submitted a statement from J.B., an acquaintance, indicating that she had witnessed firsthand the effect of disabilities, including swelling in the legs and feet, on the Veteran's ability to function. She noted that these disabilities caused the Veteran difficulty walking, standing, lifting, stooping, kneeling and bending. 1. Schedular Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2015). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). In claims for increases, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different ratings, staged ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). A disability may require re-evaluation in accordance with changes in a veteran's condition. In determining the level of current impairment, it is thus essential that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The RO has rated the peripheral neuropathy in each of the Veteran's feet 0 percent disabling prior to July 9, 2001, and 10 percent disabling from July 9, 2001, pursuant to DC 8620, which governs ratings of neuritis of the sciatic nerve. Neuritis, whether cranial or peripheral, is to be rated on the scale provided for injury of the nerve involved. 38 C.F.R. § 4.123 (2015). The maximum rating for neuritis characterized by organic changes such as loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, which is at times excruciating, is equal to that for severe incomplete paralysis of the nerve. Id. The maximum rating for neuritis not characterized by such organic changes is equal to that for moderate incomplete paralysis, or if sciatic nerve involvement, for moderately severe incomplete paralysis. Id. In July 2013, a VA examiner identified the musculocutaneous nerve (superficial peroneal), rather than the sciatic nerve, as being impaired and, as such, DC 8622, which governs ratings of neuritis affecting such nerve, is also pertinent to this claim. DC 8620 provides that a 10 percent rating is assignable for mild incomplete paralysis of the sciatic nerve. A 20 percent rating is assignable for moderate incomplete paralysis of the sciatic nerve. A 40 percent rating is assignable for moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating is assignable for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. An 80 percent rating is assignable for complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8620 (2015). DC 8522 is less advantageous to the Veteran, providing that a 0 percent rating is assignable for mild incomplete paralysis of the musculocutaneous nerve. A 10 percent rating is assignable for moderate incomplete paralysis of the musculocutaneous nerve. A 20 percent rating is assignable for severe incomplete paralysis of the musculocutaneous nerve. A 30 percent rating is assignable for complete paralysis of the musculocutaneous nerve; eversion of foot weakened. 38 C.F.R. § 4.124a, DC 8522 (2015). The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture 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. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. The Veteran's description of his peripheral neuropathy has remained constant since service and especially during the course of this appeal such that the Board does not believe that two separate ratings covering different periods of time, more specifically, prior to July 9, 2001, and since July 9, 2001, are warranted in this case. During the earlier part of this appeal, testing did not confirm the Veteran's assertions regarding the existence of this condition. Moreover, the medical professionals who nonetheless acknowledged sensory disturbances in the lower extremities disagreed regarding the etiology thereof. This caused some confusion and, based on that, the AOJ assigned the Veteran 0 percent ratings for his service-connected peripheral neuropathy. This is despite the fact that, long before filing any claim for compensation, including during service and for purposes of treatment, the Veteran began reporting tingling, numbness and pain in his feet. According to the criteria noted above, nerve damage wholly sensory in nature, which the Veteran exhibited before and after July 9, 2001, demands the assignment of at least a 10 percent rating under DCs 8520 and 8620 for both periods of time at issue in this appeal. The evidence of record fails to establish that the Veteran is entitled to a rating in excess of 10 percent for either period of time at issue in this appeal. Beginning in 1999, medical professionals either refrained from objectively confirming neurological abnormalities in the Veteran's lower extremities, or, based on testing, began describing those reported abnormalities as slight or mild. Years later, medical professionals continued to describe these abnormalities as mild. For instance, during a VA examination conducted in November 1999, the examiner noted a slight decrease in the arterial pulses in the Veteran's lower extremities. Nerve conduction studies conducted in December 1999 revealed slight elevation of the left sural delay and a decrease in conduction velocity along the right peroneal motor nerve. In July 2004, testing revealed mild peripheral neuropathy. In October 2004, a neurosurgeon noted mildly diminished pinprick on the left lower extremity, Testing conducted in December 2007 demonstrated that the Veteran's demyelinating sensory motor polyneuropathy was in its early stages. In January 2010, the Veteran had intact strength, vibration and sensation in the lower extremities. A report of electrodiagnostic examination conducted in June 2015 showed normal results other than sensory abnormalities, including hypoesthesia and absent vibratory stimulation on pinprick. During July 2013 and July 2015 VA examinations, examiners described the Veteran's peripheral neuropathy as causing mild, intermittent pain, mild paresthesias and mild numbness. The July 2013 examiner indicated that this equated to mild incomplete paralysis. The July 2015 VA examiner referred to treatment records dated since 1999, in which medical professionals acknowledged the Veteran's lower extremity complaints, but did not characterize the severity of any associated disorder, the testing conducted in July 2015, testing conducted prior to that time, and reports of VA examinations conducted from 2002 to 2013, and explained that the normal findings shown on various tests of the Veteran's lower extremities indicate that the symptoms affecting those extremities have not progressed significantly. There is very little evidence suggesting that the Veteran's peripheral neuropathy is more than mild. With the exception of testing conducted shortly after the Veteran fractured his right ankle in the early 2000s, during the course of this appeal, motor testing remained normal, failing to show atrophy or muscle loss. In its July 2014 Remand, the Board point out that, although the July 2013 VA examiner described the Veteran's peripheral neuropathy as mild, equating to mild incomplete nerve paralysis, in describing the functional loss caused by the peripheral neuropathy, he painted a disability picture suggesting the condition is more severe than mild. The Board thus remanded the claim for an addendum opinion reconciling this seemingly conflicting information. Unfortunately, that examiner was not available and was thus unable to offer further comment. The Board therefore considers this report the only evidence of record suggesting that the Veteran's peripheral neuropathy is more than mild. As the preponderance of the evidence indicates otherwise, the Board finds that, during the entire course of this appeal, peripheral neuropathy of the Veteran's right and left feet caused mild incomplete paralysis, whether affecting the sciatic or musculocutaneous nerve. Based on this finding, the Board concludes that the criteria for entitlement to 10 percent schedular ratings for peripheral neuropathy of the right and left feet, prior to July 9, 2001, are met, but the criteria for entitlement to schedular ratings in excess of 10 percent for peripheral neuropathy of the right and left feet, from July 9, 2001, are not met. 2. Extraschedular In certain circumstances, a claimant may be assigned a higher initial or increased rating on an extraschedular basis. The question of whether such a rating may be assigned on such a basis is a component of a claim for a higher initial or increased evaluation. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign a rating on an extraschedular basis in the first instance, when the question is raised either by the claimant, or reasonably by the evidence of record, the RO or Board must specifically decide whether to refer the claim to the Chief Benefits Director of VA's Compensation and Pension Service under 38 C.F.R. § 3.321 for consideration of the matter. Barringer v. Peake, 22 Vet. App. 242 (2008). He is authorized to approve the assignment of an extraschedular rating if the claim "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2015). If the claimant or the evidence raises the question of entitlement to a higher initial or increased evaluation on an extraschedular basis, as a threshold matter, the Board must determine whether the evidence before VA presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. This requires comparing the level of severity and symptomatology of the service-connected disability with the established criteria found in the rating schedule pertaining to that disability. Thun v. Peake, 22 Vet. App. 111, 118 (2008). If the criteria reasonably describe the level of severity and symptomatology of the disability, the disability picture is contemplated by the rating schedule, the assigned schedular rating is adequate and no referral is necessary. Id. If the criteria do not reasonably describe the level of severity and symptomatology of the disability, the disability picture is not contemplated by the rating schedule and the assigned schedular rating is inadequate. The RO or Board must then determine whether the exceptional disability picture involves other related factors such as those outlined in 38 C.F.R. 3.321(b)(1) as "governing norms", including "marked interference with employment" and "frequent periods of hospitalization". Id. In this case, by asserting interference with employment (cannot stand for 8 hours as his prior job required) the Veteran has raised such a claim, but no referral is necessary. The rating criteria reasonably describe the level of severity and symptomatology of the Veteran's neuropathy. The 10 percent rating contemplates the tingling, burning pain and numbness, symptoms typical of neuropathy, and also contemplates a mild degree of nerve damage caused by those symptoms. Referral for extraschedular consideration is therefore unnecessary. ORDER Service connection for an enlarged prostate is denied. Service connection for ED, including as secondary to service-connected disability, is denied. Service connection for a gastrointestinal disorder, claimed as GERD, is denied. A 10 percent rating for peripheral neuropathy of the RLE, prior to July 9, 2001, is granted. A rating in excess of 10 percent for peripheral neuropathy of the RLE, from July 9, 2001, is denied. A 10 percent rating for peripheral neuropathy of the LLE, prior to July 9, 2001, is granted. A rating in excess of 10 percent for peripheral neuropathy of the LLE, from July 9, 2001, is denied. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs