Citation Nr: 1611028 Decision Date: 03/17/16 Archive Date: 03/23/16 DOCKET NO. 06-21 294 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to a rating in excess of 10 percent for diabetic neuropathy of the right lower extremity (RLE) prior to May 30, 2012 and in excess of 20 percent from May 30, 2012. 2. Entitlement to a rating in excess of 10 percent for diabetic neuropathy of the left lower extremity (LLE) prior to May 30, 2012 and in excess of 20 percent from May 30, 2012. 3. Entitlement to a rating in excess of 10 percent for diabetic neuropathy of the right upper extremity (RUE) prior to November 14, 2013; and in excess of 30 percent from November 14, 2013. 4. Entitlement to ratings in excess of 10 percent for diabetic neuropathy prior to May 30, 2012 and in excess of 20 percent each for bilateral lower extremities on an extra-scheduler basis pursuant to 38 C.F.R. § 3.321(b)(1) . 5. Entitlement to ratings in excess of 10 percent for diabetic neuropathy prior to May 30, 2012 and in excess of 30 percent for RUE on an extra-scheduler basis pursuant to 38 C.F.R. § 3.321(b)(1) . REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The Veteran served on active duty from August 1983 to July 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana (hereinafter Agency of Original Jurisdiction (AOJ)). In that decision, the AOJ denied a rating greater than 40 percent for type II diabetes mellitus, denied a rating greater than 10 percent for diabetic neuropathy of the RLE, denied a rating greater than 10 percent for diabetic neuropathy of the LLE, and denied a rating greater than 10 percent for diabetic neuropathy of the RUE. A November 2012 AOJ rating decision granted 20 percent disability ratings, effective May 30, 2012, for the diabetic neuropathy of the RLE and LLE. A December 2013 AOJ rating decision granted a 30 percent disability rating for diabetic neuropathy of the RUE effective from November 14, 2013. As the Veteran did not indicate that these ratings satisfied his appeal, his claims for increased ratings remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge in December 2009. A written transcript of this hearing has been prepared and incorporated into the evidence of record. The Board had previously remanded the appeal in February 2010, March 2012 and May 2013. In a decision dated March 2015, the Board denied increased ratings for diabetic neuropathy of the RLE, LLE and RUE, and remanded to the AOJ a claim of entitlement to ratings in excess of 10 percent for diabetic neuropathy prior to May 30, 2012 and in excess of 30 percent for RUE on an extra-scheduler basis pursuant to 38 C.F.R. § 3.321(b)(1). The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an order dated December 7, 2015, the Court remanded the claims to the Board pursuant to the terms of a Joint Motion for Remand (JMR). In January 2016, the Veteran's representative waived AOJ consideration of additional evidence added to the record since the AOJ's last adjudication in January 2014. This appeal was processed using the VBMS paperless claims processing system. The Board notes that, in addition to the VBMS file, there is a separate electronic (Virtual VA) file associated with the Veteran's claim. When evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to a TDIU will be considered to have been raised by the record as "part and parcel" of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In this case, the Veteran's claim for TDIU was denied in an unappealed November 2012 rating decision. Since then, the Veteran has continued to indicate that he is currently employed with the United States Postal Services. As such, the Board finds that the issue of TDIU has not been re-raised by the record. As noted in the Board's prior decisions, issues of entitlement to service connection for erectile dysfunction and for a mental disorder have been REFERRED to the AOJ for appropriate action. FINDINGS OF FACT 1. For time period prior to December 31, 2008, the Veteran's RLE and LLE diabetic neuropathy was manifested by no more than moderate incomplete paralysis of the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal (tibial) and posterior tibial nerves as demonstrated by subjective complaint of tingling, numbness and pain sensation with objective findings of decreased sensation, and diminished reflexes and right peripheral pulse, but absent impairment of motor function or trophic changes. 2. For the time period prior to December 31, 2008, the Veteran's RLE and LLE diabetic neuropathy was manifested by no more than moderate incomplete paralysis of the internal saphenous nerve as demonstrated by subjective complaint of tingling, numbness and pain sensation of the thigh with objective findings of decreased sensation and diminished reflexes and right peripheral pulse, but absent impairment of motor function or trophic changes. 3. For the time period since December 31, 2008, the Veteran's RLE and LLE diabetic neuropathy has been manifested by no more than moderately severe incomplete paralysis of the sciatic nerve, or severe incomplete paralysis of the external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal (tibial) and posterior tibial nerves, as demonstrated by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation, and diminished reflexes and right peripheral pulse and impairment of proprioception which interfered with his ability to ambulate. 4. For the time period since December 31, 2008, the Veteran's RLE and LLE diabetic neuropathy has been manifested by no more than severe incomplete paralysis of the internal saphenous nerve as demonstrated by subjective complaint of tingling, numbness and pain sensation of the thigh with objective findings of decreased sensation and diminished reflexes and right peripheral pulse and impairment of proprioception which interfered with the his ability to ambulate. 5. For the time period prior to May 30, 2012, the Veteran's RUE diabetic neuropathy was manifested by no more than mild incomplete paralysis of the radial, median, ulnar and musculocutaneous nerves as demonstrated by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation including proprioception and diminished reflexes but absent motor or trophic changes. 6. For the time period from May 30, 2010 to November 13, 2013, the Veteran's RUE diabetic neuropathy was manifested by no more than moderate incomplete paralysis of the radial, median, ulnar and musculocutaneous nerves as demonstrated by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation including proprioception, diminished reflexes and interference with manual dexterity but absent additional motor or trophic changes. 7. For the time period since November 14, 2013, the Veteran's RUE diabetic neuropathy has been manifested by no more than severe incomplete paralysis of the radial, median, ulnar and musculocutaneous nerves as demonstrated by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation including proprioception, diminished reflexes, interference with manual dexterity and 4/5 grip and pinch strength. CONCLUSIONS OF LAW 1. The criteria for higher schedular ratings for RLE diabetic neuropathy are met as follows: a 20 percent rating under DC 8520 for the time period prior to December 31, 2008; a 40 percent rating under DC 8520 for the time period since December 31, 2008; and a 10 percent rating under DC 8527 since December 31, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.120, 4.124a, Diagnostic Codes (DCs) 8520-8527 (2015). 2. The criteria for higher schedular ratings for LLE diabetic neuropathy are met as follows: a 20 percent rating under DC 8520 for the time period prior to December 31, 2008; a 40 percent rating under DC 8520 for the time period since December 31, 2008; and a 10 percent rating under DC 8527 since December 31, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.120, 4.124a, Diagnostic Codes (DCs) 8520-8527 (2015). 3. The criteria for higher schedular ratings for RUE diabetic neuropathy are met as follows: a 20 percent rating under DC 8514 for the time period from May 30, 2012 to November 13, 2013, and a 50 percent rating since November 14, 2013. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.120, 4.124a, Diagnostic Codes (DC) 8514-8517 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In a claim for increase, the VCAA requires only generic notice as to 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, 1277 (2009). In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. The Board finds that VA has satisfied its duty to notify under the VCAA with respect to the claims for increased ratings on appeal. An April 2004 letter, sent prior to the initial unfavorable decision issued in September 2004, advised the Veteran of the evidence and information necessary to substantiate the claims for increased ratings on appeal, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, a June 2008 letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. The issues were readjudicated after all critical notice was provided. See August 2008 supplemental statement of the case (SSOC) and subsequent SSOCs. See generally Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). Relevant to the duty to assist, to the extent possible, the Veteran's service treatment records (STRs) as well as post-service VA and private treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded VA examinations addressing the disabilities for which increased compensation is claimed in May 2004, December 2008, May 2012, and November 2013. The Board finds that the November 2013 VA examination report is adequate to evaluate these disabilities as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria and providing sufficient detail so as to allow the Board to make fully informed determinations. Barr v. Nicholson, 21 Vet. App. 303 (2007). These examination reports are supplemented by findings in the private and VA clinic setting as well as the Veteran's statements and testimony during the appeal period. Since the November 2013 examination was conducted, the Board does not find that the lay or medical evidence suggests an increased severity of disability. See VAOPGCPREC 11-95 (Apr. 7, 1995). Therefore, the Board finds that the November 2013 examination report is adequate to adjudicate the Veteran's increased rating claims and no further examination is necessary. Additionally, the Veteran was provided an opportunity to set forth his contentions before the undersigned Veterans Law Judge at the aforementioned December 2009 Board videoconference hearing. In Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the officials who chair such hearings fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the December 2009 hearing, the undersigned noted the increased rating issues on appeal, and information was solicited as to the nature and severity of the service-connected disabilities at issue, to include the nature and severity of the symptoms as well as the impact such have on the Veteran's daily life and employability. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Furthermore, based on such hearing testimony, the record was held open for 60 days for the submission of additional evidence, and the Board subsequently remanded the case in order to obtain outstanding treatment records and a VA examination that addressed the current severity of the disabilities at issue. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claims decided herein. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been complied and that the Board may proceed to adjudicate the claims addressed in the decision below based on the current record. As indicated previously, the Board remanded the Veteran's claims in February 2010, March 2012 and May 2013, the purpose of which was to provide the Veteran with an opportunity to identify and obtain any outstanding private treatment records, obtain updated VA treatment records, and afford him VA examinations with opinions to determine severity of his service-connected disabilities. Following the remands, the AOJ provided the Veteran with letters in April 2010, May 2012 and June 2013 requesting that he identify any outstanding treatment records. The most recent May 2013 remand requested that the AOJ obtain the Veteran's United States Postal Service (USPS) employment records. In June 2013, the AOJ sent a letter to the USPS requesting the Veteran's employment records. In July 2013, the AOJ received a negative response from the USPS indicating that the records were not available. The AOJ sent the Veteran a letter in September 2013 informing him that additional employment records were not available and if he had any additional records in his possession to submit such records. The Veteran did not respond to the letter. The AOJ subsequently associated a September 2013 unavailability memorandum with the claims file. As for the updated VA treatment records requested in the remands, such records, dated through March 2015, have been obtained, and the November 2013 VA examination with addendum opinion of the Veteran's extremities was responsive to the directives of the May 2013 remand. Therefore, the Board finds that there has been substantial compliance with the prior remand instructions such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Thus, the Board finds that VA has fully satisfied the duty to notify and assist with respect to the issues adjudicated herein. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA with respect to the claims for increased ratings on appeal would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case with respect to the issues decided herein, at least insofar as any errors committed were not harmful to the essential fairness of the adjudication of these issues below. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims for increased compensation on appeal. II. Analysis On April 9, 2004, VA received the Veteran's claim for increased ratings for diabetic neuropathy of the right upper extremity and his bilateral lower extremities. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155. Separate DCs identify the various disabilities. The assignment of a particular DC is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One DC may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which DC or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the Veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. See generally 38 U.S.C.A. § 5110(b)(2). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. However, separate disability ratings may be assigned for distinct disabilities resulting from the same injury, or involving the same bodily part, so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating which may be assigned for neuritis not characterized by organic changes as noted above will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate, incomplete paralysis. 38 C.F.R. § 4.124. In rating diseases of the peripheral nerves, 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. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for peripheral nerves are for unilateral involvement; when bilateral, they are combined with application of the bilateral factor. Id. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The Veteran's RLE and the LLE diabetic neuropathy has been rated under DC 8520. DC 8520 provides ratings for paralysis of the sciatic nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, DC 8520. DC 8520 provides that mild incomplete paralysis is rated 10 percent disabling. Moderate incomplete paralysis is rated 20 percent disabling. Moderately severe incomplete paralysis is rated 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. 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, is rated 80 percent disabling. DC 8620 refers to neuritis of the sciatic nerve while DC 8720 refers to neuralgia of the sciatic nerve. DC 8521 provides ratings for paralysis of the external popliteal nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, 8521. DC 8521 provides that mild incomplete paralysis is rated as 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; and severe incomplete paralysis is rated 30 percent disabling. Complete paralysis of the external popliteal nerve, foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes, is rated 40 percent disabling. A 40 percent disability rating is the maximum schedular disability rating available under DC 8521. DC 8621 refers to neuritis of the external popliteal nerve while DC 8720 refers to neuralgia of the external popliteal nerve. DC 8522 provides ratings for paralysis of the musculocutaneous (superficial peroneal) nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, 8522. DC 8522 provides that mild incomplete paralysis is rated noncompensably (0 percent) disabling. Moderate incomplete paralysis is rated 10 percent disabling. Severe incomplete paralysis is rated 20 percent disabling. Complete paralysis of the musculocutaneous (superficial peroneal) nerve, eversion of foot weakened, is rated 30 percent disabling. A 30 percent disability rating is the maximum schedular disability rating available under DC 8522. DC 8622 refers to neuritis of the musculocutaneous (superficial peroneal) nerve while DC 8722 refers to neuralgia of the musculocutaneous (superficial peroneal) nerve. DC 8523 provides ratings for paralysis of the anterior tibial nerve (deep peroneal) and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, 8523. DC 8523 provides that mild incomplete paralysis is rated as noncompensable, moderate incomplete paralysis is rated as 10 percent disabling, and severe incomplete paralysis is rated as 20 percent disabling. Complete paralysis, dorsal flexion of foot lost, is rated 30 percent disabling. DC 8623 refers to neuritis of the anterior tibial nerve (deep peroneal) while DC 8723 refers to neuralgia of the anterior tibial nerve (deep peroneal) nerve. DC 8524 provides ratings for paralysis of the internal popliteal nerve (tibial) and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, 8524. DC 8524 provides that 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. Complete paralysis, plantar flexion lost, frank adduction of foot impossible, flexion and separation of toes abolished; no muscle in sole can move; in lesions of the nerve high in popliteal fossa, plantar flexion is lost; is rated as 40 percent disabling. DC 8624 refers to neuritis of the internal popliteal nerve (tibial) while DC 8724 refers to neuralgia of the internal popliteal nerve (tibial) nerve. DC 8525 provides ratings for paralysis of the posterior tibial nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, 8525. DC 8525 provides that mild and moderate incomplete paralysis is rated as 10 percent disabling, and severe incomplete paralysis is rated as 20 percent disabling. Complete paralysis-complete paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; plantar flexion is impaired-is rated as 30 percent disabling. DC 8625 refers to neuritis of the posterior tibial nerve while DC 8725 refers to neuralgia of the posterior tibial nerve. DC 8526 provides ratings for paralysis of the anterior crural nerve (femoral) and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, 8526. DC 8526 provides that mild incomplete paralysis is rated 10 percent disabling. Moderate incomplete paralysis is rated 10 percent disabling. Severe incomplete paralysis is rated 20 percent disabling. Complete paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; plantar flexion is impaired, is rated 30 percent disabling. A 30 percent disability rating is the maximum schedular disability rating available under DC 8526. DC 8626 refers to neuritis of the musculocutaneous (superficial peroneal) nerve while DC 8726 refers to neuralgia of the musculocutaneous (superficial peroneal) nerve. DC 8527 provides ratings for paralysis of the internal saphenous nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, 8527. DC 8527 provides that mild to moderate incomplete paralysis is rated as noncompensable. Severe to complete paralysis is rated 10 percent disabling. DC 8627 refers to neuritis of the musculocutaneous (superficial peroneal) nerve while DC 8727 refers to neuralgia of the musculocutaneous (superficial peroneal) nerve. The Veteran's RUE diabetic neuropathy has been rated under DC "7913-8515." DC 8515 provides ratings for paralysis of the median nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, DCs 8515. Complete paralysis of the median nerve, which is rated as 70 percent disabling for the major extremity, contemplates the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of left thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. For the major extremity, a 10 percent rating is warranted for mild incomplete paralysis, a 30 percent rating is warranted for moderate incomplete paralysis, and a higher 50 percent evaluation is warranted for severe incomplete paralysis. DC 8615 refers to neuritis of the median nerve while DC 8715 refers to neuralgia of the median nerve. DC 8514 provides the rating criteria for paralysis of the musculospiral nerve (radial nerve) and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, DC 8514. Complete paralysis of the radial nerve, which is rated as 70 percent disabling for the major extremity, contemplates drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; can not extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of the wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. For the major extremity, a 20 percent rating is warranted for mild incomplete paralysis, a 30 percent rating is warranted for moderate incomplete paralysis, and a higher 50 percent evaluation is warranted for severe incomplete paralysis. DC 8614 refers to neuritis of the radial nerve while DC 8714 refers to neuralgia of the radial nerve. DC 8516 provides the rating criteria for paralysis of the ulnar nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, DC 8516. Complete paralysis of the ulnar nerve, which is rated as 60 percent disabling for the major extremity, contemplates the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. For the major extremity, a 10 percent rating is warranted for mild incomplete paralysis, a 30 percent rating is warranted for moderate incomplete paralysis, and a higher 40 percent evaluation is warranted for severe incomplete paralysis. DC 8616 refers to neuritis of the ulnar nerve while DC 8716 refers to neuralgia of the ulnar nerve. DC 8517 provides the rating criteria for paralysis of the musculocutaneous nerve and, therefore, neuritis and neuralgia of that nerve. 38 C.F.R. § 4.124a, DC 8517. Complete paralysis of the musculocutaneous nerve, which is rated as 30 percent disabling for the major extremity, contemplates weakness but not loss of flexion of elbow and supination of the forearm. For the major extremity, a noncompensable rating is warranted for mild incomplete paralysis, a 10 percent rating is warranted for moderate incomplete paralysis, and a higher 20 percent evaluation is warranted for severe incomplete paralysis. DC 8617 refers to neuritis of the musculocutaneous nerve while DC 8717 refers to musculocutaneous nerve of the ulnar nerve. A NOTE following the criteria for the upper extremity nerve groups states that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. Descriptive words such as "slight," "moderate" 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. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. However, VA's Adjudication Manual does provide guidance in evaluating the severity of nerve paralysis. According to the Manual, "mild" incomplete paralysis is demonstrated by subjective symptoms or diminished sensation. M-21, III.iv.4.G.4.b. "Moderate" incomplete paralysis is manifested by the absence of sensation confirmed by objective findings. Id. "Severe" incomplete paralysis is manifested when more than sensory findings are demonstrated, such as atrophy, weakness, and diminished reflexes. Id. Separate evaluations may not be assigned when evaluating an upper extremity peripheral nerve disability. M-21, III.iv.4.G.4.b. When the specific nerve branch affected cannot be identified by the evidence, the rating specialist should rate the upper extremity symptoms using DC 8514 (the radial nerve). M-21, III.iv.4.G.4.e. Additionally, the rating specialist should evaluate the nerve branch which is most beneficial to the Veteran. Id. However, the Veterans Benefits Administration (VBA) has determined that there are 5 separate nerve branches in the lower extremities which may be separately rated. M21-1, III.iv.4.G.4.c. According to VBA, the sciatic nerve (DCs 8520, 8620 and 8720), the external popliteal nerve (common peroneal) (DCs 8521, 8621 and 8721), the musculotaneous nerve (DCs 8522, 8622 and 8722), the anterior tibial nerve (deep peroneal) (DCs 8523, 8623, 8723), the internal popliteal nerve (tibial) (DCs 8524, 8624, and 8724), and the posterior tibial nerve (DCs 8525, 8625, and 8725) affect the foot and leg sensory and motor function of the buttock, leg, knee, muscles below knee, lower leg, fibula, foot, muscles of the sole of the feet, plantar flexion, and toes. Id. M21-1, Part III, Subpart iv, 4.G.4.c. Assigning separate ratings from within these nerve branches is not warranted as it would constitute impermissible pyramiding. M21-1, III.iv.4.G.4.d. The anterior crural nerve (femoral) (DCs 8526, 8626, and 8726) and internal saphenous nerve (DCs 8527, 8627, and 8727) affect the thigh and leg sensory and motor function of the quadriceps muscle, front of thigh; medial calf; and medial malleolus. M21-1, Part III, Subpart iv, 4.G.4.c. These are part of a separate nerve group that may receive a separate evaluation from the sciatic nerve group. M21-1, III.iv.4.G.4.d. The obturator (DCs 8528, 8628, and 8728) affects the motor and sensory function of the hip and muscles of the hip; and medial thigh. The external cutaneous nerve of thigh (DCs 8529, 8629, and 8729) affects the sensory function of the lateral thigh. The amputation rule under 38 CFR 4.68 is not applied in evaluating peripheral nerves of the lower extremity as long as separate evaluations are warranted. M21-1, III.iv.4.G.4.d. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this 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). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. Historically, the Veteran was diagnosed with type II diabetes mellitus in service. A September 1984 AOJ rating decision granted service connection for type II diabetes mellitus, and assigned an initial 20 percent rating. An August 1985 AOJ rating decision granted service connection for peripheral neuropathy of the RUE and assigned an initial 10 percent rating under DC 8515, granted service connection for peripheral neuropathy of the RLE and assigned an initial 10 percent rating under DC 8521, and granted service connection for peripheral neuropathy of the LLE and assigned an initial 10 percent rating under DC 8521. As noted, the Veteran filed the instant claims for increased ratings in April 2004. Therefore, for purposes of this appeal, the evaluation period for each disability begins in April 2003 (i.e., one year prior to the date of claims). In pertinent part, the Veteran underwent a private electromyography (EMG) study of the right upper arm in September 2002 which was interpreted as normal. In May 2004, a VA clinician indicated that the Veteran should not work more than 8 hours in a day as a mail carrier due to his current medical problems. An October 2003 private clinic record generally noted that deep tendon reflexes (DTRs) were diminished throughout. A December 2003 VA foot care clinic record generally noted the Veteran's feet to have a normal hair distribution pattern with sensation intact to 5.07 and 10 gm monofilament testing. The examiner was unable to palpate the right peripheral pulses, but this was strong with Doppler testing. An April 2004 private medical record recorded the Veteran's complaint of some right arm and hand numbness. Examination was significant for faintly positive Tinel sign of the wrist with good grip strength. His deep tendon reflexes DTRs were diminished throughout. He was given an impression of paresthesia of the right hand. On May 2004 VA examination, the Veteran reported working as a postal worker and requiring frequent time schedule changes due to difficulty regulating his insulin and diet. He also endorsed increased work stress and fatigue which caused him to miss workdays. He further reported thigh numbness and tingling of his feet which was worse in the evenings. He described occasional numbness of his legs and hands. On examination, the Veteran's neurologic examination of the feet demonstrated good pulses, warm feet, and mild fungal infection of the toes. There was decreased sensation to pinprick and soft touch in the lower extremities as well as decreased vibration sense. There was normal motor, proprioception and position sense as well as normal ankle jerks "consistent with very mild early diabetic neuropathy affecting both of his lower extremities, his feet, up to the ankle." The Veteran's hands demonstrated normal pinprick, position, vibration, soft touch and reflexes with the examiner noting "I do not appreciate any neuropathy affecting his hands." The examiner provided an impression of type II diabetes mellitus with evidence of visual complications as well as peripheral neuropathy affecting both legs from the lower feet up to the ankles. In a statement received in May 2004, the Veteran reported difficulty managing his diabetic condition which interfered with his ability to work extra hours. He described increased pains in his legs and feet, episodes of blurred vision and difficulty in maintaining his blood sugars. He indicated that his treating VA physician advised him to maintain an 8-hour work day due to stress and physical requirements of his job. In so doing, he provided copies of his earnings and leave statements reflecting the use of over 370 hours of leave for the year 2003. A February 2005 private treatment record noted that the Veteran had occasional bouts of hypoglycemia which caused him to miss work. He further reported some numbness in his thighs and calves over the last weekend. The physician completed Family and Medical Leave (FMLA) paperwork due to these problems. The Veteran reported symptoms of tingling and paresthesia in this right hand in June 2005. An examination in July 2005 noted diminished DTRs throughout. An August 2005 private clinic record noted the Veteran to have a normal hair growth pattern of the lower extremities. In December 2005, the Veteran was given work restrictions due to a left shoulder injury. A physical examination in January 2006 noted good grip strength of the right hand. In March 2006, the Veteran continued to report tingling and numbness sensation in his lower extremities. An April 2006 VA clinic record reflected the Veteran's report of sharp pain and numbness of his lower extremities. Examination of his feet revealed intact pulses but diminished sensation to 10g monofilament. He was prescribed Neurontin. In his VA Form 9 received in June 2006, the Veteran described a sensation of tingling in his legs with numbness as well as burning and stabbing pains in his feet. He reported being prescribed Gabapentin. A March 2007 private clinic record described the Veteran as manifesting mild neuropathy of the feet. A March 2007 VA clinic record reported diminished sensation of the feet with monofilament testing. An April 2007 VA clinic record noted that the Veteran's feet demonstrated intact pulses with sensation to 10g monofilament. His DTRs were diminished throughout. He described burning of the feet and legs. A private electromyography (EMG) report in May 2008, to evaluate symptoms of burning feet, was interpreted as showing findings suggestive of sensory diabetic neuropathy. A December 2008 VA clinic record resumed a prescription of Gabapentin due to diabetic neuropathy of the feet. The Veteran described his foot pain ranging from 4-10/10 in severity. On VA peripheral nerves examination dated December 31, 2008, reflected the Veteran reported of burning pain of the feet, accompanied by numbness, tingling and painful paresthesia. His symptoms, which had been present for the past four years and possibly longer, were increasing in severity and beginning to interfere with his ability to walk unaided. To date, he did not require the use of a walker or cane. He further reported that the numbness and tingling extended to the entire lower extremities to the level of the hips. He further indicated that, for the past few years, he had been experiencing numbness and tingling in his hands and distal aspect of his arms, which was worse on the right. He had been prescribed Gabapentin which slightly improved his painful paresthesia symptoms. He continued to work full-time as a mail carrier. Examination revealed normal muscle strength, tone and coordination of the upper lower extremities without evidence of muscle atrophy, fasciculations, tremor or involuntary movements. His DTRs were diminished in the upper and lower extremities with no pathologic reflexes. There was diminished perception to all sensory modalities including touch, pinprick, temperature, vibration and proprioception in the upper and lower extremities. The Veteran had normal gait and tandem walking with no ataxia. There was good arm swing. The examiner diagnosed progressive, severe distal sensory polyneuropathy of the upper and lower extremities related to diabetes mellitus. An April 2009 VA clinic record included the Veteran's description of burning foot pain ranging from 2-9/10 in severity. On December 2, 2009, a VA clinician noted in the Veteran's clinic records that he manifested severe, progressive painful diabetic neuropathy. He was noted to have burning, pain and numbness sensation of the feet with poor balance which had become worse since the last visitation. On VA diabetes mellitus examination in February 2010, the Veteran's neurologic examination demonstrated mild decreased sensation in his feet. There was no motor loss. His DTRs were absent for the triceps and Achilles. The right and left lower extremity demonstrated normal temperature, color and dorsalis pedis pulse. There were no trophic changes. The posterior tibial pulse was decreased. The examiner indicated that the Veteran's diabetes mellitus and complications resulted in increased absenteeism with vision difficulty, weakness or fatigue, and decreased strength in the lower extremities. An earnings and leave statement from January to July 2010 reflected over 200 hours of leave used. On September 15, 2011, the Veteran reported a recent onset of worsening neuropathic pain in the lower extremities which kept him up at night due to burning pain and tingling. He described pain of 8/10 severity which worsened with standing or walking. He requested a prescription of amitriptyline to help him sleep at night. On VA peripheral nerves examination dated May 30, 2012, the Veteran described a progressive worsening of diabetic peripheral neuropathy of the upper and lower extremities which had progressed to shocking pains up and down his lower extremities with a crawling sensation. He denied constant, sometimes excruciating pain of the right upper extremity, but did describe severe usually dull intermittent pain, paresthesias and numbness. On examination, there was 5/5 strength for elbow flexion and extension, wrist flexion and extension, grip and thumb to index finger pinch. There was decreased (1+) biceps and triceps reflex with an absent (0) brachioradialis. There was normal light touch to the shoulder area, but decreased light touch to the inner/outer forearm and hand/fingers. Position sense was normal while vibration and cold sense were decreased. There was no muscle atrophy or trophic changes. The examiner diagnosed mild incomplete paralysis of the radial (musculospiral) nerve, mild incomplete paralysis of the median nerve and mild incomplete paralysis of the ulnar nerve. With respect to the left lower extremity, the Veteran described severe and constant pain, sometimes excruciating, as well as severe usually dull intermittent pain, paresthesias and numbness. There was 5/5 strength for knee extension and flexion as well as ankle plantar flexion. There was 4/5 strength with ankle dorsiflexion. There were absent reflexes for the knee and ankle. There was normal light touch to the knee/thigh, but decreased light touch to the ankle/lower leg and foot/toes. Position sense was decreased with vibration and cold sensation sense being absent. There was no muscle atrophy or trophic changes. The examiner diagnosed moderate incomplete paralysis of the sciatic nerve and normal femoral (anterior crural) nerve. With respect to the right lower extremity, the Veteran described severe and constant pain, sometimes excruciating, as well as usually dull intermittent pain, paresthesias and numbness. There was 5/5 strength knee for extension and flexion as well as ankle plantar flexion. There was 4/5 strength with ankle dorsiflexion. There were absent reflexes for the knee and ankle. There was normal light touch to the knee/thigh, but decreased light touch to the ankle/lower leg and foot/toes. Position sense was decreased while vibration and cold sense were absent. There was no muscle atrophy or trophic changes. The examiner diagnosed moderate incomplete paralysis of the sciatic nerve and normal femoral (anterior crural) nerve. The VA examiner indicated that the Veteran was a USPS mail carrier who had difficulty with holding brakes to stop at mail boxes and difficulty switching his feet off the brakes. He had difficulty holding and handling due to hand numbness. He may feel drowsy and have difficulty driving due to the tramadol and gabapentin he took for pain. He could not walk on some days and, last year, he used all 8 weeks of annual leave and had already used 5 of 8 weeks for the current year. The examiner also offered the following opinion: This patient is most likely unable to secure and maintain gainful employment in any job requiring him to have good manual dexterity and to drive walk or stand for any length of time. This would, in all probability, make him disabled from continuing his job effectively as a letter carrier for the USPS for the above stated reasons. On VA examination dated November 14, 2013, the Veteran reported continued neuropathy symptoms affecting his upper and lower extremities. He now described episodes of stumbling with a feeling that his feet were stuck on something even though nothing was there. He described going up stairs as being an effort. His numbness and tingling extended to his groin area. He also had a numbness, tingling and crawling sensation to above the elbows which caused difficulty with grasping items. His hands became numb at night, when he held a steering wheel or with prolonged use. He also had low back pain radiating down both legs for which he had underwent rhizotomies and almost yearly epidural steroid injections (ESIs) which somewhat relieved the pain from back down his legs, but did not relieve the numbness, tingling and distal weakness and burning from his feet and hands radiating upward. The Veteran had back problems since around 2005 which was predated by his numbness and tingling in hands and feet since the 1990s. With respect to the right upper extremity, the Veteran endorsed constant pain (at times excruciating), usually dull intermittent pain, paresthesias and numbness which was severe. He had 4/5 grip and pinch strength, but normal strength for elbow flexion and extension as well as wrist flexion and extension. There was no muscle atrophy or trophic changes. There were absent reflexes for the biceps, triceps and brachioradialis. Sensory examination was normal for the shoulder area, but decreased for the inner/outer forearm as well as the hand/fingers. There was decreased vibratory sense in the hand, and decreased temperature sense in the hand and forearm. There was a positive Phalen's sign, but negative Tinel's sign. The examiner diagnosed the Veteran with mild incomplete paralysis of the radial (musculospiral) nerve, moderate incomplete paralysis of the median nerve, moderate incomplete paralysis of the ulnar nerve, and mild incomplete paralysis of the musculocutaneous nerve. The long thoracic nerve, upper radicular group (5th and 6th cervicals), middle radicular group and lower radicular groups nerves were normal. The Veteran occasionally used wrist braces for carpal tunnel syndrome. The Veteran's overall functional impairment was not so diminished that no effective function remained that amputation with prosthesis would equally serve him. His functional impairment included difficulty handling mail due to hand numbness. With respect to the right lower extremity, the Veteran endorsed constant pain (at time excruciating), usually dull intermittent pain, paresthesias and numbness which was severe. He had 4/5 strength with ankle plantar flexion and dorsiflexion, and 5/5 strength with knee extension. There was no muscle atrophy or trophic changes. There were absent reflexes for the knee and ankle. There was decreased sensory examination for the lower leg/ankle and foot/toes with normal sensation in the thigh/knee and upper anterior thigh. There was decreased vibratory sense in the toes and ankle with decreased temperature sense from the feet up to the knees. The Veteran had an abnormal gait which was mildly broad-based, and he could not tandem walk due to numbness in his feet and lower legs. He could not heel or toe walk well. The examiner diagnosed moderate incomplete paralysis of the sciatic nerve, moderate incomplete paralysis of the external popliteal (common peroneal) nerve, mild incomplete paralysis of the musculocutaneous (superficial peroneal) nerve, moderate incomplete paralysis of the anterior tibial (deep peroneal) nerve, moderate incomplete paralysis of the posterior tibial nerve, and mild incomplete paralysis of the internal saphenous nerve. The anterior crural (femoral) and obturator and ilio-inguinal nerves were normal. The Veteran's overall functional impairment was not so diminished that no effective function remained that amputation with prosthesis would equally serve him. The Veteran's functional impairments included tripping easily and having fallen. With respect to the left lower extremity, the Veteran endorsed constant pain (at times excruciating), usually dull intermittent pain, paresthesias and numbness which was severe. He had 4/5 strength with ankle plantar flexion and dorsiflexion, and 5/5 strength with knee extension. There was no muscle atrophy or trophic changes. There were absent reflexes for the knee and ankle. There was decreased sensory examination for the lower leg/ankle and foot/toes with normal sensation in the thigh/knee and upper anterior thigh. There was decreased vibratory sense in the toes and ankle with decreased temperature sense from the feet up to the knees. The examiner diagnosed moderate incomplete paralysis of the sciatic nerve, moderate incomplete paralysis of the external popliteal (common peroneal) nerve, mild incomplete paralysis of the musculocutaneous (superficial peroneal) nerve, moderate incomplete paralysis of the anterior tibial (deep peroneal) nerve, moderate incomplete paralysis of the posterior tibial nerve, and mild incomplete paralysis of the internal saphenous nerve. The anterior crural (femoral) and obturator and ilio-inguinal nerves were normal. The Veteran's overall functional impairment was not so diminished that no effective function remained that amputation with prosthesis would equally serve him. The VA examiner opined that the Veteran's symptoms attributable to carpal tunnel syndrome could not be distinguished from those attributable to peripheral neuropathy. In fact, patients with diabetic neuropathy often developed carpal tunnel syndrome superimposed on the underlying diabetic neuropathy and secondary to the underlying generalized neuropathy. Additionally, Veteran's symptoms attributable to radiculopathy involved asymmetric pain radiating from the hip or back which was distinguishable by EMG study. However, the Veteran's current symptoms of numbness, tingling, burning and weakness of his feet which continued unabated were due to his diabetic peripheral neuropathy. The examiner also provided the following opinion regarding the effects of his diabetic peripheral neuropathy on his employability: INDIVIDUAL UNEMPLOYABILITY: The patient continues to work as a letter carrier for the USPS, albeit with some difficulty due to his diabetic peripheral neuropathy. He would be expected from his exam and symptoms to have a moderate amount of difficulty maintaining this job or securing another job due to loss of dexterity and feeling in his hands and weakness and loss of feeling and balance in his lower legs. He would have difficulty with any activities requiring him to have good manual dexterity and sensation. [H]e would have difficulty with any activities requiring him to have good balance and distal strength in his legs. For instance, he would have difficulty climbing and should not work at heights. MEDICATION EFFECTS: Meds include amitriptyline 75 mg nightly and gabapentin 300 mg TID. These medications would very likely cause drowsiness and lethargy that may very well be disabling. NOTE: Veteran's symptoms and findings on exam of diabetic peripheral neuropathy are worse today than when last seen and evaluated by myself in [M]ay, 2012. i. Lower extremity diabetic neuropathy At the outset, the Board observes that the November 2013 VA examiner identified the Veteran as having incomplete paralysis of the sciatic nerve, the external popliteal (common peroneal) nerve, the musculocutaneous (superficial peroneal) nerve, the anterior tibial (deep peroneal) nerve, the internal popliteal (tibial) nerve, the posterior tibial nerve and the internal saphenous nerve had incomplete paralysis. Pursuant to VBA policy, the sciatic nerve, the external popliteal (common peroneal) nerve, the musculocutaneous (superficial peroneal) nerve, the anterior tibial (deep peroneal) nerve, the internal popliteal (tibial) nerve and the posterior tibial nerve are part of the sciatic nerve group which affect the same functions in the leg and, therefore, may not be separately rated without violating the rule against pyramiding. M21-1, III.iv.4.G.4.d. However, the internal saphenous nerve affects a different function in the leg and, therefore, may be separately rated. Id. A. RLE and LLE diabetic neuropathy for time period prior to December 31, 2008 Applying the criteria to the facts of the case, the Board finds that the criteria for separate 20 percent ratings for RLE and LLE diabetic neuropathy under DC 8520 for time period prior to December 31, 2008 have been met. In this respect, the lay and medical evidence established that the Veteran's RLE and LLE diabetic neuropathy was manifested by no more than moderate incomplete paralysis of the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal (tibial) and posterior tibial nerves as demonstrated by subjective complaint of tingling, numbness and pain sensation with objective findings of decreased sensation, and diminished reflexes and right peripheral pulse, but absent impairment of motor function or trophic changes. Additionally, the Board finds that the criteria for a separate compensable rating for RLE and LLE diabetic neuropathy under DC 8527 for time period prior to December 31, 2008 have not been met. In this respect, the lay and medical evidence established no more than moderate incomplete paralysis of the internal saphenous nerve as demonstrated by subjective complaint of tingling, numbness and pain sensation of the thigh with objective findings of decreased sensation and diminished reflexes and right peripheral pulse, but absent impairment of motor function or trophic changes. Here, the Veteran credibly reported symptoms of tingling, numbness and pain sensation extending to his feet, including his thighs. There were objective findings of decreased sensation. See VA examination dated May 2004. There were also objective findings of diminished reflexes and right peripheral pulse. See Private clinic records dated October 2003 and July 2005; and VA clinic record dated April 2007. However, the Veteran's RLE and LLE demonstrated no trophic changes with a normal hair distribution pattern. See VA clinic record dated December 2003 and private clinic record dated August 2005. There were no motor abnormalities or evidence of muscle atrophy. See VA examination in May 2004. In addition, a VA examiner in May 2004 described the Veteran as manifesting very mild early diabetic neuropathy while a March 2007 private examiner described "mild" neuropathy of the feet. Thus, the lay and medical evidence demonstrated sensory abnormalities which were not complete which is not consistent with a finding of "moderate" incomplete paralysis. See M-21, III.iv.4.G.4.b. The Veteran did demonstrate diminished reflexes, which is a feature of disability associated with "severe" incomplete paralysis. Id. However, the Veteran did not demonstrate any additional aspects of "severe" incomplete paralysis such as motor abnormality, atrophy or weakness. Id. The Board additionally observes that the private and VA examiners described the overall RLE and LLE neuropathy as "mild" in degree. When considering the relative severity and degree of impaired function of the Veteran's sciatic nerve, the external popliteal (common peroneal) nerve, the musculocutaneous (superficial peroneal) nerve, the anterior tibial (deep peroneal) nerve, the internal popliteal (tibial) nerve, posterior tibial and internal saphenous nerves, as instructed by 38 C.F.R. § 4.120, the Board finds that the Veteran's symptoms of paralysis of these nerves meet the criteria for "moderate" incomplete paralysis but do not meet, or more closely approximate, the criteria for "severe" incomplete paralysis or "complete" paralysis. Thus, separate 20 percent ratings for RLE and LLE diabetic neuropathy under DC 8520 - for the nerve group involving the sciatic nerve, the external popliteal (common peroneal) nerve, the musculocutaneous (superficial peroneal) nerve, the anterior tibial (deep peroneal) nerve, the internal popliteal (tibial) nerve and the posterior tibial nerve - have been met. The Board may not assign separate ratings as this would violate the rule against pyramiding. 38 C.F.R. § 4.14; M21-1, III.iv.4.G.4.d. The Board may assign a separate rating for impairment of the internal saphenous nerve, but the criteria for a compensable rating have not been met. B. RLE diabetic neuropathy for time period since December 31, 2008 Applying the criteria to the facts of the case, the Board finds that the criteria for separate 40 percent ratings for RLE and LLE diabetic neuropathy under DC 8520 for the time period since December 31, 2008 have been met. In this respect, the lay and medical evidence for the first time established that the Veteran's RLE and LLE diabetic neuropathy was manifested by no more than moderately severe incomplete paralysis of the sciatic nerve, or severe incomplete paralysis of the external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal (tibial) and posterior tibial nerves, as demonstrated by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation, and diminished reflexes and right peripheral pulse and impairment of proprioception which interfered with his ability to ambulate. Additionally, the Board finds that the criteria for separate 10 percent ratings under DC 8527 since December 31, 2008 have been met. In this respect, the lay and medical evidence for the first time established no more than severe incomplete paralysis of the internal saphenous nerve as demonstrated by subjective complaint of tingling, numbness and pain sensation of the thigh with objective findings of decreased sensation and diminished reflexes and right peripheral pulse and impairment of proprioception which interfered with the Veteran's ability to ambulate. On VA examination dated December 31, 2008, the Veteran first reported that his RLE and LLE diabetic neuropathy had started to interfere with his ability to walk unaided. At this examination, the Veteran demonstrated no pathologic reflexes. His physical examination was significant for decreased sensation in all sensory modalities, to include proprioception. The examiner described the Veteran as manifesting "severe" distal polyneuropathy. In December 2009, a VA clinician also described the Veteran as manifesting "severe" progressive diabetic neuropathy noting that the Veteran had developed poor balance. A February 2010 VA diabetes mellitus examination noted decreased strength in the lower extremities. The May 2012 VA examiner described the Veteran's RLE and LLE diabetic neuropathy as interfering with activities such as driving and walking. Thus, on December 31, 2008, the Veteran first demonstrated impairment of gait and lower extremity weakness which is a feature of disability associated with "severe" incomplete paralysis. See M-21, III.iv.4.G.4.b. However, the criteria of DC 8520 have a category of "moderately severe" which is not discussed in the Adjudication Manual and the criteria for "severe" incomplete paralysis of the sciatic nerve specifically lists "marked muscular atrophy" as a distinguishing feature from the moderately severe criteria. Thus, the Board finds that the Veteran's RLE and LLE diabetic neuropathy of the sciatic nerve meets the specific definition of "moderately severe" as used in DC 8520, and does not meet or more nearly approximate the criteria of "severe" as used in DC 8520 as there is lay or medical evidence of "marked muscular atrophy." As such, the Board finds that the Veteran met the criteria for separate 40 percent ratings for RLE and LLE diabetic neuropathy under DC 8521, and separate 10 percent ratings for RLE and LLE diabetic neuropathy under DC 8721. The Board further finds that the criteria for higher ratings still are not met. The Board first observes that it is not factually ascertainable that the increased severity of the Veteran's RLE and LLE diabetic neuropathy occurred prior to December 31, 2008. In this respect, there is no lay description of gait impairment prior to the December 31, 2008 VA examination. At that examination, the Veteran described his RLE and LLE diabetic neuropathy as "beginning" to interfere with his ability to walk unaided. In December 2009, he was noted to have poor balance which had become worse since the last visitation, which occurred in April 2009. Additionally, the Veteran has not met the criteria for ratings in excess of 40 percent for RLE and LLE diabetic neuropathy involving the sciatic nerve, the external popliteal (common peroneal) nerve, the musculocutaneous (superficial peroneal) nerve, the anterior tibial (deep peroneal) nerve, the internal popliteal (tibial) nerve and the posterior tibial nerve, or for ratings greater than 10 percent for the internal saphenous nerve. In this respect, a rating greater than 40 percent rating is not available for severe or complete paralysis of the external popliteal (common peroneal) nerve, the musculocutaneous (superficial peroneal) nerve, the anterior tibial (deep peroneal) nerve, the internal popliteal (tibial) nerve or posterior tibial nerve, and a rating greater than 10 percent is not available for complete paralysis of the internal saphenous nerve. As for a rating greater than 40 percent for paralysis of the sciatic nerve, the criteria for the next higher 60 percent rating for "severe" incomplete paralysis requires "marked muscular atrophy." The Veteran has not specifically described this feature of disability, and there is no medical description of muscular atrophy. Rather, VA examiners in December 2008, May 2012 and November 2013 found no muscle atrophy. Additionally, the Veteran demonstrated no features of disability which more nearly approximated the criteria for complete paralysis of the sciatic nerve in either extremity. In this respect, the Veteran demonstrated active movement of the muscles below the knee and there is no lay or medical evidence of foot dangle/drop, or flexion of the knee weakened or (very rarely) lost. In so holding, the Board has found the Veteran's descriptions of RLE and LLE diabetic neuropathy symptoms and functional limitations to be credible and consistent with the medical evidence of record. In fact, the Board has relied, in part, upon his description of gait impairment due to his RLE and LLE diabetic neuropathy symptoms as demonstrating an increased severity of disability warranting separate 40 percent and 10 percent ratings for each extremity effective December 31, 2008. To the extent that he argues his entitlement to higher ratings still, the Board places greater probative weight to the findings of the private and VA physicians who have greater expertise and training than the Veteran in identifying the symptoms and functional impairments caused by his neurologic disability. ii. RUE diabetic neuropathy As noted above, the Schedule of Ratings instructs that combined nerve injuries of the upper extremity nerve groups should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. The VBA has provided guidance that separate evaluations may not be assigned when evaluating an upper extremity peripheral nerve disability. M-21, III.iv.4.G.4.b. The Board will evaluate the nerve branch which is most beneficial to the Veteran. Id. Here, the November 2013 VA examiner identified the Veteran's RUE diabetic neuropathy as involving the radial nerve, the median nerve, the ulnar nerve and the musculocutaneous nerve. Thus, the Board will evaluate the Veteran's RUE diabetic neuropathy under the criteria for the radial nerve. M-21, III.iv.4.G.4.e. A. Time period prior to May 30, 2012 Applying the criteria to the facts of the case, the Board finds that the criteria for a rating greater than 10 percent for RUE diabetic neuropathy under DC 8514 have not been met for any time prior to May 30, 2012. In this respect, the lay and medical evidence established no more than mild incomplete paralysis of the radial, median, ulnar and musculocutaneous nerves as demonstrated by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation including proprioception, diminished reflexes but absent motor or trophic changes. Here, the Veteran credibly reported symptoms of tingling and numbness of his right hand and distal aspect of the arm. There were also objective findings of diminished reflexes. See Private clinic records dated April 2004 and July 2005; and VA clinic record dated April 2007. However, the Veteran showed no objective evidence of decreased sensation until December 2008, at which time he demonstrated diminished sensation to all modalities including proprioception. See VA examinations dated May 2004 and December 2008. The Veteran's RUE demonstrated no motor abnormalities with normal muscle strength, tone, and coordination. See VA examinations dated May 2004 and December 2008. The May 2004 VA examiner commented that neuropathy affecting the hands was not appreciated. A private examiner in April 2004 and January 2006 noted good grip strength. The December 2008 VA examination, while first demonstrating objective sensory deficits including proprioception and no pathologic reflexes, still showed normal muscle strength, tone and coordination without evidence of fasciculations, tremor or involuntary movements. The Veteran had good arm swing. Thus, the lay and medical evidence demonstrated sensory abnormalities which were not complete which is not consistent with a finding of "moderate" incomplete paralysis. See M-21, III.iv.4.G.4.b. The Veteran did demonstrate diminished reflexes, which is a feature of disability associated with "severe" incomplete paralysis. Id. However, the Veteran did not demonstrate any additional aspects of "severe" incomplete paralysis such as motor abnormality, atrophy or weakness. Id. When considering the relative severity and degree of impaired function of the Veteran's radial, median, ulnar and musculocutaneous nerves, as instructed by 38 C.F.R. § 4.120, the Board finds that the Veteran's symptoms of paralysis of these nerves does not meet or more closely approximate, the criteria for "moderate" incomplete paralysis. In so holding, the Board acknowledges that the December 2008 VA examiner described "severe" distal polyneuropathy of the RUE. However, the clinic findings as described above do not reveal any significant impairment of motor abnormality, atrophy or weakness and sensory impairment was not complete. Notably, a VA examiner in May 2012 described the Veteran's paralysis of the radial, median and ulnar nerves as "mild" in degree. Thus, the Board places greater probative weight to the totality of the clinic findings rather than VA examiner general descriptions of "mild" and "severe." B. Time period from May 30, 2012 to November 13, 2013 Applying the criteria to the facts of the case, the Board finds that the criteria for a 20 percent rating for RUE diabetic neuropathy under DC 8514 have been met from May 30, 2010 to November 13, 2013. In this respect, the lay and medical evidence established no more than moderate incomplete paralysis of the radial, median, ulnar and musculocutaneous nerves as demonstrated by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation including proprioception, diminished reflexes and interference with manual dexterity but absent additional motor or trophic changes. The May 30, 2012 VA examination for the first time included an examiner opinion that the Veteran's RUE diabetic neuropathy interfered with his manual dexterity. This examiner described the Veteran's RUE diabetic neuropathy as causing him difficulties with handling objects. However, that examination continued to demonstrate 5/5 strength for the upper extremity and hands absent evidence of muscle atrophy or trophic changes. Notably, the VA examiner described the Veteran's overall paralysis of the radial, median and ulnar nerves as "mild" in degree. When considering the relative severity and degree of impaired function of the Veteran's radial, median, ulnar and musculocutaneous nerves, as instructed by 38 C.F.R. § 4.120, the Board finds that the Veteran's symptoms of paralysis of these nerves does not meet or more closely approximate, the criteria for more than "moderate" incomplete paralysis. In so holding, the Board observes that it is not factually ascertainable from the lay and medical evidence of record that the Veteran's impairment of manual dexterity was manifested prior to May 30, 2012. C. Time period since November 14, 2013 Applying the criteria to the facts of the case, the Board finds that the criteria for a 50 percent rating for RUE diabetic neuropathy under DC 8514 have been met since November 14, 2013. In this respect, the lay and medical evidence first established severe incomplete paralysis of the radial, median, ulnar and musculocutaneous nerves manifested by subjective complaint of tingling, numbness and pain sensation and objective findings of decreased sensation including proprioception, diminished reflexes, interference with manual dexterity and 4/5 grip and pinch strength. The November 14, 2013 VA examination demonstrated for the first time that the Veteran's RUE diabetic neuropathy involved demonstrable weakness which is feature of disability associated with "severe" incomplete paralysis. See M-21, III.iv.4.G.4.b. The Board observes that it is not factually ascertainable from the lay and medical evidence of record that this demonstrable weakness was manifested prior to November 14, 2013. The Board further finds that the lay and medical evidence does not meet or more nearly approximate the criteria for "complete" paralysis of the radial, median, ulnar and musculocutaneous nerves. In this respect, there is no lay or medical evidence of drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; inability to extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of the wrist; supination of hand, extension and flexion of elbow weakened; the loss of synergic motion of extensors impairs the hand grip seriously; or total paralysis of the triceps. In so holding, the Board has found the Veteran's descriptions of RUE diabetic neuropathy symptoms and functional limitations to be credible and consistent with the medical evidence of record. To the extent that he argues his entitlement to higher ratings still, the Board places greater probative weight to the findings of the private and VA physicians who have greater expertise and training than the Veteran in identifying the symptoms and functional impairments caused by his neurologic disability. ORDER A 20 percent rating under DC 8520 for the time period prior to December 31, 2008, a 40 percent rating under DC 8520 for the time period since December 31, 2008, and a 10 percent rating under DC 8527 since December 31, 2008 is granted for RLE diabetic neuropathy. A 20 percent rating under DC 8520 for the time period prior to December 31, 2008, a 40 percent rating under DC 8520 for the time period since December 31, 2008, and a 10 percent rating under DC 8527 since December 31, 2008 is granted for LLE diabetic neuropathy. A 20 percent rating under DC 8514 for the time period from May 30, 2012 to November 13, 2013, and a 50 percent rating since November 14, 2013, for RUE diabetic neuropathy is granted. REMAND As discussed in the prior Board remand, the record contains evidence that the Veteran's diabetic neuropathy has had a significant effect on his employment. During the May 2012 VA examination, the examiner noted that the Veteran was most likely unable to secure and maintain gainful employment in any job that required him to have good manual dexterity and to drive, walk, or stand for any length of time. The examiner indicated that the Veteran's disability affected his job as a mail carrier for the Postal Service. She indicated that the Veteran had difficulty holding the brakes to stop at mail boxes and that his feet burned which caused difficulty with feeling and keeping his feet on the brakes. Additionally, the examiner noted that the Veteran's hands are numb and he had difficulty holding and handling the mail. And due to his medications for his diabetic neuropathy, he had difficulty driving; and some days he was unable to walk. She noted that the Veteran had already used five of the eight weeks of his annual leave due to his disability. On the most recent November 2013 VA examination, the examiner indicated that, while the Veteran continued to work as a mail carrier, he had increased difficulty due to his diabetic neuropathy. She indicated that the Veteran's symptoms had a moderate effect on his job due to the loss of dexterity and feeling in his hands and weakness and loss of feeling and balance in his lower legs. Moreover, the examiner indicated that the medication the Veteran needs to take for his diabetic neuropathy caused drowsiness and lethargy. Based on the foregoing, the Board found that the record contained evidence of effects upon the Veteran's ability to maintain employment that were not contemplated by the established schedular criteria, as well as evidence of marked interference with employment. As such, the Board remanded the claim to refer the case to the Director of Compensation and Pension for consideration of an extra-schedular rating under the provisions of 38 C.F.R. § 3.321(b)(1). In July 2015, the Director of Compensation and Pension service provided opinion that the Veteran was not entitled to an increased evaluation for his peripheral neuropathy on an extra-schedular basis. In so doing, the examiner stated that the evidence indicated that the Veteran was reporting difficulties at work and interference with work due to peripheral neuropathies of the upper and lower extremities, but that he continued to be employed on a full-time basis with the USPS. There was no discussion, however, regarding the Veteran's excessive use of work time due to his diabetes mellitus and its complications or the effects of his medications which are not specifically addressed in the applicable schedular criteria. The Board notes that, in Johnson v. McDonald, 762 F.3d 1362, 1366 (Fed Cir. 2014), the Federal Circuit Court stated that "[l]imiting referrals for extra-schedular evaluation to considering a Veteran's disabilities individually ignores the compounding negative effects that each individual disability may have on the Veteran's other disabilities." The Court has recently held that a decision by the Director of Compensation and Pension denying extraschedular consideration must be supported by "a statement of reasons for the decision and a summary of the evidence considered." Kuppamala v. McDonald, 2015 WL 9584022 (Dec. 30, 2015). And more recently, the Federal Circuit recently held that, when considering whether referral is warranted based on the combined effects of a Veteran's service-connected disabilities, the Board first must compare the Veteran's symptoms with the assigned schedular ratings. Yancy v. McDonald, No. 14-3390 (Fed. Cir. February 26, 2016). Here, the Director's July 2015 decision did not discuss the Veteran's full use of annual and sick leave for the complications of the Veteran's diabetes mellitus and/or the effects of his medications which are not specifically addressed in the schedular criteria. Inasmuch as the Veteran's use of annual and sick leave results, in part, from his inability to manage his blood sugars and diet, the Board will request the Director of Compensation and Pension to consider the Veteran's diabetes mellitus and all complications. Thus, the Board must return the Director's July 2015 administrative decision for a complete summary of the evidence considered and a statement of reasons why the schedular criteria are adequate in this case. Accordingly, the case is REMANDED for the following action: 1. Obtain all relevant VA treatment records since March 2015. 2. Contact the Veteran and request information with respect to any additional private medical care providers who may possess current records pertinent to his claims. After obtaining any necessary consent forms for the release of the Veteran's private medical records, obtain, and associate with the electronic file, all records noted by the Veteran that are currently not on file. Moreover, ask the Veteran again to provide any additional evidence related to the marked interference with his employment as a mail carrier - such as additional copies of sick leave statements for the years 2004 to the present. 3. After associating all the evidence in connection with the above development (to the extent possible) with the record, the AOJ must refer the Veteran's claim for consideration of an extra-schedular evaluation to the Under Secretary of Benefits or Director of Compensation and Pension, pursuant to 38 C.F.R. § 3.321(b)(1). The determination must consider the combined effects of a Veteran's service-connected disabilities, including the Veteran's full use of annual and sick leave for the complications of the Veteran's diabetes mellitus and/or the effects of his medications which are not specifically addressed in the schedular criteria. See Yancy v. McDonald, No. 14-3390 (Fed. Cir. February 26, 2016); Mingo v. Derwinski, 2 Vet. App. 51 (1992). Additionally, the determination must be supported by "a statement of reasons for the decision and a summary of the evidence considered." See Kuppamala v. McDonald, 2015 WL 9584022 (Dec. 30, 2015). 4. If, after consideration by the Under Secretary or Director, the benefit sought on appeal remains denied, the Veteran and his representative should be provided a SSOC, which should include all pertinent law and regulations. The Veteran and his representative should then be given an opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs