Citation Nr: 1707977 Decision Date: 03/16/17 Archive Date: 04/03/17 DOCKET NO. 10-24 268 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a cervical spine disability. 2. Entitlement to an increased rating for residuals of a right knee meniscectomy, currently evaluated as 10 percent disabling. 3. Entitlement to an increased rating for diabetes mellitus, type II, currently evaluated as 20 percent disabling. 4. Entitlement to an increased rating for peripheral neuropathy of the right lower extremity, currently evaluated as 10 percent disabling. 5. Entitlement to an increased rating for peripheral neuropathy of the left lower extremity, currently evaluated as 10 percent disabling. 6. Entitlement to an increased rating for peripheral neuropathy of the right upper extremity, currently evaluated as 10 percent disabling. 7. Entitlement to an increased rating for peripheral neuropathy of the left upper extremity, currently evaluated as 10 percent disabling. 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Robert P. Walsh, Attorney WITNESSES AT HEARING ON APPEAL Veteran and his Wife ATTORNEY FOR THE BOARD B. Muetzel, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to March 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from multiple decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board will briefly clarify the procedural history of this appeal. In a July 2009 decision, the RO, inter alia, denied service connection for a cervical spine neck disability and peripheral neuropathy of the upper extremities. The Veteran filed a timely Notice of Disagreement (NOD) in September 2009 and the RO issued a Statement of the Case (SOC) in May 2010. The Veteran perfected his appeal with a VA Form 9 in June 2010. Prior to the Board's May 2014 remand, the RO granted the Veteran's claim of entitlement to service connection for peripheral neuropathy of the bilateral lower extremities by way of a June 2013 rating decision. It also granted the claim of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities in a November 2013 rating decision. Because these grants represented a full grant of the benefits sought on appeal, these issues were no longer before the Board at the time of the May 2014 remand. The Board remanded the claims in May 2014 and a Supplemental SOC was issued in June 2014. The Board remanded the claims again in September 2014. A Supplemental SOC was issued in April 2015. A Board hearing was held regarding the claims of entitlement to service connection for a cervical spine disability and entitlement to TDIU in September 2016. The transcript is of record. The Veteran's claims of entitlement to increased ratings for residuals of a right knee meniscectomy, diabetes mellitus, and peripheral neuropathy of the bilateral upper and lower extremities were denied in a January 2015 rating decision. The Veteran filed a timely NOD in February 2015 and the RO issued a SOC in September 2016. The Veteran perfected his appeal in October 2016 and the claims were certified to the Board in October 2016 as well. The Veteran did not request a hearing in connection with the foregoing claims. The issues of entitlement to service connection for a cervical spine disability, entitlement to an increased rating for residuals of a right knee meniscectomy, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. During the entire appeal period the Veteran's diabetes mellitus has required insulin. 2. The Veteran's right and left lower extremity peripheral neuropathy is manifested by moderately-severe incomplete paralysis of the sciatic nerve with symptoms of constant pain, paresthesias and/or dysesthesias, and numbness. 3. The Veteran's right and left extremity peripheral neuropathy is manifested by no more than moderate incomplete paralysis with symptoms of intermittent pain, numbness, and some difficulty grasping. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus type II have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, (West 2014); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2016). 2. The criteria for a rating of 40 percent, but no higher, for peripheral neuropathy of the right lower extremity are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8620 (2016). 3. The criteria for a rating of 40 percent, but no higher, for peripheral neuropathy of the left lower extremity are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Codes 8620 (2016). 4. The criteria for a rating of 30 percent, but no higher, for peripheral neuropathy of the right upper extremity are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2016). 5. The criteria for a rating of 20 percent, but no higher, for peripheral neuropathy of the left upper extremity are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014)) redefined VA's duty to notify and assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2016). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2016). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Prinicipi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. VA's duty to notify was satisfied by letters dated in September 2008, April 2009, September 2011, and September 2012. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The record contains the VA, private and service treatment records; statements submitted by the Veteran, his friends, and his family; and reports of VA examinations. The reports of the VA examinations included a review of the Veteran's medical history, including private and VA treatment records, an interview and examination of the Veteran. The examinations also include sufficient clinical and diagnostic findings for purposes of determining the nature and severity of the Veteran's diabetes mellitus and associated peripheral neuropathy of the bilateral upper and lower extremities. Therefore, the Board concludes that the VA examinations are adequate. 38 C.F.R. § 4.2 (2016); see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide an examination or obtain a VA opinion, it must ensure that examination or opinion is adequate). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Ratings Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2016); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2016); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2016); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2016). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's claims. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2016). Diabetes Mellitus, Type II The Veteran contends that he is entitled to an evaluation in excess of 20 percent for his service-connected diabetes mellitus. The Veteran was granted service connection for diabetes mellitus in a July 2012 rating decision. An evaluation of 20 percent was assigned under Diagnostic Code 7913, effective as of August 18, 2011. The Veteran filed his claim for an increased rating for diabetes mellitus in June 2014. The Veteran's diabetes mellitus type II is rated under the diagnostic code for diabetes mellitus in accordance with the General Rating Formula for the Endocrine system. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2016). A 10 percent evaluation is warranted for diabetes manageable by diet only. A 20 percent evaluation is warranted for requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent evaluation is warranted for requiring insulin, restricted diet, and regulation of activities. A 60 percent evaluation is warranted for requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent evaluation is warranted for requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. "Regulation of activities" has been defined as the situation where a veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,443 (May 7, 1996) (defining "regulation of activities," as used by VA in 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). The Veteran's VA treatment records show that he has had an ongoing diagnosis of diabetes mellitus, type II, with no complaints of complication. Private treatment records from the Heartland Clinic of Cameron show that the Veteran was seen in May 2014 for complaints that his blood sugar was staying high. He indicated that his fatigue was a little better. It was noted that his diabetes mellitus was uncontrolled. In January 2016, the Veteran's VA treatment records noted that his diabetes was controlled. The Veteran was scheduled for an examination in October 2014, but he did not attend. In November 2014, he requested a rescheduled examination. A VA examination was provided in January 2015. The examiner reviewed the VA treatment and civilian medical records. The examiner noted that the Veteran was diagnosed with diabetes mellitus type II in 2009. The examiner noted that the Veteran was treating his diabetes with insulin injections more than once per day. The examiner noted that the Veteran's diabetes did not require regulations of activities as part of medical management. The examiner noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times per month. There were no hospitalizations for episodes of ketoacidosis or hypoglycemic reactions in the preceding 12 months. The Veteran did not exhibit any progressive unintentional weight loss or loss of strength attributable to his diabetes. The examiner noted the Veteran's complications of diabetes included diabetic peripheral neuropathy, for which he is separately service-connected. There were no other conditions caused or aggravated by the diabetes mellitus. There were no associated scars or other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the diagnosis section. The examiner noted that the Veteran's diabetes and associated complications impact his ability to work insofar as the Veteran stated he only worked half days because he felt run down. Based on the evidence above, the Board finds that the assigned 20 percent rating is most appropriate for the entire appeal period. While the Veteran has been shown to require insulin more than once per day, there is no medical evidence that there is a regulation of the Veteran's activities. Medical evidence continued to show no evidence of prescribed regulation of activities. The Board acknowledges that the Veteran believes his diabetes warrants a higher rating. However, the Board finds that the Veteran's sincere lay belief is outweighed by competent and credible medical evidence that evaluates the true extent of the diabetes mellitus based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. Indeed, as noted above, medical evidence is required to show that occupational and recreational activities have been restricted which is not shown here. In fact, the January 2015 VA examiner explicitly stated that the Veteran was not restricted in his activity. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. As the medical evidence does not show that the Veteran's activities are regulated, the criteria for a 40 percent rating are not met. Additionally, according to the United States Court of Appeals for Veterans Claims (Court), the rating of diabetes mellitus under Diagnostic Code 7913 includes successive rating criteria, whereby "the evaluation of each higher disability rating included the criteria of each lower disability rating, such that if a component was not met at any one level, the Veteran could only be rated at the level that did not require the missing component." Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009); see Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met). As the criteria for a 40 percent rating are not met the requirements for an even higher rating are also not met. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to a disability evaluation in excess of 20 percent must be denied. Peripheral Neuropathy of the Bilateral Upper and Lower Extremities The Veteran seeks higher evaluations for his service-connected peripheral neuropathy of the bilateral upper and lower extremities. Lower extremities The Veteran was granted service connection for peripheral neuropathy of the bilateral lower extremities related to his diabetes mellitus by a June 2013 rating decision. An evaluation of 10 percent was assigned to each lower extremity, effective August 18, 2011, under Diagnostic Code 8521 for the right lower extremity and Diagnostic Codes 8599-8521 for the left lower extremity. Diagnostic Code 8599 indicates that peripheral neuropathy for the left lower extremity is rated by analogy under closely related injuries in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. He filed a claim for an increased rating in June 2014. The Veteran's lower extremity diabetic peripheral neuropathy is rated under Diagnostic Code 8521, which provides ratings for paralysis of the external popliteal nerve. 38 C.F.R. § 4.124a. Disability ratings of 10, 20 and 30 percent are warranted, respectively, for mild, moderate, and severe incomplete paralysis of the external popliteal nerve. A disability rating of 40 percent is warranted for complete paralysis of the relevant 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. 38 C.F.R. § 4.124a, Diagnostic Code 8521. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C.A. § 7104; 38 C.F.R. §§ 4.2, 4.6 (2016). In rating diseases of the 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. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Neither the Rating Schedule nor the regulations provide definitions for words such as "moderately severe." Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2016). The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. See 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The VA treatment records show that the Veteran has maintained a diagnosis of diabetic peripheral neuropathy. In July 2012, it was noted that the Veteran had neuropathy since 1997, which preceded his diabetes diagnosis in 2009. In February 2013, the Veteran reported that his neuropathy was very uncomfortable. In November 2013, the Veteran noted that he had tried numerous medications for neuropathy and that Cymbalta was the only thing that gave him relief. A May 2014 statement from the Veteran's coworker indicated that the Veteran was often absent from work due, in part, to his neuropathy. In March 2015, the Veteran's daughters and wife submitted statements concerning the Veteran's condition, which indicated that the Veteran's peripheral neuropathy contributed to his physical disabilities. The Veterans' daughters noted that the Veteran had difficulty grasping and complained of tingling in his hands. His wife also noted that he had a loss of strength, numbness and pain in his hands, and burning in his feet. A VA examination was provided in January 2015. The examiner conducted an in-person examination and reviewed the VA treatment records and private treatment records. The examiner noted the diagnosis of peripheral neuropathy, dating back to approximately 2001. The examiner also noted the history of diabetes mellitus. The Veteran reported that he first experienced peripheral neuropathy in 2001 or 2002. He reported that it began before his diabetes diagnosis in 2009. The Veteran stated that the neuropathy began in his feet and legs; later, he began to exhibit signs of it in his hands as well. The Veteran stated that his feet feel like they are on fire after he walks. He reported numbness from the knee down. He reported moderate constant pain in the bilateral lower extremities. He denied intermittent dull pain in either lower extremity. The Veteran endorsed moderate paresthesias and/or dysesthesias in the bilateral lower extremities and moderate numbness in the bilateral lower extremities. He exhibited full strength in all of the lower extremities. His deep tendon reflexes were normal in all extremities. The light touch/monofilament testing results were also normal in all lower extremities. The Veteran's vibration sensation and cold sensation was normal in the bilateral lower extremities. There was no muscle atrophy or any skin changes attributable to diabetic peripheral neuropathy. The examiner diagnosed moderately-severe incomplete paralysis of the sciatic nerve, bilaterally. He noted that the Veteran's femoral nerve was normal. After review of the evidence of record, the Board finds that a higher schedular rating of 40 percent disabling is warranted for each lower extremity under Diagnostic Code 8620 for moderately severe incomplete paralysis of the sciatic nerve. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as it is supported by reasons and bases as well as the evidence. 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, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). It is permissible to switch Diagnostic Codes to reflect more accurately a claimant's current symptoms. See also Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the diagnostic code associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). Diagnostic Code 8620 provides that ratings of 10, 20, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. A disability rating of 60 percent is warranted for severe incomplete paralysis with marked muscle atrophy. An 80 percent rating is warranted with complete paralysis of the sciatic nerve. 38 C.F.R. § 4.124(a). With regard to rating neurologic disabilities, cranial or peripheral neuritis, 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 that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized 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. Here, the Board finds that changing the diagnostic code under which the Veteran's bilateral lower extremity peripheral neuropathy is rated to Diagnostic Code 8620, more closely approximates the sciatic nerve incomplete paralysis symptomatology and is more favorable to the Veteran. Diagnostic Code 8620 applies to the sciatic nerve, and the January 2015 VA examiner determined that the Veteran's lower extremity peripheral neuropathy resulted from moderately severe incomplete paralysis of the sciatic nerve. Thus, Diagnostic Code 8620 is the appropriate code based on the location and severity of the Veteran's nerve dysfunction. Given the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 40 percent for either the right or left lower extremity as the Veteran's symptoms most nearly approximate the criteria for a 40 percent rating. As discussed, Diagnostic Code 8620 assigns a 40 percent rating for moderately severe incomplete paralysis, which is the precise description of the Veteran's disability offered by the January 2015 VA examiner. The Board notes that the involvement is wholly sensory, and as such, the rating should be for at most, the moderately severe degree. 38 C.F.R. § 4.123. There is no persuasive evidence that the Veteran's bilateral lower extremity peripheral neuropathy is more severe than described by the VA examiner; there is no persuasive indication that the peripheral neuropathy resulted in symptoms that were not wholly sensory. The Veteran did not have marked muscular atrophy and he did not exhibit complete paralysis. Upper extremities The Veteran was granted service connection for peripheral neuropathy of the bilateral upper extremities related to herbicide exposure and diabetes mellitus in November 2013. An evaluation of 10 percent was assigned to each upper extremity, effective August 7, 2008, under Diagnostic Code 8515. He filed a claim for an increased rating in June 2014. The Veteran's upper extremity diabetic peripheral neuropathy is rated under Diagnostic Code 8515, which provides ratings for paralysis of the median nerve. The record shows that the Veteran is right-handed. Therefore, for the right upper extremity, Diagnostic Code 8515 provides 10, 30, and 50 percent, respectively, for mild, moderate, and severe incomplete paralysis of the median nerve. A rating of 70 percent is warranted for complete paralysis. For the left upper extremity, Diagnostic Code 8515 provides 10, 20, and 40 percent, respectively, for mild, moderate, and severe incomplete paralysis of the median nerve. A rating of 60 percent is warranted for complete paralysis. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C.A. § 7104; 38 C.F.R. §§ 4.2, 4.6 (2016). In rating diseases of the 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. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Neither the Rating Schedule nor the regulations provide definitions for words such as "moderately severe." Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2016). The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. See 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The VA treatment records show that the Veteran has maintained a diagnosis of diabetic peripheral neuropathy. In February 2013, the Veteran reported that his neuropathy was very uncomfortable. In November 2013, the Veteran noted that he had tried numerous medications for neuropathy and that Cymbalta was the only thing that gave him relief. A May 2014 statement from the Veteran's coworker indicated that the Veteran was often absent from work due, in part, to his neuropathy. In March 2015, the Veteran's daughters and wife submitted statements concerning the Veteran's condition, which indicated that the Veteran's peripheral neuropathy contributed to his physical disabilities. The Veterans' daughters noted that the Veteran had difficulty grasping and complained of tingling in his hands. His wife also noted that he had a loss of strength, numbness and pain in his hands, and burning in his feet. A VA examination was provided in January 2015. The examiner conducted an in-person examination and reviewed the VA treatment records and private treatment records. The examiner noted the diagnosis of peripheral neuropathy, dating back to approximately 2001. The examiner also noted the history of diabetes mellitus. The Veteran reported that he first experienced peripheral neuropathy in 2001 or 2002. He reported that it began before his diabetes diagnosis in 2009. The Veteran stated that the neuropathy began in his feet and legs; later, he began to exhibit signs of it in his hands as well. The Veteran reported that he had carpal tunnel and a cubital tunnel surgery. He also reported having had three injections on the right side. The Veteran also reported diminished feeling in both of his hands. He reported difficulty picking up small items. The Veteran's dominant hand was noted to be his right hand. The Veteran denied any constant pain in his bilateral upper extremities. He endorsed mild intermittent pain in the bilateral upper extremities. He denied paresthesias and/or dysesthesias in his bilateral upper extremities. He endorsed mild numbness in the bilateral upper extremities. The Veteran's strength was normal in all of his bilateral upper extremities. His deep tendon reflexes were also normal. The light touch/monofilament testing was also normal in all bilateral upper extremities. His sensation to vibration and cold was normal and there was no muscle atrophy or trophic changes. The examiner noted that the radial nerve and ulnar nerves were not affected. The examiner diagnosed moderate bilateral incomplete paralysis of the median nerve. After review of the evidence of record, the Board finds that a higher schedular rating of 30 percent disabling for the right upper extremity and 20 percent disabling for the left upper extremity under Diagnostic Code 8515 for moderate incomplete paralysis of the median nerve. Given the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent for the right upper extremity or in excess of 20 percent for the left upper extremity as the Veteran's symptoms most nearly approximate the criteria for a 30 percent rating for the major extremity and a 20 percent rating for the minor extremity. As discussed, Diagnostic Code 8515 assigns a 30 percent rating for moderate incomplete paralysis of the major extremity and a 20 percent rating for moderate incomplete paralysis, which is the precise description of the Veteran's disability offered by the January 2015 VA examiner. There is no persuasive evidence that the Veteran's bilateral lower extremity peripheral neuropathy is more severe than described by the VA examiner; there is also no persuasive indication that the peripheral neuropathy resulted in symptoms that were not wholly sensory. The Veteran did not exhibit complete paralysis. III. Other Considerations The VA Schedule of Disability Ratings will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321 (b)(1). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's diabetes or peripheral neuropathy are so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.331 (b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id.; see also VAOGCPREC 6-96 (Aug. 16, 1996). The evidence in this case does not show that the Veteran has such an exceptional disability picture that the available schedular ratings are inadequate. As discussed above, there are higher ratings available under the Diagnostic Codes relating to diabetes, peripheral neuropathy involving the sciatic nerve, and peripheral neuropathy involving the median nerve. There are higher evaluations available for diabetes mellitus for more severe symptomatology that was not exhibited by the Veteran, such as restriction of activities. There are also higher evaluations available for peripheral neuropathy that results in symptoms that are not wholly sensory. In this case, the Veteran's bilateral upper and lower peripheral neuropathy results in symptoms that are wholly sensory. As such, the ratings assigned by this decision are the highest available. As such, it cannot be said that the available schedular evaluation for the disability is inadequate, and no extraschedular referral is required. 38 C.F.R. § 3.321 (b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. Reasonable doubt has been resolved in favor of the Veteran when possible. See 38 U.S.C.A. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to an increased rating in excess of 20 percent for diabetes mellitus is denied. An increased evaluation of 40 percent for right lower extremity peripheral neuropathy is granted, subject to the law and regulations governing the award of monetary benefits. An increased evaluation of 40 percent for left lower extremity peripheral neuropathy is granted, subject to the law and regulations governing the award of monetary benefits. An increased evaluation of 30 percent for right upper extremity peripheral neuropathy is granted, subject to the law and regulations governing the award of monetary benefits. An increased evaluation of 20 percent for left upper extremity peripheral neuropathy is granted, subject to the law and regulations governing the award of monetary benefits. REMAND Although the Board regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim. Cervical Spine Disability The Veteran is seeking entitlement to service connection for a cervical spine disability on the basis that his current disability is related to an injury he alleges he sustained in service. Specifically, he contends that he first injured his neck while loading nuclear weapons onto B-52s; conventional racks were converted so that they could practice bombing and he was rising up under a conventional bomb rack that resulted in "quite a jolt." (See Hearing Transcript Page 7.) He went on to state that his neck was reinjured by mortar attacks, rocket attacks, and ground attacks. (See Hearing Transcript Page 9.) The Veteran's DD Form 214 indicates that he served two years and ten days overseas, and his service personnel file contains declassified records from the 56th Special Operations Wing. His service personnel records also show that he was stationed at Tac Air Sup Sq in PACAF. The Veteran's service treatment records also support the Veteran's contention that he hit his head on a bomb rack during active duty. He was seen for a laceration to his medial scalp in April 1967. Given his lay evidence regarding his in-service injury and the service treatment records, the Veteran should be afforded a VA examination with medical opinion to determine whether his current cervical spine is related to his period of service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (38 C.F.R. § 3.159(c)(4) presents a low threshold for the requirement that evidence indicates that the claimed disability may be associated with in-service injuries for the purposes of a VA examination). Residuals of right knee meniscectomy The Veteran was last provided a VA examination in conjunction with his service-connected residuals of a right knee meniscectomy in January 2015, which is contemporaneous in time. Nonetheless, the Court recently held in Correia v. McDonald, 28 Vet. App. 158 (2016), that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court's holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. In addition, as relevant to the present case, the Court stated in Correia that knees were "undoubtedly weight-bearing." Id. A review of the claims file reveals that the prior VA examination report includes only active range of motion findings and does not include range of motion findings for passive range of motion. It also does not specify whether the results are weight-bearing or nonweight-bearing. As the previous examination report does not fully satisfy the requirements of Correia and 38 C.F.R. § 4.59, a new examination is necessary to decide the claim. TDIU The Veteran seeks entitlement to a TDIU due to his service-connected disabilities. The Veteran is in receipt of a 70 percent rating for PTSD, a 10 percent rating for residuals of a right knee surgery, a 20 percent rating for diabetes mellitus, type II, a 40 percent rating for peripheral neuropathy of the bilateral lower extremities (to be implemented by the RO), a 30 percent rating for peripheral neuropathy of the right upper extremity (to be implemented by the RO), a 20 percent rating for peripheral neuropathy of the left upper extremity (to be implemented by the RO), a 10 percent rating for a left knee disability, a 10 percent rating for degenerative joint disease of the lumbar spine associated with the residuals of the right knee meniscectomy, and a noncompensable rating for hearing loss of the left ear. The Veteran, therefore, meets the schedular requirements for consideration for entitlement to a TDIU. 38 C.F.R. § 4.16. The issue of entitlement to a TDIU is inextricably intertwined with the claims discussed above. As the case is being remanded for new VA examinations, the findings contained therein will be relevant as to the functional impact the Veteran's disabilities have on his ability to perform the mental and physical acts required of sedentary and physical work. Therefore, the appropriate remedy is to defer consideration of the claim of entitlement to a TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). Accordingly, the case is REMANDED for the following action: 1. Schedule a VA examination to determine the etiology of the Veteran's cervical spine disability. The record must be made available to the examiner, and the examiner must specify in the report that the claims file has been reviewed. All pertinent symptomatology and findings must be reported in detail. After reviewing the claims folder, obtaining a history of complaints from the Veteran, and conducting a thorough examination of the Veteran, the examiner is asked to provide an opinion addressing the following question: is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability is related to the Veteran's period of active duty? The examiner is asked to specifically note and discuss the Veteran's contentions regarding an in-service injury. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion or other information needed to provide the requested opinion. 2. Schedule a new examination to evaluate the severity of the service-connected residuals of a right knee meniscectomy. The claims file and copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should note in the examination report that the claims folder has been reviewed. All indicated tests must be accomplished and all clinical findings must be reported in detail. The examiner must describe to what extent, if any, the Veteran has any right knee pathology or reduced function in the right knee, including any associated gait impairment or ligamentous instability. It must be determined whether there is any objective evidence of functional limitation due to pain caused by the service-connected right knee disability. If so, each of those limitations should be set forth in detail. The examiner must state whether or not the appellant has any recurrent subluxation or lateral instability of the right knee. If so, the examiner must characterize such subluxation or lateral instability as slight, moderate, or severe. The examiner must test the range of motion of the Veteran's right knee. In order to comply with the Courts recent precedential decision in Correia v. McDonald, 28 Vet. App. 158 (2016), the examiner must test and record the range of motion for BOTH knees in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups (if the Veteran describes flare-ups). The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If not feasible to do so to any degree of medical certainty without resort to speculation, then the examiner must provide an explanation for why this is so. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner should fully discuss why this is the case. 3. After the above development has been completed, review the file and ensure that all development sought in this Remand is completed. Re-adjudicate the issues of entitlement to service connection, entitlement to increased rating, and entitlement to TDIU. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) 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). ______________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs