Citation Nr: 1744512 Decision Date: 10/05/17 Archive Date: 10/17/17 DOCKET NO. 10-33 149 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus (previously rated as diabetes mellitus with proteinuria). 2. Entitlement to a separate higher rating for diabetic nephropathy associated with diabetes mellitus (previously rated as diabetes mellitus with proteinuria), evaluated as noncompensable prior to August 19, 2016, and 60 percent disabling thereafter. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to January 1989. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a Board video conference hearing before the undersigned Veterans Law Judge in March 2012. The transcript has been associated with the record. In March 2014, the Board remanded the case for further development. Subsequently, in July 2015, the Board denied a rating in excess of 20 percent for diabetes mellitus with proteinuria and denied a compensable rating for diabetic retinopathy prior to November 24, 2014. The Board also denied a rating in excess of 30 percent for diabetic retinopathy beginning November 24, 2014. Further, the Board remanded the issues of entitlement to an initial compensable rating for bilateral hearing loss; entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD); and entitlement to a total disability rating based in individual unemployability (TDIU). Subsequently, the Veteran appealed the denials of a rating in excess of 20 percent for diabetes mellitus with proteinuria and a compensable rating for diabetic retinopathy prior to November 24, 2014 to the United States Court of Appeals for Veterans Claims (Court). In a March 2016 Order, the Court granted a March 2016 Joint Motion for Partial Remand (JMPR) and vacated the part of the July 2015 Board decision that denied rating in excess of 20 percent for diabetes mellitus with proteinuria and a compensable rating for diabetic retinopathy prior to November 24, 2014. The Veteran did not appeal the denial of a rating in excess of 30 percent for diabetic retinopathy from November 24, 2014. Subsequently, in a June 2016 decision, the Board denied the issue of entitlement to a compensable rating for diabetic retinopathy prior to November 24, 2014; and remanded the issue of entitlement to a rating in excess of 20 percent for diabetes mellitus with proteinuria, to include a separate compensable rating for nephropathy/ renal dysfunction for further development consistent with the JMPR. Specifically, the JMPR found that the Board failed to adequately discuss whether a separate compensable rating was warranted for the Veteran's renal dysfunction. In turn, the Board remanded the case to afford the Veteran a VA examination to address his diabetic nephropathy. An examination was done in August 2016. As such, the Board finds that there has been substantial compliance with its prior remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In an October 2016 rating decision, the Appeals Management Center (AMC) in Washington, D.C. awarded a separate 60 percent rating for diabetic nephropathy, effective August 19, 2016 and recharacterized the issues on appeal as set forth on the front page of this decision. An additional VA examination was associated with the record in January 2017 that address the severity of the Veteran's hearing loss and tinnitus. As this examination, is not relevant to the issues currently on appeal, waiver of RO consideration of this evidence is not necessary and the Board may proceed with the decision. The remanded issues of entitlement to an initial compensable rating for bilateral hearing loss; entitlement to an initial rating in excess of 50 percent for PTSD; and entitlement to a TDIU have not been certified back to the Board for adjudication as the development ordered in the July 2015 remand order has not been substantially completed. As such, the claims are not before the Board for adjudication. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's service-connected diabetes mellitus has not required any regulation of activities and has been treated with restricted diet, oral medication, and as of July 2012, insulin. 2. Prior to October 15, 2015, the Veteran's service-connected diabetic nephropathy was not manifested by constant or recurring albumin with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. 3. From October 15, 2015, the Veteran's service-connected diabetic nephropathy was manifested by constant albuminuria with some edema, but without findings of by persistent edema and albuminuria with BUN 40 to 80mg% or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus with proteinuria have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.119, Diagnostic Code 7913, 4.115a (2016). 2. Prior to October 15, 2015, the criteria for a separate, compensable rating for diabetic nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including §§ 4.7, 4.115a, Diagnostic Code 7541 (2016). 3. From October 15, 2015, the criteria for a 60 percent rating, but no higher, for diabetic nephropathy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including §§ 4.7, 4.115a, Diagnostic Code 7541 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2016). In this case, the Veteran has not alleged that VA has not fulfilled its duty notify or assist in the development of his claims. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Analysis Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). As in the instant case, where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Separate ratings for distinct periods of time, based on the facts are for consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007). Moreover, the effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C.A. § 5110 (b)(2). As such, the Board has considered the medical evidence within one year prior to the date of the Veteran's increased rating claim. Diabetes Mellitus The Veteran seeks a rating in excess of 20 percent for his Type II diabetes mellitus. At the Board hearing, the Veteran testified that he was prescribed oral Glucotrol and Actos to treat his diabetes. He stated that he was never prescribed insulin. Additionally, he testified that his physician advised him to regulate his activities "to a certain degree." Specifically, he indicated that his physician advised him not to go hunting, fishing, or into the woods alone. The Veteran stated that his activities were not otherwise regulated. The Veteran also reported persistent urination at night, excessive thirst, and erectile problems. The Veteran's diabetes mellitus, type II, is rated 20 percent disabling under the criteria of 38 C.F.R. § 4.119, Diagnostic Code 7913. Diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, is rated as 20 percent disabling. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities is rated as 40 percent disabling. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated, is rated as 60 percent disabling. Diabetes mellitus 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 rated, is rated as 100 percent disabling. Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under Diagnostic Code 7913). Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119. The Veteran filed his current claim for an increased rating in September 2007. Importantly, a November 2006 clinical record showed atrophic skin changes, varicosities, a little bit of edema and no hair noted on the legs and feet bilaterally. Moreover, treatment records dated January 2007 through August 2007 indicate that the Veteran reported some atrophic skin changes in the feet and legs, bilaterally. However, there was no evidence of edema. A September 2007 private treatment record indicates that the Veteran reported symptoms of waking during the night to urinate and mild numbness in both hands. When asked to circle his symptoms on a form, the Veteran did not circle rashes, itchiness, excessive thirst, excessive urination, swelling, nerve pain, or weakness. The Veteran was afforded a VA examination in May 2008. The examination report indicates that the Veteran's diabetes was non-insulin dependent. The Veteran reported being independent in his activities of daily living and working full-time in a civil service position at a warehouse. He denied any physician-prescribed bedrest, incapacitation, hospitalizations, hypoglycemia, hypoglycemic ketoacidotic episodes in past 12 months, or any impediments to his usual occupation. The Veteran reported symptoms of episodic tingling in the hands, feet, fingers, and thighs, which lasted about five to ten minutes in duration. He denied any weakness, loss of strength, or restricted activities. He also denied any dysuria, hesitancy, decreased stream, infections, stones, or nephritis. The Veteran reported urinating approximately four or five times per day and about three times during the night. He denied wearing any absorbent devices or undergoing catheterizations, dilations, or drainage procedures in the last 12 months. The Veteran claimed a 12-year history of erectile dysfunction, for which he was prescribed Viagra and Levitra. The examiner noted that the Veteran's treatment records indicated that the Veteran reported good nocturnal erections in 2005. A physical examination revealed no dominant lesions, rashes, scars, or diabetic skin changes. There were no venous varicosities, venous stasis, stasis dermatitis, pallor, or lower extremity edema. Deep tendon reflexes were 2+ in the upper extremities and 1+ in the lower extremities, bilaterally. There was no muscle atrophy. Strength testing to gravity and resistance were within normal limits for the Veteran's age for both lower and upper extremities. Sharp and dull discrimination and light touch testing was normal in both upper and lower extremities. Monofilament testing sites were intact in the feet, bilaterally. Vibratory sense was intact to the first metatarsal phalangeal joints, bilaterally. The examiner found no objective evidence of peripheral neuropathy. The diagnoses were diabetes mellitus, type II, on medical therapy; proteinuria, likely due to diabetes; and subjective erectile dysfunction without loss of sexual organ. The examiner indicated that the etiology of the erectile dysfunction was multifactorial, noting that several other risk factors were present, including hyperlipidemia, hypertension, and natural aging. The examiner opined that the Veteran's subjective erectile dysfunction was less likely than not caused by or related to his diabetes. An April 2009 treatment records indicates that the Veteran was advised to modify his diet and exercise daily. The record also indicates that the Veteran exhibited no neurological or genitourinary symptoms. Treatment records dated May 2010 and August 2010 indicate that the Veteran reported exercising regularly and engaging in moderate aerobic activity. It was noted that the Veteran should engage in regular activity to improve his health. There was no edema present. A February 2012 private treatment record shows that the Veteran denied dysuria, urinary frequency, urgency, or hesitancy. He also denied any localized numbness, weakness, or tingling. The record indicates that the Veteran's diabetes with complications has remained unchanged. A November 2011 treatment record shows that the Veteran reported starting a new job and getting exercise at work. The Veteran reported seeing a podiatrist the previous month without any complications. He stated that overall, he was feeling good. The treatment provider prescribed Actos and advised the Veteran to carefully watch his diet and begin exercising. A July 2012 treatment record, indicates that the Veteran's diabetes was uncomplicated, but poorly controlled on Actos and Metformin. The treatment provider discontinued Actos and prescribed Janumet and nightly insulin injections. There was no edema present. The Veteran was afforded another VA examination in May 2014. The Veteran reported that his service-connected diabetes mellitus was stable and asymptomatic. The examination report indicates that the Veteran was prescribed oral hypoglycemic agents, including Linagliptin and Glucovance, to which he responded well and experienced no side effects. The Veteran reported no skin changes. A physical examination revealed warm and dry skin with good color, normal turgor, and no evidence of ecchymosis, jaundice, breakdown, or rashes. The Veteran did not walk with any assistive devices. Physical examination revealed no deformity, malalignment, drainage, tenderness, edema, redness, heat, spasms, painful motion, abnormal or guarding movement, fatigue, lack of endurance, weakness, atrophy, incoordination, instability, or pertinent abnormal weight bearing. The examination report indicates that the Veteran did not have to regulate his activities as part of medical management of his diabetes. The Veteran denied any hospitalizations for ketoacidosis or hypoglycemic reactions within the past 12 months. There was no evidence of any progressive unintentional weight loss or loss of strength attributable to his diabetes. The only complications noted were diabetic retinopathy and nephropathy or renal dysfunction. The only sign or symptom associated with the Veteran's renal dysfunction was recurring proteinuria that was described as asymptomatic. Contemporaneous lab results showed that BUN, creatinine and EGFR were all abnormal. The examiner indicated that the Veteran's diabetes mellitus, and related complications, did not impact his ability to work. A February 2015 private treatment record indicates that the Veteran denied dysuria, hematuria, and polyuria. The record also shows an active prescription for Lantus insulin through October 2015. On remand, the Veteran was afforded another VA examinant in August 2016. Again, it was noted that the Veteran took a prescribed oral hypoglycemic as well as insulin. However, the Veteran did not require regulation of activities as part of his medical management. The Veteran visited his diabetic care provider less than two times per month. Further, there were no episodes of ketoacidosis or hypoglycemic reasons requiring hospitalizations. There was no progressive unintentional weight loss or loss of strength attributable to diabetes. The only complications observed were diabetic peripheral neuropathy and diabetic nephropathy. The examiner also noted that the Veteran's diabetes did not impact his ability to work. The examiner concluded that there were no functional limitations. In accordance with Note (1), the Board will first consider the Veteran's complications of diabetes. In this regard, the Veteran already has been awarded separate disability ratings for his complications of peripheral neuropathy of the right and left lower extremities and diabetic retinopathy. As the Veteran is separately rated for each of these complications of diabetes and these matters are not currently before the Board, no consideration of those complications is warranted as part of the current claim for a higher rating for diabetes mellitus. Moreover, the issue of a higher rating for diabetic nephropathy is discussed further below. Furthermore, the record also shows some symptoms of atrophic skin changes, dryness, and varicosities. However, VA examinations performed in May 2008, April 2014 and August 2016 showed no skin abnormalities or varicosities related to the Veteran's service-connected diabetes. Accordingly, there is no evidence of record to support a finding that a separate compensable rating is warranted for any distinct period throughout the pendency of this appeal based on any skin disorders or varicosities related to the Veteran's service-connected diabetes. See 38 C.F.R. §§ 4.104, 4.118, Diagnostic Codes 7806, 7119 (2016); Hart, 21 Vet. App. at 509-10. Likewise, there is not objective evidence that the Veteran has erectile dysfunction associated with his diabetes. In this regard, the May 2008 examiner indicated that the etiology of the erectile dysfunction was multifactorial, noting that several other risk factors were present, including hyperlipidemia, hypertension, and natural aging. The examiner opined that the Veteran's subjective erectile dysfunction was less likely than not caused by or related to his diabetes. The subsequent VA examinations also do not list erectile dysfunction as a complication of the Veteran's diabetes. Accordingly, there is no evidence of record to support a finding that a separate compensable rating is warranted for any distinct period throughout the pendency of this appeal for erectile dysfunction related to the Veteran's service-connected diabetes. See 38 C.F.R. § 4.115b, Diagnostic Code 7522 ; Hart, 21 Vet. App. at 509-10. Turning to the criteria for a rating in excess of 20 percent for diabetes mellitus under Diagnostic Code 7913, the Board concludes, after a review of the record, that at no time throughout the course of the appeal has the Veteran's disability met the criteria for a 40 percent disability rating. Specifically, while the evidence shows the Veteran has been prescribed an oral hypoglycemic agent, takes insulin daily and used a restricted diet to control his diabetes, he has not been prescribed limited physical activity or advised to avoid strenuous occupational or recreational activities. Although the Veteran testified that he was advised not to go hunting or fishing alone, the record shows that the Veteran was not otherwise restricted in his activities in any other way. In fact, the record shows that the Veteran was encouraged to engage in regular activities to improve his health. Furthermore, the record reveals no episodes of ketoacidosis or hypoglycemic reactions, no hospitalizations, and no progressive loss of weight or strength. In sum, the preponderance of the evidence does not support finding that the Veteran requires regulation of activities, as defined by Diagnostic Code 7913 (regulation of activities as the avoidance of strenuous occupational and recreational activities). 38 C.F.R. § 4.119, Diagnostic Code 7913. The probative evidence of record thus shows that the Veteran has not been required to regulate his activities as defined by the rating criteria. Therefore, the criteria for an increased rating for diabetes mellitus, type II, under the criteria of Diagnostic Code 7913, are not met. As the criteria for the next higher, 40 percent, rating are not met and the criteria are cumulative, it follows that the criteria for an even higher rating (60 or 100 percent) likewise are not met. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of diabetes mellitus type II. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's diabetes mellitus; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for his diabetes mellitus. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Diabetic Nephropathy The present appeal also includes the issue of entitlement to separate and/or higher rating for diabetic nephropathy. The Veteran's service-connected diabetic nephropathy associated with diabetes mellitus has been rated by the RO under the provisions of Diagnostic Code 7541. Under this regulatory provision, renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease process is rated as renal dysfunction. 38 C.F.R. § 4.116, Diagnostic Code 7541. For renal dysfunction, a noncompensable rating is warranted for albumin and casts with history of acute nephritis; or hypertension non-compensable under diagnostic code 7101. A 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A 60 percent rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating is warranted for persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss or limitation of exertion. A maximum rating of 100 percent is warranted where renal dysfunction requires regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a. Under Diagnostic Code 7101 for hypertensive vascular diseases (hypertension and isolated systolic hypertension), a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or: systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. A maximum rating of 60 percent is warranted for diastolic pressure predominantly 130 or more. NOTE (1): Hypertension or isolated systolic hypertension must be confirmed by readings taken two more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic pressure is predominately 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. NOTE (2): Evaluate hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. NOTE (3): Evaluate hypertension separately from hypertensive heart disease and other types of heart disease. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Board also observes that separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis, on account of the close interrelationships of cardio-vascular disabilities, unless there is absence of a kidney or regular dialysis is required. 38 C.F.R. § 4.115. Pursuant to the JMPR, the Board directed the RO to afford the Veteran a VA examination to address the severity of his diabetic nephropathy. The Veteran was afforded a VA examination in August 2016. It was noted that the Veteran was completely asymptomatic from his kidneys standpoint. He denied any dysuria, hematuria, urinary frequency or incontinence. The Veteran also denied having any lower extremity edema problems at any time. The examiner also noted that nonservice-connected essential hypertension was stable and well-controlled. There was no objective evidence of secondary hypertension, caused by or related to diabetes mellitus or diabetic nephropathy. The only symptom observed for the Veteran's renal dysfunction was persistent proteinuria. No other findings were noted. The examiner observed that October 5, 2015 lab results showed that BUN, creatinine and EFGR were normal. Urinalysis at that time showed normal hyaline casts, granular casts and RBC's/HPF. However, tests for proteinuria and constant albuminuria with some edema were abnormal with 2+ protein. There was no functional impact on the Veteran's ability to work. The examiner also found that the Veteran's diabetic nephropathy had not been accompanied by constant or recurring albumin with hyaline and granular casts or red blood cells; transient or slight edema or hypertension rated at least 10 percent disabling under Diagnostic Code 7101. The examiner also found that the Veteran's noctura was less likely a symptom of the Veteran's nephropathy/renal dysfunction and most likely due to nonservice-connected unrelated benign prostatic hyperplasia. Initially, the Board notes that the RO awarded a 60 percent rating for the Veteran's diabetic nephropathy effective the date of the August 2016 examination that showed constant albuminuria with some edema. However, a review of the examination report shows that it was actually October 5, 2015 lab results that first showed constant albuminuria with some edema. As such, the Board finds that the Veteran's diabetic nephropathy met the criteria for a 60 percent rating as of that date. In turn, a 60 percent rating is warranted, effective October 5, 2015. However, prior to October 5, 2015, the Board must find that a compensable rating is not warranted. Although there was evidence of slight edema on one occasion in November 2006, remaining clinical records show no objective findings of edema. As such, the Board finds that as this finding is inconsistent with the remaining medical evidence, it is considered an outlier and not a reflection of the nature of the Veterans diabetic nephropathy during this period. Although the May 2014 VA examiner observed recurrent albumin, there was no evidence that there was hyaline and granular casts or red blood cells; or, transient or slight edema on examination. Importantly, the May 2014 examiner characterized the Veteran's proteinuria as asymptomatic. Further, given the lack of findings decreased kidney function during this period, higher ratings under the regulations for renal dysfunction are also not for application. See 38 C.F.R. § 4.115a. Moreover, the Veteran's essential hypertension has been found to not be related to his diabetes mellitus and thus, the rating criteria under 38 C.F.R. § 4.104, Diagnostic Code 7101 for hypertension is not for application. Likewise, the VA examiner found that the Veteran's noctura was less likely as not a symptom of the Veteran's nephropathy/renal dysfunction and most likely due to nonservice-connected unrelated benign prostatic hyperplasia. As such, a compensable rating based on this symptom is also not warranted. The first evidence that the Veteran met the criteria for a higher rating is the October 5, 2015 lab results. Moreover, based on the evidence of record, an 80 percent rating as well as a maximum 100 percent rating is not warranted from October 5, 2015. The Board must find that the Veteran's current symptoms are adequately contemplated in the current 60 percent rating. Significantly, laboratory reports in October 2015 consistently showed that BUN and creatinine levels were much less than 40mg% and 4mg%, respectively, as required to allow an 80 percent disability rating. The BUN level reading was 19.8mg%, and the creatinine level reading was around 1.06mg%, which are significantly less than the requirements to award a higher rating. Importantly, there have been no current objective findings of lethargy, weakness, anorexia, weight loss or limitation of exertion to warrant a higher rating. See 38 C.F.R. § 4.115a. Again, the Veteran's hypertension has been found to not be related to his diabetes mellitus and thus, the rating criteria under 38 C.F.R. § 4.104, Diagnostic Code 7101 for hypertension are not for application. Again, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of his renal dysfunction. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. When applying the case-law discussed above, again, in this case, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. Again, in rating this disability, laboratory tests done by a medical professional are necessary to assess the severity. It has not been shown that the Veteran has the medical knowledge to perform these necessary tests. In turn, he cannot be considered competent to offer testimony with respect to such findings. In sum, the lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In conclusion, prior to October 15, 2015, the preponderance of the evidence is against a separate compensable rating for the Veteran's diabetic nephropathy. As the preponderance of the evidence weighs against the claim prior to this date, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). However, when resolving the benefit of the doubt in favor of the Veteran, from October 15, 2015, the Board finds that a 60 percent rating, but no higher, is warranted. Extraschedular Additionally, in an August 2017 Informal Hearing Presentation, the Veteran's representative specifically requested that the Board consider whether the case should be referred for extra-schedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1)). An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected diabetes mellitus and associated diabetic nephropathy with the established criteria found in the rating schedule. The Board finds that the Veteran's diabetes mellitus and diabetic nephropathy symptomatology is fully addressed by the rating criteria under which such disabilities are rated. In this regard, the rating schedule fully contemplates the described diabetes mellitus symptomatology, to include regulation of diet and the need for constant medication, and provides for ratings higher than that assigned based on more significant functional impairment. Likewise, the rating schedule fully contemplates the symptoms associated with the Veteran's renal dysfunction, including constant albuminuria and some edema. Again, higher ratings are available for more significant impairment. Notably, there is no evidence that the schedular criteria are inadequate to rate the Veteran's diabetes mellitus and diabetic nephropathy. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional impairment that has not been attributed to a specific, rated disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). ORDER A rating in excess of 20 percent for type II diabetes mellitus is denied. Prior to October 15, 2015, a separate compensable rating for diabetic nephropathy is denied. From October 15, 2013, a 60 percent, but not higher, for diabetic nephropathy, is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs