Citation Nr: 1752371 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 03-25 377 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for kidney dysfunction/disease, as secondary to diabetes mellitus. 2. Entitlement to a higher rating for diabetes mellitus, currently rated as 20 percent disabling prior to February 17, 2004 and as 60 percent disabling thereafter. 3. Entitlement to an initial rating in excess of 10 percent for diabetic peripheral neuropathy, left lower extremity. ATTORNEY FOR THE BOARD P. Lopez, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1972 to June 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The July 2002 rating decision, in relevant part, denied service connection for kidney dysfunction and left foot pain, and denied a rating in excess of 20 percent for diabetes. The Veteran appealed via an August 2002 notice of disagreement. Thereafter, a March 2009 rating decision assigned a higher rating of 60 percent for diabetes, effective February 17, 2004, and granted service connection for diabetic peripheral neuropathy, left lower extremity, with a rating of 10 percent, effective April 2, 2008. As discussed in the Board's July 2009 remand, the issue of a higher rating for diabetic peripheral neuropathy, left lower extremity, is under the Board's jurisdiction as part-and-parcel of the claim of an increased rating for diabetes. The Board last considered these matters in July 2009, when it remanded for additional evidentiary development. The Board's July 2009 remand also covered the issues of service connection for hypertension, diabetic retinopathy, and peripheral vascular disease of the lower extremities. Service connection for these disabilities was established via a January 2017 rating decision. This was a full grant of the benefit sought, and the Veteran has not appealed the assigned ratings or effective dates. Nevertheless, the ratings for diabetic retinopathy and peripheral vascular disease of the lower extremities are under the Board's jurisdiction as part-and-parcel of the claim of an increased rating for diabetes. The January 2017 rating decision also granted entitlement to a TDIU, effective February 17, 2004. In August 2016, VA received a statement from the Veteran, stating that he wanted to be represented by Disabled American Veterans. However, a power of attorney for this organization is not of record. In August 2017, the Board sent a letter to the Veteran, affording him the opportunity to formally appoint a representative. The Board advised the Veteran that if the Board did not hear from him within 30 days, it would assume that the Veteran wishes to represent himself. VA has not received a response from the Veteran. Therefore, he is deemed to be representing himself. FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran has a kidney disability that is related to service or secondary to his service-connected diabetes. 2. Prior to February 17, 2004, the Veteran's diabetes required oral hypoglycemic agents, insulin and a restricted diet, but not regulation of activities. 3. Since February 17, 2004, there have been reports of episodes of ketoacidosis or hypoglycemic reactions, but these have not required hospitalization or visits to a diabetic care provider with a frequency of at least twice a month. 4. Since March 17, 2008, the evidence shows that the Veteran's peripheral neuropathy of the right lower extremity has manifested as moderate incomplete paralysis. 5. Prior to March 17, 2008, the evidence fails to show symptoms of peripheral neuropathy of the left lower extremity. 6. Since March 17, 2008, forward, the evidence shows that the Veteran's peripheral neuropathy of the left lower extremity manifested as mild incomplete paralysis. 7. Since September 8, 2016, forward, the evidence shows that the Veteran's peripheral neuropathy of the left lower extremity manifested as moderate incomplete paralysis. 8. For the entire rating period, the evidence shows that the Veteran's has had diabetes-related retinal irregularities, to include diplopia. CONCLUSIONS OF LAW 1. The criteria for service connection for a kidney disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 2. For the period prior to February 17, 2004, the criteria for a rating in excess of 20 percent for diabetes mellitus type 2 have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913 (2017). 3. For the period since February 17, 2004, the criteria for a rating in excess of 60 percent for diabetes mellitus type 2 have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913. 4. Since March 17, 2008, the criteria for a higher rating of 20 percent for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 8520 (2017). 5. Prior to March 17, 2008, the criteria for a compensable rating for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 8520. 6. Since March 17, 2008, forward, the criteria for a rating of 10 percent for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 8520. 7. Since September 8, 2016, forward, the criteria for a rating of 20 percent for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 8520. 8. For the entire rating period, the criteria for a rating of 10 percent for diabetic retinopathy, with cataracts and diplopia, have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 6011 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist VA notified the Veteran of the evidence and information necessary to substantiate his claim in November 2001, prior to the initial adjudication of his claim. VA provided additional notice in March 2006. The Veteran underwent VA examinations in April 2002 and March 2008. More recently, in December 2016, he submitted relevant DBQs completed by a private provider. As such, the Board will proceed to the merits of the appeal. . II. Analysis Service Connection for Kidney Dysfunction/Disease Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all of the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Service connection requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Service connection may also be granted on a secondary basis where a condition is aggravated by a service-connected disability. 38 C.F.R. § 3.310(b). To warrant service connection on a secondary basis, the evidence must show that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Compensation for secondary service connection based on aggravation of a non-service-connected condition is only warranted for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). When there is an approximate balance of positive and negative evidence regarding any material issue, or the evidence is in relative equipoise, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The Veteran raised the issue of service connection for a kidney disability in September 2001, in the context of his claim of a higher rating for his service-connected diabetes. See 09/20/2001 VBMS, Correspondence. In detail, he stated that he had a diagnosis of "extreme low renal threshold induced hypercalciuria with calculi," adding that he was first diagnosed with low renal threshold during service at Camp Pendleton. Id. VA has not been able to verify this assertion, as the Veteran's service treatment records are unavailable. The Board also notes that the Veteran is a retired nurse and is arguably competent to express medical opinions. An April 2002 VA examination indicates that the Veteran's renal function was satisfactory. See 04/09/2002 VBMS, VA examination. The examiner added that the Veteran had intermittent albuminuria, more likely related to his medullary sponge kidney with recurrent urinary calculi rather than to diabetic nephropathy. In a statement dated July 2003, the Veteran rebutted the April 2002 examiner's conclusion. See 07/07/03 VBMS, Correspondence. In detail, the Veteran stated that he started medication treatment for microalbuminuria (to prevent renal disease) several years prior to the diagnosis of urinary calculi and medullary sponge disease (which, according to the Veteran, developed after a multi-month episode of glandular fever with associated hepatomegaly and splenomegaly). Id. at 2. A May 1998 treatment note indicates that, in early 1997, the Veteran was found to have a small amount of protein in his urine and that in October/November 1997 he developed an intercurrent viral infection, with associated abnormal liver function, increase size of the spleen, and staghorn calculus in his left kidney. See 09/07/2006 VBMS, Medical Treatment Record - Non-Government Facility, at 28. It was added that the exact etiology of which was unknown but he developed abnormal liver function tests, increase .size of the spleen and an ultrasound examination of his upper abdomen at that time revealed the presence of staghorn calculus in his left kidney. This was subsequently confirmed on an IVP examination. There was no surgical removal of this calculus, but he has had several bouts of haematuna since the diagnosis. A March 2008 VA examination for diabetes noted the Veteran's history of renal calculi, medullary sponge kidney disease, and microalbuminuria. See 04/25/2008 VBMS, VA examination. With regard to kidney dysfunction, the examiner indicated that he was unable to address this aspect as recent laboratory testing was not available. Nonetheless, at the end of the examination report, a handwritten note shows the results of a March 2008 laboratory test (performed days after the examination report). It shows a urine albumin/creatinine ratio and a hemoglobin A1c level within normal range. It was also noted that kidney and liver function was normal. Treatment records show that the Veteran was referred to an urologist in May 2008. See 11/24/2008 VBMS, Third Party Correspondence, at 7-9. Pertinent treatment notes indicate that over the last few years the Veteran had developed initially urgency of bowel actions, followed soon after by urgency of micturition. The Veteran reported severe urgency of both urine and bowel function, with associated incontinence. The examiner noted that the Veteran had recently had gastric banding, but this had not made much difference. Blood testing was satisfactory, except for elevated glucose. A CT scan of the abdomen showed no significant abnormality or evidence of stones. The examiner concluded that it was unlikely that the Veteran had prostatic obstruction. The Veteran was prescribed medication for his urgency and urge incontinence in June 2008. A treatment note from August 2008 indicates that the medication has improved both urinary and bowel symptoms. An August 2016 DBQ for diabetes (completed by a private provider) shows a negative finding for renal dysfunction caused by diabetes (while affirmative noting peripheral neuropathy and retinopathy associated with his diabetes). See 12/12/2016 VBMS, VA examination, at 8-10. A September 2016 treatment note from the same provider indicates that kidney function was normal. See 12/12/2016 VBMS, Medical Treatment Record - Non-Government Facility, at 9. A subsequent treatment note (also dated September 2016) from an endovascular specialist shows a diagnosis of polycystic kidney. Id. at 6. Based on the above, the Board finds that service connection for a kidney disability is not warranted. The evidence fails to show that the Veteran has a current kidney disability due to his diabetes. See, e.g., August 2016 DBQ for diabetes. Additionally, examinations conducted for VA purposes suggest that the Veteran's kidney function was normal. See April 2002 and March 2008 VA examinations. The Board acknowledges that the evidence shows a diagnosis of intermittent albuminuria. Albuminuria is a term that denotes the presence of albumin (protein) in a person's urine. See National Kidney Foundation, "Albuminuria," available at https://www.kidney.org/atoz/content/albuminuria. Albuminuria may be an early sign of kidney disease. Id. An April 2002 examiner attributed the Veteran's albuminuria to his medullary sponge kidney with recurrent urinary calculi. According to the National Institute of Diabetes and Digestive and Kidney Diseases, medullary sponge, also known as Cacchi-Ricci disease, is a birth defect where changes occur in the tubules, or tiny tubes, inside a fetus' kidneys. See National Institute of Diabetes and Digestive and Kidney Diseases, "Medullary Sponge Disease," available at https://www.niddk.nih.gov/health-information/kidney-disease/children/medullary-sponge-kidney. Complications of medullary sponge kidney include hematuria (blood in the urine), kidney stones (renal calculi), and urinary tract infections. Id. Medullary sponge kidney rarely leads to more serious problems, such as chronic kidney disease or kidney failure. Id. The Board also notes that the Veteran has a diagnosis of polycystic kidney disease. See 12/12/2016 VBMS, Medical Treatment Record - Non-Government Facility, at 6. According to the U.S. National Library of Medicine, polycystic kidney disease is a kidney disorder, passed down through families, in which many cysts form in the kidneys, causing them to become enlarged. See MedlinePlus, "Polycystic kidney disease," available at https://medlineplus.gov/ency/article/000502.htm. As already mentioned, the Veteran has questioned the April 2002 examiner's conclusion that the Veteran's albuminuria is more likely related to his medullary sponge disease rather than to diabetic nephropathy. The Veteran's argument in this regard is that treatment for albuminuria started several years prior to his diagnosis of medullary sponge disease (which, according to the Veteran, developed after a multi-month episode of glandular fever with associated hepatomegaly and splenomegaly). The evidence, in fact, shows that the Veteran's albuminuria preceded an intercurrent viral infection that resulted in abnormal liver function, increase size of the spleen, and staghorn calculus in his left kidney. See 09/07/2006 VBMS, Medical Treatment Record - Non-Government Facility, at 28. There is, however, no clear evidence of when was medullary sponge disease first diagnosed. The Veteran asserts that his albuminuria is secondary to his diabetes. There is, however, no evidence to support this assertion. While the Veteran is competent to provide medical opinions based on his training, he has not provided a medical rationale in support of his assertion. As such, the Board places little to no weight on this bare opinion. Even assuming that his albuminuria was discovered prior to his diagnosis of medullary sponge disease, such fact would not be sufficient to establish a relationship between the Veteran's albuminuria and his diabetes. Similarly, such fact would not render the April 2002 VA opinion inadequate, since, as discussed above, medullary sponge disease is considered a birth defect. Based on the above, the Board finds that the April 2002 VA opinion outweighs the Veteran's assertions in probative value. Accordingly, the Board finds that the Veteran's albuminuria is not related to his diabetes. With regard to the diagnoses of medullary sponge disease and polycystic kidney disease, the Board notes that these are considered birth defects, as noted in the reference material above. 38 C.F.R. § 19.9(d)(5) (2017). Therefore, by definition, these were not caused by the Veteran's diabetes. Additionally, there is no indication that the Veteran's diabetes has aggravated these conditions. Rather, as already discussed, the evidence weighs against finding that these disabilities have manifested as chronic renal dysfunction at any point during the appeal period. The Board acknowledges that the evidence shows urinary and bowel incontinence. There is, however, no indication that these symptoms are related to the Veteran's diabetes. As already stated, an August 2016 DBQ for diabetes (completed by a private provider) clearly indicates that the Veteran does not have renal dysfunction due to his diabetes. As the 2016 report reflects that the Veteran was examined, to include diagnostic testing, the Board places much weight on it. In sum, the Board finds that service connection for a kidney disability is not warranted, as there is no evidence that the Veteran's service-connected diabetes has manifested as kidney dysfunction or caused or aggravated a renal condition. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of the disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the propriety of an initial disability rating, the evidence since the effective date of the grant of service connection must be evaluated. Fenderson v. Brown, 12 Vet. App. 119, 126-27 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In all cases, the Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 1. Diabetes The Veteran's diabetes is rated as 20 percent disabling prior to February 17, 2004, and as 60 percent disabling thereafter. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet; a 40 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities; a 60 percent rating is warranted when the diabetes requires 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; and a 100 percent rating when the diabetes requires 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. 38 C.F.R. § 4.119, Diagnostic Code 7913. An April 2002 examination for VA purposes indicates that the Veteran started insulin treatment four months earlier. As noted by the examiner, the Veteran was overweight, his diet had not been particularly strict but he had recently made some positive changes, and his physical activity was curtailed by a foot injury. The examiner did not detect diabetic retinopathy, but noted that the Veteran had had episodes of retinal ischemia in the past. Blood pressure was controlled by medication. There was evidence of peripheral neuropathy with absent ankle jerks and reduced vibration sensation at the right ankle. There was no evidence of peripheral vascular disease and erectile dysfunction. There were no other diabetic complications. In a July 2003 statement, the Veteran indicated that he required two insulin injections daily and he had 3-5 episodes (per week) of elevated or hypoglycemic reactions, including extreme fatigue. A March 2004 letter from a private provider indicates that the Veteran had impeccable blood sugar control and that his hypoglycemic episodes had disappeared. See 09/19/2006 VBMS, Medical Treatment Record - Non-Government Facility, at 23. A March 2008 VA examination for VA purposes indicates that the Veteran required insulin twice a day. The Veteran had reduced his food intake, increased his activity, and lost weight, but he remained overweight. He had hypoglycemic episodes twice a week if he changed meal times or increased his activity. The examiner was not aware of hospitalizations for hypoglycemic episodes. The Veteran indicated that he visited his local doctor eight to nine times per years. As to complications, the examiner indicated his belief that the Veteran had diabetic retinopathy but deferred the matter to an eye specialist. The Veteran had peripheral neuropathy, described as a reduction in light touch in both feet to the ankles, more marked in the left than the right, and reduced vibration sense below both knee, again more marked in the left than the right. He had good peripheral pulses with no evidence of peripheral vascular disease. Blood pressure was elevated. Erectile dysfunction was noted as being quite likely related to his diabetes. An August 2016 DBQ for diabetes indicates that the Veteran's diabetes is managed by restricted diet and requires prescribed oral hypoglycemic agents and insulin (more than one injection per day) as well as regulation of activities. Frequency of visits for diabetic care was less than twice per month. As noted by the examiner, there had not been any episodes of ketoacidosis or hypoglycemia, requiring hospitalization, over the past 12 months. As to complications, the examiner indicated that the Veteran had diabetic peripheral neuropathy and diabetic retinopathy. With regard to the period prior to February 17, 2004, for the Veteran to be entitled to a rating in excess of 20 percent, the evidence must show 40 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities. In this case, the evidence shows insulin treatment and restricted diet, but fails to show that the Veteran's diabetes requires regulation of activities. The Court has explained that the term "regulation of activities" means that a claimant must have a medical need to avoid not only strenuous occupational activity, but also strenuous recreational activity. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Medical evidence is required to show that occupational and recreational activities have been restricted. Id. at 364. Here, VA examination reports and private treatment records do not reflect that the Veteran's activities are regulated due to his diabetes mellitus. There have been reports of episodes of ketoacidosis or hypoglycemic reactions, but these have not required hospitalization or visits to a diabetic care provider with a frequency of at least twice a month. As such, for the period prior to February 17, 2004, the evidence fails to show that the Veteran met the criteria for a rating in excess of 20 percent under DC 7913. With regard to the period from February 17, 2014, forward, for the Veteran to be entitled a rating in excess of 60 percent, the evidence must show episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider. In this case, there have been reports of episodes of ketoacidosis or hypoglycemic reactions, but these have not required hospitalization or visits to a diabetic care provider with a frequency of at least twice a month. See, e.g., August 2016 DBQ. As such, for the period since February 17, 2014, the evidence fails to show that the Veteran meets the criteria for a rating in excess of 60 percent under DC 7913. Compensable complications from diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation. 38 C.F.R. § 4.119, DC 7913, Note (1). Noncompensable complications are considered part of the diabetic process under DC 7913. Id. In this case, separate ratings are in effect for the following complications: bilateral leg peripheral vascular disease, bilateral lower extremity peripheral neuropathy, and bilateral diabetic retinopathy. Additionally, the Veteran is in receipt of special monthly compensation for loss of use of a creative organ. The Board will consider whether higher ratings are warranted for these complications from diabetes. 2. Peripheral Vascular Disease The Veteran is in receipt of a 40 percent rating for right leg peripheral vascular disease and a 20 percent rating for left leg peripheral vascular disease, both effective September 8, 2016. It is rated under 38 C.F.R. § 4.104, DC 7114. Under DC 7114, a rating of 20 percent is assigned for claudication on walking more than 100 yards, and diminished peripheral pulses, or ankle/brachial index of 10.9 or less. A rating of 40 percent is assigned for claudication on walking between 25 and 100 yards on a level grade at two miles per hour; and, trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index (ABI) of 0.7 or less. A rating of 60 percent is assigned for claudication on walking less than 25 yards on a level grade at two miles per hour; and, either persistent coldness of the extremity or ABI of 0.5 or less. A rating of 100 percent is assigned for ischemic limb pain at rest; and, either deep ischemic ulcers or ABI of 0.4 or less. Id. A diagnosis of peripheral vascular disease was first shown in a DBQ dated September 8, 2016. See 12/12/2016 VBMS, VA examination. Although the examiner noted a history of peripheral vascular disease since 2003, confirmed by ultrasound in 2006. However, a review of the ultrasound report does not show a diagnosis of peripheral vascular disease. See 04/25/2008 VBMS, Medical Treatment Record - Non-Government Facility, at 2-3. Moreover, a medical statement dated November 2006 indicated that an August 2006 risk assessment revealed adequate peripheral flow to the extremities; still, the Veteran was at a high risk from a neurological perspective. Id. at 4. As to the severity of the Veteran's peripheral vascular disease, the September 2016 examiner indicated that it manifested as claudication on walking more than 100 years for the left leg, as claudication on walking between 25 and 100 years on a level grade at 2 miles per hour for the right leg, and as persistent coldness of the extremity for both legs. The examiner did not endorse ischemic limb pain at rest. These finding support the currently assigned 20 percent rating for the left leg and 40 percent rating for the right leg. A higher rating for the left leg is not warranted because the evidence fails to show claudication on walking less than 100 yards or ischemic limb pain at rest. A higher rating for the right leg is not warranted because the evidence fails to show ischemic limb pain at rest. 3. Lower Extremity Peripheral Neuropathy The Veteran is in receipt of separate 10 percent ratings for bilateral lower extremity peripheral neuropathy, under 38 C.F.R. § 4.124a, DC 8520. The rating for the right leg is in effect since September 20, 2011, and predates the rating period. The rating for the left leg is in effect since April 2, 2008. Under DC 8520, ratings of 10, 20, 30, and 60 percent are assigned for mild, moderate, moderately severe and severe incomplete paralysis of the sciatic nerve, respectively. Id. A rating of 100 percent is assigned for complete paralysis. Id. An April 2002 examination for VA purposes shows peripheral neuropathy manifesting as absent ankle jerks and reduced vibration sensation at the right ankle. There is no explicit description of the severity of the symptoms. A March 2008 VA examination for VA purposes shows peripheral neuropathy, described as a reduction in light touch in both feet to the ankles, more marked in the left than the right, and reduced vibration sense below both knee, again more marked in the left than the right. A September 2016 DBQ for peripheral neuropathy (received December 12, 2016) shows the following symptoms: moderate constant pain in right leg, none in the left leg; moderate intermittent pain in both legs; moderate paresthesia in both legs; and moderate numbness in both legs. Based on the above, the Board finds that a higher rating of 20 percent is warranted for right lower extremity peripheral neuropathy, but only from March 17, 2008, forward (date of the March 2008 VA examination), as that is the earliest evidence of moderate symptoms. A higher rating is not warranted from March 17, 2008, forward, as there is no indication that the Veteran's symptoms were moderately severe. For example, the August 2016 DBQ noted normal muscle strength and normal or decreased deep tendon reflexes. With regard to the left leg lower extremity, the Board finds that a rating of 10 percent is warranted from the earlier date of March 17, 2008 (date of the March 2008 VA examination). The Board further finds that a higher rating of 20 percent is warranted from September 8, 2016, forward (date of the September 2016 DBQ), as there is evidence of moderate symptoms. Higher ratings are not warranted as there is no indication that the Veteran's symptoms were moderate between March 17, 2008, and September 7, 2016, or moderately severe since September 8, 2016. Again, as noted above, the August 2016 DBQ noted normal muscle strength and normal or decreased deep tendon reflexes. 4. Diabetic Retinopathy The Veteran is service-connected for bilateral diabetic retinopathy, maculopathy and diplopia (left eye only), rated as noncompensable since September 9, 2016. Private medical records show that the Veteran reported a steady deterioration of vision in both during the past nine months. He also reported right eye dimming. See 09/07/2006 VBMS, Medical Treatment Record - Non-Government Facility, at 6. The treating provider indicates that the symptoms were likely related to the Veteran's diabetes. Thereafter, in October 2002, that same provider indicated that the Veteran had retinal ischemia, formally diagnosed as retinal claudication associated with ischemia. Nevertheless, a fluorescein angiography revealed no angiographic evidence of significant diabetic retinopathy or maculopathy. Id. at 4. A diagnosis of diabetic retinopathy first appears in a March 2008 VA examination (received April 25, 2008). The examiner stated that, in his opinion, the Veteran had diabetic retinopathy of the right eye. An August 2013 medical statement confirms that the Veteran has diabetic retinopathy, with bilateral cortical cataracts. See 12/12/2016 VBMS, Medical Treatment Record - Non-Government Facility, at 2. A November 2016 DBQ for eye conditions (received December 12, 2016) shows a diagnosis of mild pre-proliferative (also known as non-proliferative) peripheral neuropathy, with diplopia. According to an online resource from the American Academy of Ophthalmology, many diabetes patients have non-proliferative diabetic retinopathy (NPDR). With NPDR, blood vessels in the retina can close off. This is called macular ischemia. Patients with NPDR have blurry vision. See American Academy of Ophthalmology, "What is Diabetic Retinopathy?" available in https://www.aao.org/eye-health/diseases/what-is-diabetic-retinopathy. Based on the above, the Board finds that the Veteran has had diabetes-related eye symptoms for the entire rating period. Furthermore, the Board finds that a rating of 10 percent is warranted under DC 6011 for the entire rating period. DC 6011 provides a single rating of 10 percent for retinal scars, atrophy, or irregularities that result in an irregular, duplicated, enlarged, or diminished image. 38 C.F.R. § 4.84a (2008); 38 C.F.R. § 4.79 (2017). The October 2002 medical statement indicates that the Veteran had right monocular double vision , with his main symptoms being right visual blur (when doing concentrated tasks), followed by visual dimness that took two hours to recover. A November 2016 DBQ for eye condition (received December 12, 2016) confirms that the Veteran has diplopia. As such, the Board finds that the criteria for a rating of 10 percent under DC 6011 have been met. A separate rating, however, is not warranted under DC 6006 for retinopathy. In this regard, the evidence fails to show visual impairment at a level of severity commensurate with a rating of 20 percent or more. Further, there is no evidence that the Veteran's diabetic retinopathy has manifested as incapacitating episodes. 5. Erectile Dysfunction With regard to erectile dysfunction, the Board notes that the Veteran is already in receipt of special monthly compensation for loss of use of a creative organ. Erectile dysfunction is technically rated under DC 7522, for penis deformity. 38 C.F.R. § 4.115b. In this case, a compensable rating under DC 7522 is not warranted, as the evidence weighs heavily against a finding that the Veteran has a penis deformity. As the erectile dysfunction is noncompensable, it is rated under DC 7913 as part of the diabetic process. ORDER Service connection for kidney dysfunction/disease is denied. A higher rating for diabetes under DC 7913 is denied. From March 17, 2008, forward, a higher rating of 20 percent for peripheral neuropathy of the right lower extremity is granted. Prior to March 17, 2008, forward, a compensable rating for peripheral neuropathy of the left lower extremity is denied. From March 17, 2008, forward, a higher rating of 10 percent for peripheral neuropathy of the left lower extremity is granted. From September 8, 2016, forward, a higher rating of 20 percent for peripheral neuropathy of the left lower extremity is granted. A rating of 10 percent for diabetic retinopathy under DC 6011 is granted. ____________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs