Citation Nr: 1756542 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 11-08 915A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Entitlement to an increased rating for service-connected diabetes mellitus with erectile dysfunction, evaluated as 20 percent disabling prior to September 21, 2015, and 60 percent thereafter. 2. Entitlement to an increased rating for service-connected peripheral neuropathy of the right upper extremity (RUE), evaluated as 10 percent disabling prior to December 12, 2014, 40 percent from December 12, 2014 to May 5, 2016, and 50 percent after May 6, 2016. 3. Entitlement to an increased rating for service-connected peripheral neuropathy of the left upper extremity (LUE), evaluated as 30 percent disabling prior to May 6, 2016, and 40 percent thereafter. 4. Entitlement to an increased rating for service-connected peripheral neuropathy of the right lower extremity (RLE), evaluated as 20 percent disabling prior to May 6, 2016, and 40 percent thereafter. 5. Entitlement to an increased rating for service-connected peripheral neuropathy affecting the left lower extremity (LLE), evaluated as 10 percent disabling prior to May 6, 2016, and 40 percent thereafter. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and T.S. ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from October 1965 to August 1967. This matter comes before the Board of Veterans' Appeals (Board) from a February 2014 rating decision issued by the RO in Chicago, Illinois. In August 2015, the Veteran and a friend, T.S., testified before the undersigned via video conference. This appeal was previously remanded by the Board in February 2016. FINDINGS OF FACT 1. The Veteran's diabetes mellitus has required an oral hypoglycemic medication and insulin injections not more than once a day during the appeal period. The Veteran was hospitalized for a hypoglycemic episode manifested by hypertensive urgency on September 21, 2015; however, prior to that date, there is no evidence of episodes of ketoacidosis or hypoglycemic reactions that required a hospitalization or visits to a diabetic care provider two or more times a month; nor is there evidence of regulation of activities prior to September 21, 2015. 2. The Veteran's diabetes mellitus has resulted in erectile dysfunction throughout the appeal period but the evidence does not reflect deformity of the penis. 3. Prior to December 12, 2014, the Veteran's RUE neuropathy was manifested by mild incomplete paralysis variously manifested by slightly decreased sensation, muscle tone, and reflexes. 4. From December 12, 2014 to May 6, 2016, the Veteran's RUE neuropathy more nearly approximated moderate incomplete paralysis manifested by subjective complaints of pain, paresthesias, and numbness, with objective evidence of less than normal muscle strength and decreased sensory impairment in light touch, vibration, and temperature testing. 5. From May 6, 2016, the Veteran's RUE neuropathy more nearly approximated severe incomplete paralysis manifested by absent sensation to vibration and light touch, decreased reflexes, and impaired muscle strength with no movement against resistance and gravity in the right elbow, wrist, and hand respectively. 6. Prior to May 6, 2016, the Veteran's LUE neuropathy more nearly approximated moderate incomplete paralysis manifested by subjective complaints of pain, paresthesias, and numbness, with objective evidence of decreased sensation to light touch and vibration testing and decreased muscle strength in the LUE. 7. From May 6, 2016, the Veteran's LUE neuropathy more nearly approximated severe incomplete paralysis manifested by manifested by absent sensation to vibration and light touch, decreased reflexes, and impaired muscle strength with no movement against resistance and gravity in the left elbow, wrist, and hand. 8. Prior to May 6, 2016, the Veteran's right and left lower extremity neuropathy disabilities were manifested by a moderate neurologic impairment with a varying sensory impairment that ranged from decreased to absent in light touch and vibration testing throughout the lower extremities, as well as less than normal muscle strength in both lower extremities and a varying reflexes impairment. 9. From May 6, 2016, the Veteran's right and left lower extremity neuropathy disabilities were manifested by a moderately severe neurologic impairment with a more severe impairment in muscle strength and continued evidence of decreased and absent sensation in light touch and vibration throughout the lower extremities, as well as decreased and absent reflexes in the knees and ankles; there is no evidence of muscle atrophy. CONCLUSIONS OF LAW 1. Prior to September 21, 2015, the criteria for a rating in excess of 20 percent for diabetes mellitus with erectile dysfunction were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2017). 2. The criteria for a rating in excess of 60 percent for diabetes mellitus with erectile dysfunction have not been met since September 21, 2015. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 3. Prior to December 12, 2014, the criteria for a rating in excess of 10 percent for peripheral neuropathy affecting the right upper extremity were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DC 8515. 4. Prior to May 6, 2016, the criteria for a rating in excess of 40 percent for peripheral neuropathy affecting the right upper extremity were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DC 8512 (2017). 5. From May 6, 2016, the criteria for a rating in excess of 50 percent for peripheral neuropathy affecting the right upper extremity are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DCs 8512, 8515. 6. Prior to May 6, 2016, the criteria for a rating in excess of 30 percent for peripheral neuropathy affecting the left upper extremity were not met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.25, 4.26, 4.124a, DC 8513 (2017). 7. The criteria for a rating in excess of 40 percent for peripheral neuropathy affecting the left upper extremity have not been met since May 6, 2016. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DCs 8512, 8515. 8. Prior to May 6, 2016, the criteria for a rating in excess of 20 percent for peripheral neuropathy affecting the right lower extremity are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DC 8520 (2017). 9. The criteria for a rating in excess of 40 percent for peripheral neuropathy affecting the right lower extremity have not been met since May 6, 2016. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DCs 8520 (2017). 10. Prior to May 6, 2016, the criteria for a 20 percent rating, but no higher, for peripheral neuropathy affecting the left lower extremity were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DC 8520. 11. The criteria for a rating in excess of 40 percent for peripheral neuropathy affecting the left lower extremity have not been met since May 6, 2016. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.25, 4.26, 4.124a, DCs 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Diabetes Mellitus and Erectile Dysfunction The Veteran's diabetes mellitus with erectile dysfunction is evaluated under 38 C.F.R. § 4.124a, DC 7913 and rated 20 percent disabling until September 21, 2015, after which the disability is rated 60 percent disabling. The Board will consider whether a higher rating is warranted both prior to and after September 21, 2015. The pertinent evidence of record includes VA examination reports dated September 2013 and May 2016, as well as VA outpatient treatment records dated from 2013 to 2016; the hearing testimony, and the Veteran's statements. The preponderance of the evidence reflects that the Veteran's service-connected diabetes mellitus has been treated with oral hypoglycemic medication and insulin injections not more than once a day during the appeal period. See VA examination reports. During the September 2013 examination, the examiner noted that the Veteran's diabetes mellitus did not require regulation of activities or visits to a diabetic provider for episodes of ketoacidosis or hypoglycemic reactions two or more times a month. There was also no evidence of hospitalization for episodes of ketoacidosis or hypoglycemic reactions. However, the May 2016 VA examiner noted that the Veteran's diabetes had worsened to the point that it required regulation of activities, as activity resulted in decreased glucose and required medication. The May 2016 VA examiner also noted that the Veteran's diabetes mellitus required visits to a diabetic provider for episodes of ketoacidosis or hypoglycemic reaction more than two times a month and had resulted in one hospitalization. VA treatment records show that, from September 21 to September 23, 2015, the Veteran was hospitalized and given additional insulin for a hypoglycemic episode manifested by hypertensive urgency. In a September 2014 statement, the Veteran suggested that his activities were limited and regulated as a result of his diabetes mellitus; however, the medical evidence dated prior to September 2015, inclusive of the September 2013 VA examination report and VA treatment records, do not reflect that the Veteran was advised to avoid strenuous occupational or recreational activities. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007) (medical evidence is required to show that occupational and recreational activities have been restricted); see also 61 Fed. Reg. 20,440, 20,443 (May 7, 1996) (defining "regulation of activities" as used by VA in 7913). There is also no evidence or allegation that, prior to September 21, 2015, the Veteran's diabetes mellitus was manifested by episodes of ketoacidosis or hypoglycemic reactions that required a hospitalization or visits to a diabetic care provider two or more times a month. Therefore, a rating in excess of 20 percent is not warranted for diabetes mellitus prior to September 21, 2015. The Board also finds that a rating in excess of 60 percent is not warranted from September 21, 2015. Indeed, there is no evidence or allegation showing the Veteran's diabetes mellitus has required more than one daily injection of insulin or has been manifested by episodes of ketoacidosis or hypoglycemic reactions that required three or more hospitalizations or weekly visits to his diabetic care provider. Nor is there evidence of progressive weight loss and strength due to diabetes mellitus. The Board notes that Note (1) to DC 7913 instructs that compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under DC 7913. 38 C.F.R. § 4.119, DC 7913. In this context, the evidence shows that the Veteran was diagnosed with erectile dysfunction in 2004 and is unable to achieve an erection. See May 2016 VA examination report. However, because the evidence does not reflect both the loss of erectile power and deformity of the penis, a separate compensable rating is not warranted for erectile dysfunction. See 38 C.F.R. § 4.119, DC 7913. The evidence reflects that the Veteran's diabetes mellitus has also resulted in peripheral neuropathy affecting the bilateral upper and lower extremities. The ratings assigned to those disabilities will be discussed below. There is, however, no other evidence showing the Veteran's diabetes mellitus has resulted in any other residual complication and, thus, a separate compensable rating for any additional associated condition is not warranted pursuant to Note (1) of DC 7913. In summary, and for the foregoing reasons, the Board finds that the preponderance of the evidence is against the grant of an increased rating for the Veteran's service-connected diabetes mellitus with erectile dysfunction at any point during the appeal period, including a rating in excess of 20 percent prior to September 21, 2015, or a rating in excess of 60 percent thereafter. As the evidence preponderates against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application in this case. See 38 U.S.C.A. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); 38 C.F.R. §§ 3.102, 4.3. Right Upper Extremity (RUE) Neuropathy The Veteran's RUE neuropathy impacts his dominant extremity and is variously rated throughout the appeal period. From March 2013 (the date of receipt of his increased rating claim) to December 12, 2014, the RUE neuropathy is rated 10 percent disabling (mild) under DC 8515, which provides the criteria for neurologic impairments affecting the median nerve. From December 12, 2014 to May 6, 2016, the RUE neuropathy is rated 40 percent disabling (moderate) under DC 8512, which provides the criteria for neurologic impairments affecting the lower radicular group of the RUE. From May 6, 2016, the RUE neuropathy is rated 50 percent disabling (severe) under DC 8515. The pertinent evidence includes VA examination reports dated in September 2013, December 2014, and May 2016, as well as VA outpatient treatment records dated from 2013 to 2016; hearing testimony and the Veteran's statements. Prior to December 12, 2014, the relevant evidence includes VA treatment records dated May and September 2013 and a September 2013 VA examination, all of which reflect that the Veteran's neurologic impairment in his RUE was no more than mild. Indeed, the May 2013 VA treatment record reflects that the Veteran had decreased sensation to vibration, pinprick, light touch, and temperature testing in the RUE. The clinician who evaluated the Veteran in September 2013 also noted there was diminished sensation in his upper extremities from his fingertips to the elbows, including completely diminished sensation to vibratory testing in the RUE. The September 2013 clinician also noted there was some loss of muscle bulk in the right forearm; however, there was no evidence of decreased muscle strength or reflexes in the RUE. Likewise, during the September 2013 VA examination, the Veteran's strength was normal while flexing and extending his right elbow and wrist, as well as gripping and pinching his right hand. Sensory examination also revealed normal sensation to light touch and vibration testing throughout the RUE. Nevertheless, the September 2013 VA examiner noted the Veteran's reflexes were decreased in his right bicep, triceps and brachioradialis. The forgoing evidence reflects that, from March 2013 to December 2014, the Veteran's RUE neuropathy was manifested by decreased sensation, muscle tone, and reflexes in his RUE; however, none of these impairments were diffuse or severe in nature and were not shown consistently during the time period in question. As a result, the Board finds that, prior to December 12, 2014, the overall neurologic impairment in the RUE is no more than mild and, thus, warrants no more than a 10 percent rating under DC 8515. In this regard, the Board notes that the September 2013 VA examiner noted that the Veteran's RUE neuropathy involved the median nerve. Therefore, consideration of a higher rating under DC 8512 (lower radicular group) or any other diagnostic code is not warranted. For the time period beginning December 12, 2014, the Veteran reported having mild pain in the RUE, as well as moderate paresthesias and numbness. Objective examination revealed decreased sensation to light touch, vibration, and temperature testing and the Veteran's muscle strength was less than normal (4/5) throughout the RUE, although his reflexes were normal. There was also evidence of muscle atrophy. Notably, the December 2014 VA examiner reported that the Veteran had moderate incomplete paralysis of the radial and median nerves. The Board agrees. Indeed, the evidence dated from December 12, 2014 reflects that the Veteran's RUE neuropathy had increased in severity, as the Veteran endorsed new subjective complaints of pain, paresthesias, and numbness and objective evidence revealed decreased muscle strength and decreased sensory impairment in light touch, vibration, and temperature testing. The Board finds probative that the Veteran's muscle strength was only less than normal (4/5) and that his sensory impairment was decreased but not absent. Therefore, for the period beginning May 6, 2016, the Board finds the Veteran's RUE neuropathy more nearly approximated a moderate but not severe neurologic impairment, which warrants no more than a 40 percent rating under DC 8512. The Board notes that DC 8515 provides a 30 percent rating for a moderate impairment of the median nerve in the dominant extremity; therefore, DC 8515 does not assist the Veteran in obtaining a rating higher than the 40 percent rating currently assigned. For the time period beginning May 6, 2016, the Veteran endorsed having severe numbness in his RUE from his fingertip to the elbow and objective sensory examination revealed absent sensation to vibration and light touch throughout the RUE. The Veteran's reflexes remained decreased in his right bicep, triceps and brachioradialis but his strength was more impaired at 3/5 with no movement against resistance in movement of his elbow and wrist and 2/5 with no moment against gravity in gripping and pinching in his right hand. In this regard, the May 2016 VA examiner noted that the Veteran's strength was markedly decreased while working in his workshop and while performing buttoning and zippering functions. Notably, the May 2016 VA examiner stated that the Veteran's RUE neuropathy involved a severe impairment of the radial, median, and ulnar nerves. The evidence reveals that the Veteran's RUE neuropathy resulted in a severe sensory and functional impairment in his dominant extremity. However, complete paralysis is not shown as the Veteran retains sensation, strength, and reflexes in his RUE, albeit severely limited. Therefore, the Board finds that, for the period beginning May 6, 2016, no more than a 50 percent rating is warranted under either DC 8515 (median nerve) or DC 8512 (lower radicular group). Parenthetically, the Board notes that DC 8516 does not assist the Veteran is obtaining a rating higher than 50 percent, as the highest possible rating for severe incomplete paralysis of the ulnar nerve in the dominant extremity under DC 8516 is 40 percent. In summary, for the foregoing reasons, the Board finds that the preponderance of the evidence is against the grant of an increased rating for the service-connected RUE neuropathy at any point during the appeal period. Instead, as noted, the Veteran's RUE neuropathy warrants no more than a 10 percent rating prior to December 12, 2014, a 40 percent rating prior to May 6, 2016, and a 50 percent rating thereafter. As the evidence preponderates against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application in this case. See 38 U.S.C. § 5107(b); 4.3; Gilbert, 1 Vet. App. at 49. Left Upper Extremity (LUE) Neuropathy The Veteran's LUE neuropathy is variously rated throughout the appeal period. From March 2013 (the date of receipt of his increased rating claim) to May 6, 2016, the LUE neuropathy is rated 30 percent disabling (moderate) under DC 8513, which provides the criteria for neurologic impairments affecting all radicular groups. See February 2014 rating decision. From May 6, 2016, the LUE neuropathy is rated 40 percent disabling (severe) under DC 8515, which provides the criteria for neurologic impairments affecting the median nerve. See November 2016 rating decision. At this juncture, the Board notes it is not clear why the RO initially evaluated the Veteran's LUE under DC 8513 as opposed to any of the other diagnostic codes, particularly given that his RUE neuropathy is variously evaluated under DCs 8512 and 8516 and the neuropathy disabilities are shown to affect the same nerves in both upper extremities. In this regard, the Board previously noted that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, to radicular groups and determined that the lower radicular group under DC 8512 was appropriate to evaluate the RUE neuropathy. See February 2016 Board decision. Therefore, to achieve consistency, the Board will evaluate the Veteran's LUE neuropathy under DCs 8512 (lower radicular group) and 8515 (median nerve). Prior to May 6, 2016, the relevant evidence includes VA examination reports dated September 2013 and December 2014, during which the Veteran endorsed having moderate pain in the LUE, as well as paresthesias and numbness which was moderate in September 2013 but severe in December 2013. During the September 2013 examination, objective sensory examination revealed absent light touch sensation in the left hand and fingers, as well as decreased vibration sensation throughout the LUE. The Veteran's left hand grip was less than normal with decreased reflexes in the LUE. Similarly, during the December 2014 examination, objective sensory examination revealed decreased, but not absent, light touch, vibration, and cold sensation. The Veteran's muscle strength was less than normal as shown by decreased left hand grip in September 2013; but was more diffuse throughout the LUE in December 2014. Additionally, the Veteran's reflexes were decreased (1+) in the left bicep, triceps and brachioradialis in September 2013 but were normal in December 2014. While the foregoing evidence shows that the Veteran's LUE neuropathy varied prior to May 6, 2016, the evidence shows the Veteran consistently endorsed having pain, paresthesias, and numbness, while objective evidence has consistently revealed decreased sensation to light touch and vibration testing and decreased muscle strength in the LUE. The Board finds probative that, while impaired, the Veteran's sensory impairment was decreased, but not absent, and that his muscle strength was only less than normal, as opposed to more severely impaired with no movement against resistance or gravity to indicate a more severe neurologic impairment. Therefore, the Board finds the Veteran's LUE neuropathy is consistent with no more than a moderate impairment of the affected nerve. In this context, the Board notes that the September 2013 and December 2014 VA examiner found Veteran's LUE neuropathy to be manifested by a moderate impairment of the radial and median nerves with a severe impairment of the ulnar nerves. Taking this evidence into consideration, the Board finds that, prior to May 6, 2016, the Veteran's LUE neuropathy was no more than moderate and, thus, warranted no more than a 30 percent rating under either DC 8512 or 8515, as moderate incomplete paralysis of the non-dominant extremity warrants no more than a 30 percent rating under those diagnostic codes. From May 6, 2016, the Veteran endorsed having severe numbness in his LUE from his fingertip to the elbow and objective sensory examination revealed absent sensation to vibration and light touch throughout the LUE. The Veteran's strength was impaired at 3/5 with no movement against resistance in movement of his elbow and wrist and 2/5 with no moment against gravity in gripping and pinching in his left hand. His reflexes were also decreased in the left bicep, triceps and brachioradialis. Notably, the May 2016 VA examiner found that the Veteran's LUE neuropathy involved a severe impairment of the radial, median, and ulnar nerves. The Board finds that the preponderance of the evidence dated since May 2016 reveals that the Veteran's LUE neuropathy resulted in a severe sensory and functional impairment in his non-dominant extremity. While severe, complete paralysis is not shown as the Veteran retains sensation, strength, and reflexes in his LUE. Based on the foregoing, the Board finds that, from May 6, 2016, no more than a 40 percent rating is warranted under either DC 8515 (median nerve) or 8512 (lower radicular group). In summary, for the foregoing reasons, the Board finds that the preponderance of the evidence is against the grant of an increased rating for the service-connected LUE neuropathy at any point during the appeal period. Instead, as noted, the Veteran's LUE neuropathy warrants no more than a 30 percent rating prior to May 6, 2016, and a 40 percent rating thereafter. As the evidence preponderates against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application in this case. See 38 U.S.C.A. § 5107 (b); Gilbert, 1 Vet. App. at 49; 38 C.F.R. §§ 3.102, 4.3. Right Lower Extremity (RLE) and Left Lower Extremity (LLE) Neuropathy The Veteran's RLE neuropathy is evaluated under 38 C.F.R. § 4.124a, DC 7913-8520 and rated 20 percent disabling until May 6, 2016, and 40 percent thereafter. The Veteran's LLE neuropathy is also evaluated under 38 C.F.R. § 4.124a, DC 7913-8520 and rated 10 percent disabling until May 6, 2016, and 40 percent thereafter. The Board will consider whether a higher rating is warranted for both lower extremities prior to and after May 6, 2016. Prior to May 6, 2016, the relevant evidence includes VA examination reports dated September 2013 and December 2014, during which the Veteran endorsed having mild pain and paresthesias, with moderate numbness, in the right and left lower extremities. During both examinations, sensory examination revealed decreased light touch testing in the ankles and lower legs, absent light touch in both feet and toes, and absent vibration throughout both lower extremities. The Veteran's right and left lower extremity strength was normal in September 2013 but was less than normal (4/5) in December 2014. During the September 2013 examination, the Veteran's reflexes were also decreased in both knees and ankles, while the reflexes in both of his ankles were absent in December 2014. There was no evidence of muscle atrophy during the September 2013 but the December 2014 VA examiner noted there was evidence of muscle atrophy, without any further evidence or indication as to the severity of the atrophy. The Board notes that the physicians who conducted the September 2013 and December 2014 VA examinations noted the Veteran's right and left lower extremity neuropathy disabilities resulted in a mild impairment of the sciatic nerve. The Board also notes that the Veteran's subjective and objective symptoms were similar during the September 2013 and December 2014 VA examinations. In this regard, the Board finds probative that the Veteran's right and left lower extremity neuropathy disabilities are manifested by sensory and functional impairments which, while decreased, are not shown to be severe or diffuse. Indeed, the evidence shows the Veteran's sensory impairment is decreased and absent in certain sensation tests (such as light touch and vibration) and in certain areas in the lower extremities (such as the ankles, feet, and toes), as opposed to most or all sensation tests throughout the entire lower extremity (including light touch, position sense, vibration, and cold in the knees, thighs, ankles, feet, and toes). Likewise, the Veteran's muscle strength is also only less than normal in the lower extremities, without evidence of a more severe impairment, such as no movement against resistance or gravity. In this context, the Board notes that a more severe impairment in muscle strength is shown during the May 2016 VA examination where the Veteran demonstrated no movement against resistance in the bilateral knees and ankles, with continued evidence of absent light touch and vibration and absent reflexes in the a throughout the lower extremities, as well as decreased and absent reflexes in the knees and ankles, respectively. The Veteran also endorsed severe numbness in his right and left lower extremities from his toes to his knees. There was, however, no objective evidence of muscle atrophy in the lower extremities. Notably, the May 2016 VA examiner stated that the Veteran's bilateral lower extremity neuropathy disabilities resulted in a moderately severe impairment of the sciatic nerve. Based on the foregoing, the Board finds, prior to May 6, 2016, the Veteran's right and left lower extremity neuropathy disabilities were manifested by a moderate neurologic impairment which warrants a 20 percent rating, but no higher under DC 8520. Given the evidence of additional functional impairment, i.e., additionally decreased muscle strength in bilateral knees and ankles in May 2016, as well as the continued sensory impairment in both lower extremities, the Board finds that, as of that date, Veteran's right and left lower extremity neuropathy disabilities more nearly approximated a moderately severe impairment of the sciatic nerve, which warrants no more than a 40 percent rating under DC 8520. In summary, for the foregoing reasons, the Board finds the preponderance of the evidence is against the grant of an increased rating for the service-connected RLE neuropathy at any point during the appeal period. Therefore, a rating in excess of than 20 percent is not warranted prior to May 6, 2016, or a rating in excess of 40 percent thereafter. Nevertheless, the evidence supports the grant of a 20 percent rating for service-connected LLE neuropathy prior to May 6, 2016. The preponderance of the evidence is against the grant of a rating in excess of 40 percent thereafter. In making these determinations, all reasonable doubt has been resolved in favor of the Veteran. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 49. (CONTINUED ON NEXT PAGE) ORDER Prior to September 21, 2015, a rating in excess of 20 for diabetes mellitus with erectile dysfunction is denied. A rating in excess of 60 percent for diabetes mellitus with erectile dysfunction from September 21, 2015 is denied. Prior to December 12, 2014, a rating in excess of 10 percent for peripheral neuropathy affecting the right upper extremity is denied. A rating in excess of 40 percent is denied prior to May 6, 2016, and a rating in excess of 50 percent is denied thereafter. Prior to May 6, 2016, the criteria for a rating in excess of 30 percent for peripheral neuropathy affecting the left upper extremity is denied. A rating in excess of 40 percent from May 6, 2016 is denied. Prior to May 6, 2016, a rating in excess of 20 percent for peripheral neuropathy affecting the right lower extremity is denied. A rating in excess of 40 percent from May 6, 2016 is denied. Prior to May 6, 2016, a 20 percent rating, but no higher, is granted for peripheral neuropathy affecting the left lower extremity. A rating in excess of 40 percent from May 6, 2016 is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs