Citation Nr: 1757767 Decision Date: 12/13/17 Archive Date: 12/28/17 DOCKET NO. 09-27 492 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and dysthymic disorder. 2. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II, with onychomycosis. 3. Entitlement to a rating in excess of 10 percent for hypertension. 4. Entitlement to a compensable rating for bilateral cataracts prior to August 16, 2016 and in excess of 40 percent thereafter. 5. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, femoral nerve. 6. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, femoral nerve. 7. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, sciatic nerve, prior to December 19, 2013 and in excess of 20 percent thereafter. 8. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, sciatic nerve, prior to December 19, 2013 and in excess of 20 percent thereafter. 9. Entitlement to a rating in excess of 10 percent prior to January 6, 2014 for left carpal tunnel syndrome and in excess of 20 percent thereafter. 10. Entitlement to a rating in excess of 10 percent prior to January 6, 2014 for right carpal tunnel syndrome and in excess of 30 percent thereafter. 11. Entitlement to a rating in excess of 10 percent for bilateral hearing loss. 12. Entitlement to a total disability rating based upon individual unemployability as a result of service-connected disabilities (TDIU) prior to December 19, 2013. REPRESENTATION Veteran represented by: Eric A. Gang, attorney ATTORNEY FOR THE BOARD Shana Z. Siesser, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Houston, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2011, the Veteran testified at a hearing before a Decision Review Officer at the RO. A copy of the transcript of that hearing is of record. This matter was previously before the Board in April 2014, at which time it was remanded for additional development. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA (VVA) electronic claims processing systems. Any future consideration of this claim should take into consideration the existence of the electronic record. The claims for increased ratings for bilateral hearing loss and carpal tunnel syndrome and entitlement to TDIU are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. With resolution of the doubt in favor of the Veteran, his dysthymic disorder is related to his service-connected disorders. 2. The Veteran's diabetes requires insulin and restricted diet but not regulation of activities. 3. The Veteran's diastolic pressure is not predominantly 110 mmHg or more and his systolic pressure is not predominantly 200 mmHg or more. He takes medication for control of his blood pressure. 4. Prior to August 16, 2016, cataracts have been manifested by not worse than 20/40 visual acuity; no visual field defect or abnormalities of the functioning of the eye muscles have been shown. 5. From August 16, 2016, cataracts have been manifest by a remaining visual field of 35 degrees on the right and 21 degrees on the left and not worse than 20/50 visual acuity, bilaterally; abnormalities of the functioning of the eye muscles have not been shown. 6. The service-connected peripheral neuropathy of the right lower extremity was manifested by mild incomplete paralysis of the femoral nerve. 7. The service-connected peripheral neuropathy of the right lower extremity was manifested by mild incomplete paralysis of the femoral nerve. 8. Prior to December 19, 2013, the service-connected peripheral neuropathy of the left lower extremity was manifested by mild incomplete paralysis of the sciatic nerve. 9. Prior to December 19, 2013, the service-connected peripheral neuropathy of the right lower extremity was manifested by mild incomplete paralysis of the sciatic nerve. 10. From December 19, 2013, the service-connected peripheral neuropathy of the left lower extremity was manifested by moderate incomplete paralysis of the sciatic nerve. 11. From December 19, 2013, the service-connected peripheral neuropathy of the right lower extremity was manifested by moderate incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for an acquired psychiatric disorder, including dysthymic disorder are approximated. 38 U.S.C.A. §§ 5103, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 2. The criteria for a rating in excess of 20 percent for diabetes have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, Diagnostic Code 7913 (2017). 3. The criteria for a rating in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7101 (2017). 4. Before April 16, 2016, the criteria for a compensable rating for cataracts have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.79, Diagnostic Codes 6027, 6066, 6080 (2017). 5. Since April 16, 2016, the criteria for a rating in excess of 40 percent for cataracts have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.79, Diagnostic Codes 6027, 6066, 6080 (2017). 6. The criteria for a rating in excess of 10 percent rating for diabetic peripheral neuropathy of the left lower extremity with partial paralysis of the femoral nerve have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2017). 7. The criteria for a rating in excess of 10 percent rating for diabetic peripheral neuropathy of the right lower extremity with partial paralysis of the femoral nerve have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2017). 8. The criteria for a rating in excess of 10 percent rating prior to December 19, 2013 and in excess of 20 percent thereafter for diabetic peripheral neuropathy of the left lower extremity with partial paralysis of the sciatic nerve have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 9. The criteria for a rating in excess of 10 percent rating prior to December 19, 2013 and in excess of 20 percent thereafter for diabetic peripheral neuropathy of the right lower extremity with partial paralysis of the sciatic nerve have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 (VCAA) to notify and assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The Veteran was provided with the relevant notice and information. He has not alleged any notice deficiency during the adjudication of that claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA's duty to assist under the VCAA includes helping claimants to obtain pertinent records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (c). The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159 (c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159 (c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). For his service connection claims, the Veteran was afforded adequate VA examinations that considered his medical history, his treatment records, a physical examination of the Veteran, and his lay statements and provided opinions supported by adequate rationales. For his increased rating claims, the Veteran was afforded adequate VA examinations that considered his medical history, his treatment records, a physical examination of the Veteran, and a review of his symptoms in accordance with the schedular criteria. Finally, the Board finds that the AOJ sufficiently complied with the remand directives of the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Law and analysis - service connection claims Service connection may 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 (2017). Service connection may also be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection on a direct basis, the record must contain: (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 disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. VA has amended 38 C.F.R. § 3.310 to reflect that it will not concede aggravation unless certain additional conditions are met. 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran was afforded a VA examination in January 2007. The examiner diagnosed dysthymic disorder and personality disorder and opined that "it is not likely that his current depression is due to the diagnosis of diabetes mellitus." As a rationale, the examiner stated that the Veteran reported symptoms of depression dating back several years prior to his diabetes diagnosis and it was more likely related to the poor social relationships, social isolation, and low self-esteem from his childhood. In January 2008, the Veteran admitted that he had job difficulties due to his anger. His physician noted that the Veteran was "feeling depressed about his current living situation, unemployment, financial problems and interpersonal problems. He reported not being able to tolerate other people. He reported feeling angry that he was told he is too old to be working, and is planning to take legal action through EEOC." He was diagnosed with anxiety disorder and depressive disorder. At a June 2011 VA examination, the Veteran reported being "tired of being treated poorly by Mexicans at his job; by the Houston Police Department and by the VA." His examiner noted that "symptoms of depression appear to be longstanding and are likely multifactorial and are attributable to numerous stressors including poor social relationships which is reflected in the diagnosis of a personality disorder, social isolation, low self-esteem dating back to childhood and poor coping skills." The Veteran was diagnosed with dysthymic disorder and personality disorder, NOS, Cluster B Traits. In a January 2014 VA examination report regarding PTSD, the examiner opined that the Veteran did not have PTSD but rather, he diagnosed depressive disorder/dysthymia and personality disorder. At an October 2015 VA examination, the examiner again found that the Veteran did not have a diagnosis of PTSD. Specifically, she found that the Veteran's reported stressors were not adequate to support the diagnosis of PTSD. The examiner opined that the Veteran had depression and dysthymic disorder and it was more likely than not that his dysthymia was due to his personality disorder. She specifically noted that the Veteran had depressed mood twice a week for which he could not identify a precipient. He attributed his lack of desire to his enjoyment of retirement and not to his diabetes or its complications. The examiner further noted that the Veteran endorsed a longstanding history of interpersonal difficulties and paranoia about people's motives as well as a history of impulsivity/aggression; poor insight and a feeling of entitlement. The Veteran meets criteria for Unspecified Personality Disorder (Cluster B Traits). It is less likely than not that the dysthymic disorder is proximately due to or the result of diabetes mellitus and its complications. It is more likely than not that the Veteran's dysthymia is due to his personality disorder. In a February 2015 private opinion, the examiner suggested that if a depressive disorder existed prior to the Veteran's diagnosis of diabetes, it was not severe enough to cause functional impairment; therefore, any currently impairing symptoms of depression were exacerbated by the Veteran's diabetes. The examiner stated that diabetes is a known risk factor for depression and that anger is a predictable symptom of depression. He indicated that the Veteran's sleep apnea is related to his diabetes and that depression is a common finding among those with sleep apnea. The examiner did not consider the relationship between the Veteran's depression and his personality disorder. In a June 2016 opinion, the Veteran's private examiner opined that it was as least as likely as not that the Veteran's mental health disorder, including depressive disorder and anxiety, are secondary to, related to, and/or aggravated by his service-connected diabetes and/or peripheral neuropathies. In support of this opinion, she stated that the Veteran's "quality of life and vocational functioning is affected by his Diabetes" and "the veteran has both emotional and physical symptoms as well as functional deficits and safety concerns from his service-connected Peripheral Neuropathy of Right and Left Lower Extremities associated with Diabetes Mellitus Type II, which are well known medical causes of depression and anxiety." She cited supporting medical literature that established that diabetes and peripheral neuropathies cause pain and poor quality of life, which can result in depression. In July 2016, the private examiner indicated a number of medical conditions which she believes to be associated with the Veteran's diabetes. She indicated that he would be unable to perform substantially gainful employment due to his pain; physical disabilities and lack of education. No mental health disorders were cited as associated or complicating factors in this document. The examiner's opinion concerning the relationship between the Veteran's dysthymic disorder and his service-connected diabetes mellitus type II and its complications to include neuropathy of lower extremities was based on medical literature related to risk factors. A VA opinion regarding the Veteran's dysthymic disorder was provided in October 2016. The examiner reviewed the evidence regarding the Veteran's depression and noted that Dysthymia is a persistent depressive disorder. Personality disorders are pervasive, longstanding patterns of perceiving and interacting with one's world. Both disorders, therefore, are chronic in nature. Individuals with Cluster B personality traits frequently experience depression due to their inability to develop and to maintain appropriate interpersonal relationships. Anger is a predictable correlate of a Cluster B personality disorder. [The IME's] opinion is based on medical literature related to risk factors. There is no documented evidence in the Veteran's medical or mental health records to support the opinion that his Dysthymic Disorder was aggravated beyond its natural progression by his service-connected Diabetes Mellitus Type II and its complications, to include neuropathy of lower extremities. Consistently throughout the Veteran's history, he has related his depressive symptoms to interpersonal, financial and employment problems. He frequently perceives discrimination and is angered by this. He related occupational problems to anger and said he is most depressed when people "try to mess over me." The nature of [the Veteran's] interpersonal problems is indicative of a personality disorder. By his report, these interpersonal problems have contributed to his depression. In an October 2016 VA addendum opinion, the examiner reiterated her opinion that the Veteran's dysthymic disorder is not due to or aggravated by his service-connected disorders. Specifically, she again noted that the Veteran repeatedly related his depression symptoms to interpersonal, financial, and employment problems. After a review of the evidence of record, the Board finds that with resolution of the doubt in favor of the Veteran, service connection for a psychiatric disorder is warranted. Regarding the Veteran's claim of service connection for PTSD, the Board finds that the Veteran does not have a diagnosis of PTSD. The Board finds the Veteran competent to provide evidence as to his stressors; however, multiple VA examiners have not found that a PTSD diagnosis is warranted. Therefore, service connection on that basis cannot be granted. The Board has also considered whether service connection is warranted for another acquired psychiatric disorder. The record does show diagnoses of dysthymic disorder/depression and anxiety. The Board is cognizant that the VA examiner attributes his depression to his personality disorder. However, the VA examiner has also acknowledged that his depression has been related to his employment and financial difficulties. By way of the VA examinations for his service-connected disorders and the grant of a TDIU, VA recognizes that his service-connected disorders have a significant impact on his employment and his finances. The Veteran's private examiner opined that diabetes and its complications, including peripheral neuropathies, cause depression due to its symptoms and resulting limitations; thereby affecting his employment. Therefore, with resolution of the doubt in favor of the Veteran, the Board finds that his depression/dysthymic disorder are related to his service-connected disorders. Law and analysis - increased ratings claims 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, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 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 disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. While it is necessary to consider the complete medical history of the Veteran's condition in order to evaluate the level of disability and any changes in condition, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Francisco v. Brown, 7 Vet. App. 55 (1994). In deciding the Veteran's increased evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. Diabetes mellitus, type II, with onychomycosis The Veteran's diabetes is rated under 38 C.F.R. § 4.119, Diagnostic Code 7913. Under Diagnostic Code 7913, a rating of 20 percent is assigned for diabetes requiring insulin and a restricted diet or an oral hypoglycemic agent 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. A 100 percent rating is warranted 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. Note 2 to Diagnostic Code 7913 provides that compensable complications of diabetes are to be separately evaluated unless they are part of the criteria used to support a 100 percent rating, and that noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. The Veteran is in recepit of separate ratings for hypertension, peripheral neuropathies of the upper and lower extremities, and cataracts associated with Type 2 diabetes mellitus. Here, the Veteran claims that he warrants an increased rating for his diabetes. Because of the successive nature of the rating criteria, each of the three criteria listed in the 40 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). The Veteran's diabetes clearly requires insulin and restricted diet, which is sufficient for a 20 percent rating. Hence, the dispositive issue here is whether it also requires the regulation of activities. For reasons discussed below, the Board finds that it does not. The definition of "regulation of activities" in the criteria for a 100 percent rating, i.e., "the avoidance of strenuous occupational and recreational activities," applies to the "regulation of activities" criterion for a 40 percent rating under Diagnostic Code 7913. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). This requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Id. At an August 2007 VA examination, the examiner noted that the Veteran had been diagnosed with diabetes since December 1999. He had no history of ketoacidosis or hypoglycemia. He visits with his doctor approximately four times per year. His diabetes causes tingling and numbness in the legs and feet. He had no progressive weight loss, loss of strength, abnormal sensation, urinary incontinence, or fecal leakages. He treats his diabetes with Metformin. The Veteran denied that the diabetes affected his eyes, skin, or kidneys. The Veteran was afforded a VA examination in June 2008. The examiner noted that the Veteran medicates with Metformin twice daily and has no hypoglycemia, ketoacidosis, and no restriction of activities. The Veteran also denied the diabetes affected his eyes, skin, and cardiac symptoms. At a September 2011 VA examination, the examiner noted that the Veteran had a diagnosis of diabetes mellitus. He treated with an oral hypoglycemic agent and was prescribed diabetes more than one injection per day. The examiner also noted that the Veteran was supposed to be on an ADA diet but was non-compliant with dietary restrictions. The Veteran did not require regulation of activities as part of his medical management of his diabetes. He visited his diabetic care provider less than twice per month for episodes of ketoacidosis and hypoglycemic reactions and did not require any hospitalizations for either over the prior 12 months. In a December 2013 examination report, the examiner noted a diagnosis of diabetes that the Veteran treats with prescribed oral hypoglycemic agents and more than one insulin injection per day. The Veteran's diabetes did not require regulation of activities as part of its medical management. The Veteran visited his diabetic care provider less than twice monthly for episodes of ketoacidosis and hypoglycemia. He had no hospitalizations of ketoacidosis and hypoglycemia over the prior 12 months. The Veteran did not have progressive weight loss or loss of strength due to his diabetes. Regarding the impact on his employment, the examiner stated that the Veteran diabetes was not well-controlled but that the Veteran is employable but limited to jobs that allow him to follow a regimen in his diet, such as eating at specific times and administering his insulin shots. As is clear from a review of the evidence described above, the criteria for a 40 percent evaluation for diabetes mellitus are not met. The evidence of record shows that the Veteran requires medication, insulin, and a restricted diet for control of his diabetes. There is, however, no medical evidence that the Veteran's diabetes requires a regulation of activities. As the regulation of activities is the only criterion differentiating a 20 percent rating from a 40 percent rating, the Veteran's requirement of medication, insulin, and a restricted diet cannot be deemed to more nearly approximate the criteria for a 40 percent rating. 38 C.F.R. § 4.7. The Board is cognizant that the Veteran contends that his diabetes is more severe than the rating criteria reflect. The board finds him to be competent to provide evidence as to the symptoms he experiences; however, in the absence of some restriction on activity due to diabetes mellitus, a 40 percent rating cannot be assigned and the Veteran's claim is denied. Hypertension The Veteran's hypertensive vascular disease is currently rated 10 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7101. Hypertensive vascular disease is evaluated as follows: diastolic pressure that is predominantly 130 mmHg or more (60 percent); diastolic pressure that is predominantly 120 mmHg or more (40 percent); diastolic pressure that is predominantly 110 mmHg or more or systolic pressure that is predominantly 200 mmHg or more (20 percent); and diastolic pressure that is predominantly 100 mmHg or more or systolic pressure that is predominantly 160 mmHg or more (10 percent). 38 C.F.R. § 4.104, Diagnostic Code 7101. A 10 percent rating is also possible if a veteran who requires continuous medication for blood pressure control has a history of diastolic pressure that was predominantly 100 mmHg or more. Id. The Veteran does not meet the schedular criteria for a rating in excess of 10 percent for hypertensive vascular disease. At an August 2007 VA examination, the Veteran's blood pressure readings were 134/72, 136/70, and 132/70. The Veteran treats his hypertension with medication. At a June 2008 VA examination, the Veteran's blood pressure readings were 144/90, 144/92, and 142/90. In a September 2011 VA examination, the Veteran reported that his hypertension remained fairly well controlled. The December 2013 VA examination report showed his blood pressure readings were 159/92, 114/60, and 134/74. The examiner noted that with the exception of the 159/92 reading, the Veteran's blood pressure remained stable and the dosage of his medication had not changed. Because the record does not indicate that the Veteran's blood pressure has ever, let alone predominantly, been at least 110 mmHg diastolic or 200 mmHg systolic during the period on appeal, a 20 percent schedular rating is not warranted. The Board acknowledges the Veteran's contention that he is on continuous medication for blood pressure control. This is a factor the rating criteria contemplate for the 10 percent rating. There are no other Diagnostic Codes that might apply to the Veteran's hypertension. The Board has also taken the Veteran's lay statements into account. The Veteran is competent to report his own observations with regard to the symptomatology of his hypertension. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the rating criteria for hypertension focus entirely on diastolic and systolic blood pressure and nothing in the Veteran's lay statements indicates that his hypertension meets the criteria for a rating in excess of 10 percent. Based on the evidence of record, the Veteran's hypertension does not warrant a schedular rating in excess of 10 percent at any time during the appeal period and the Veteran's claim is denied. Bilateral cataracts The Diagnostic Code applicable to preoperative cataracts directs VA to address the disability on the basis of visual impairment. 38 C.F.R. § 4.79, Diagnostic Code 6027. Visual impairment is assessed on the basis of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. In this case, the Board will address only impairment of visual acuity and visual field, because the evidence does not demonstrate, nor does the Veteran allege, that he has suffered from an impairment of muscle function. Turning first to the provisions applicable to visual acuity, a 10 percent disability rating applies when the corrected visual acuity is: (1) 20/100 in one eye and 20/40 in the other eye; (2) 20/70 in one eye and 20/40 in the other eye; (3) 20/50 in one eye and 20/40 in the other eye, or; (4) 20/50 in both eyes. Greater ratings are available for greater losses of visual acuity. 38 C.F.R. § 4.79, Diagnostic Code 6066. Diagnostic Codes 6080 and 6081 pertain to impairment of visual fields. Eight principal meridians (expressed in degrees) represent the extent of the visual field. The normal visual field extent at the eight principle meridians are: temporally to 85, down temporally to 85, down to 65, down nasally to 50, nasally to 60, up nasally to 55, up to 45, and up temporally to 55. 38 C.F.R. § 4.76 (a), Table III. The combined extent of the visual field is 500 degrees. The average concentric contraction is calculated by measuring the remaining visual fields (in degrees) at each of the eight principal meridians 45 degrees apart, adding the values, and dividing the sum by eight. The average concentric contraction represents the remaining visual field. Id. When the remaining visual field is between 46 degrees and 60 degrees, a 10 percent applies for unilateral or bilateral impairment; alternatively, each affected eye may be evaluated as equivalent to a 20/50 visual acuity. Greater ratings are available for greater levels of loss of visual field. 38 C.F.R. § 4.79, Diagnostic Code 6080. An August 2007 VA examination showed examinations of both eyes, including the funduscope were within normal limits. At a June 2008 VA examination, the examiner noted a diagnosis of bilateral cataracts. The Veteran reported blurred vision but denied pain, distorted vision, enlarged images, redness, swelling, discharge, or watering. He also denied hospitalization, surgery, and functional impairment. A physical examination showed there was no eye nor lacrimal duct disease or injury. There was no evidence of congestive/inflammatory glaucoma. Funduscopy examination was within normal limits. The measurement of intraocular pressure bilaterally was within normal limits with no keratoconus. The visual acuity examination revealed uncorrected far vision on the right as 20/80 and corrected far vision on the right was 20/25. The uncorrected near vision on the right is 20/100 and corrected near vision was 20/25. The uncorrected far vision on the left was 20/70 and corrected far vision on the left was 20/30. The uncorrected near vision on the left is 20/100 and corrected near vision on the left was 20/25. The Veteran did not have diplopia, enucleation, or nystagmus. The examiner diagnosed diabetes with no diabetic retinopathy and mild cataracts. He noted that the degree of aggravation of the cataracts from diabetes requires speculation. At a December 2013 VA eye examination, the examiner noted a 2007 diagnosis of cataracts. Regarding the Veteran's visual acuity, his uncorrected distance vision was 20/50, bilaterally and his uncorrected near vision was 20/70, bilaterally. His corrected distance vision and near vision was 20/40 or better, bilaterally. The Veteran did not have anatomical loss, light perception only, or extremely poor vision or blindness of either eye. The Veteran also did not have an astigmatism or diplopia. The Veteran did not have a visual field defect. The examiner also noted a right eye retinopathy but found that his decrease in visual acuity or impairment was not due to this retinopathy. The Veteran underwent a VA examination of his eyes in August 2016. The examiner noted no diagnosis of an eye disorder but described a medical history of bilateral cataracts, secondary to diabetes. Regarding the Veteran's visual acuity, his uncorrected distance vision was 20/70 on the right and 20/50 on the left. His uncorrected near vision was 20/100, bilaterally. His corrected distance vision was 20/40 or better on the right and 20/50 on the left and his corrected near vision was 20/50 bilaterally. The Veteran did not have anatomical loss, light perception only, or extremely poor vision or blindness of either eye. The Veteran also did not have an astigmatism or diplopia. Regarding the Veteran's visual fields, the Veteran's visual field for his left eye was limited to 20 degrees temporally, 17 degrees down temporally, 70 degrees down, 31 degrees down nasally, 23 degrees nasally, 40 degrees up nasally, 20 degrees up, and 17 degrees up temporally. The Veteran's remaining visual field in the left eye is 170 degrees. Dividing this by the eight directions, the left eye shows an average contraction to 21.25 degrees. The left eye can be rated on its concentric contraction or based on an equivalent visual acuity of 20/100. Unilateral concentric contraction of the left eye visual field with remaining field of 16 to 30 degrees warrants a 10 percent evaluation, and is included in the overall visual fields evaluation. The Veteran's visual field for his right eye was limited to 34 degrees temporally, 34 degrees down temporally, 38 degrees down, 34 degrees down nasally, 35 degrees nasally, 35 degrees up nasally, 35 degrees up, and 37 degrees up. The Veteran's remaining visual field in the right eye, calculated by subtracting the Veteran's 70 degrees of lost visual field from a total visual field of 500 degrees, is 281 degrees. Dividing this by the eight directions, this represents an average concentric contraction in the right eye of 35.125 degrees. The right eye can be rated on its concentric contraction or based on an equivalent visual acuity of 20/70. Unilateral concentric contraction of the right eye visual field with remaining field of 31 to 45 degrees warrants a 10 percent evaluation, and is included in your overall visual fields evaluation. When both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, the visual acuity and visual field defect (expressed as a level of visual acuity), are separately evaluated and combined under the provisions of 38 C.F.R. §§ 4.25, 4.77(c). The Veteran's visual acuity warranted a 10 percent evaluation and his visual field defect warranted a 30 percent evaluation. These evaluations combine under 38 C.F.R. § 4.25 for a 40 percent evaluation, as held by the RO. The Board finds that prior to the August 19, 2016 VA examination, the evidence did not show entitlement to a compensable rating for the Veteran's cataracts. At worst, the Veteran's corrected vision was 20/40 in both eyes. The schedular criteria assign this visual acuity with a zero percent rating. The examiners did not show a loss of visual field. From the August 19, 2016 VA examination, the evidence shows entitlement to a 40 percent rating, but no higher, based on the findings set out above. Therefore, the Veteran's claim for an increased rating in excess of those assigned is denied. Peripheral neuropathy of the lower extremities The Veteran was in receipt of bilateral 10 percent ratings for peripheral neuropathies of the lower extremities under Diagnostic Code 8520, affecting the sciatic nerve. Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating is warranted for moderate incomplete paralysis, a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent is warranted for severe incomplete paralysis with marked muscular atrophy; and an 80 percent, the maximum available, is warranted for complete paralysis, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. In a July 2016 rating decision, the RO increased the Veteran's rating to 20 percent bilaterally for sciatic nerve impairment. The July 2016 rating decision also granted separate 10 percent ratings for mild incomplete paralysis of the bilateral femoral nerves under Diagnostic Code 8526. Diagnostic Code 8526 provides for a 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating is warranted for moderate incomplete paralysis, a 30 percent rating is warranted for severe incomplete paralysis; and a 40 percent rating, the maximum available, is warranted for complete paralysis of the quadriceps extensor muscles. For VA purposes, the term "incomplete paralysis," with diseases of the peripheral nerves and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. At an August 2007 VA examination, the Veteran's peripheral nerve examination was within normal limits. At a December 2013 VA examination, the examiner noted that the Veteran had controlled diabetes until July 2007 when his HGBA1C was noted to have gone up. At an October 2008 VA examination, it was noted that he had loss of sensation to monofilament. Diabetic peripheral neuropathy was added to his problem list in 2011. The Veteran presently reported numbness and parasthesias, which can become severe. Upon examination, the examiner noted mild intermittent pain of the bilateral lower extremities and moderate parasthesias and numbness of the bilateral lower extremities. A neurologic examination was normal but a reflex examination showed decreased reflexes in the bilateral biceps, triceps, brachioradialis, knee, and ankle. Light touch/monofilament testing showed decreased sensation in the bilateral lower legs/ankle and foot/toes. Position sense was normal but vibration sensation and cold sensation were decreased for the bilateral lower extremities. The Veteran did not have muscle atrophy or trophic changes. The examiner opined that the Veteran had moderate incomplete paralysis of the bilateral sciatic nerves and mild incomplete paralysis of the bilateral femoral nerves. She further stated that the Veteran's diabetic peripheral neuropathy affects his ability to work due to sedentary needs. After a review of the evidence of record, the Board finds that ratings in excess of those currently assigned are not warranted. At no point prior to December 19, 2013 does the evidence show the Veteran had more than a mild incomplete paralysis of the sciatic nerve. The December 2013 VA examination showed the Veteran had moderate incomplete paralysis of the sciatic nerve. As neither moderately severe or severe incomplete paralysis nor complete paralysis of the sciatic nerve was shown at any time during the period on appeal, ratings in excess of the 10 and 20 percent currently assigned are denied. As to the femoral nerve impairment, the Board has no reason to disagree with the VA examiner's conclusion that the symptoms of incomplete paralysis of the lower extremities are mild. Under Diagnostic Code 8526, mild incomplete paralysis of the femoral nerve warrants a 10 percent rating. There is no indication in the record that the paralysis of the nerve is more severe than reflected in the December 2013 VA examination; thus ratings in excess of 10 percent are not warranted. The Board finds that a 10 percent rating, and no more, under Diagnostic Code 8526 for each lower extremity is warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8526. VA must consider all favorable lay evidence of record. 38 USCA § 5107 (b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly considered the lay evidence offered by the Veteran in addition to the medical evidence cited above. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995). However, even affording the Veteran full competence and credibility, the evidence simply does not show entitlement to a higher rating under any applicable diagnostic code. Staged ratings Consideration has been given to assigning staged ratings, or further staged ratings; however, at no time during the period in question has the Veteran's diabetes, hypertension, peripheral neuropathies, or cataracts warranted more than the assigned ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). ORDER With resolution of the doubt in favor of the Veteran, service connection for an acquired psychiatric disorder is granted. A rating in excess of 20 percent for diabetes mellitus, type II, with onychomycosis is denied. A rating in excess of 10 percent for hypertension is denied. A compensable rating for bilateral cataracts prior to August 16, 2016 and in excess of 40 percent thereafter is denied. A rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, femoral nerve is denied. A rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, femoral nerve is denied. A rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, sciatic nerve, prior to December 19, 2013 and in excess of 20 percent thereafter is denied. A rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, sciatic nerve, prior to December 19, 2013 and in excess of 20 percent thereafter is denied. REMAND Regarding the Veteran's claim for an increased rating for his bilateral hearing loss, his most recent VA examination was in December 2013. The examiner noted hearing loss but failed to comment on the functional effects of the Veteran's hearing loss on his activities of daily living, if any. Therefore, an addendum examination is necessary. With regard to his claims for increased ratings for carpal tunnel syndrome, a December 2014 treatment record indicates the Veteran underwent left cubital nerve release surgery. As this surgery may impact the severity of his carpal tunnel syndrome, a VA examination is necessary prior to assigning a rating. The Veteran's claim for TDIU prior to December 19, 2013 is remanded as it is inextricably intertwined with the presently granted claims of service connection for dysthymic disorder and the present remanded increased ratings claims. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA treatment records. Efforts to obtain these records must be associated with the claims file and requests for these records must continue until the AOJ determines that the records sought do not exist or that further efforts to obtain those records would be futile. The Veteran's assistance in identifying and obtaining the records should be requested as needed. All attempts to obtain records should be documented in the claims folder. 2. Schedule the Veteran for a VA audiological examination to address the current severity of his service-connected bilateral hearing loss. The examiner is to be provided access to the electronic claims file. The examiner must specify in the report that these records have been reviewed. Following a complete review of the claims file and examination of the Veteran, the examiner is to provide a detailed review of the Veteran's current complaints and the nature and extent of any hearing loss disability, as well as a discussion of the functional effects of the Veteran's hearing loss on the ordinary conditions of daily life and activities of daily living including, but not limited to, his ability to work. A detailed rationale must be provided for any opinion provided, including a discussion of the evidence of record and medical principles which led to the conclusions reached. 3. Schedule the Veteran for a VA examination to assess the severity of his carpal tunnel syndrome. The examiner is to be provided access to the electronic claims file. The examiner must specify in the report that these records have been reviewed. The examiner must describe the functional limitations currently presented by the Veteran's carpal tunnel syndrome. The examiner must specify the nerves affected. A detailed rationale must be provided for any opinion provided, including a discussion of the evidence of record and medical principles which led to the conclusions reached. 4. After the development requested has been completed, review the expanded record to ensure complete compliance with the directives of this REMAND. If any report is deficient in any manner, implement corrective procedures at once. 5. After completing the above, and any other development deemed necessary, readjudicate the Veteran's appeal of the remaining issues based on the entirety of the evidence. If the benefits sought on appeal are not granted to the appellant's satisfaction, he and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs