Citation Nr: 18143081 Decision Date: 10/18/18 Archive Date: 10/17/18 DOCKET NO. 16-24 408 DATE: October 18, 2018 ORDER A disability rating higher than 0 percent for the service-connected meralgia paresthetica of the left lower extremity is denied. FINDING OF FACT The service-connected meralgia paresthetica of the left lower extremity has been manifested by pain, paresthesia, and disesthesia of the external cutaneous nerve of the thigh, which is productive of moderate impairment. CONCLUSION OF LAW The criteria for a rating higher than 0 percent for the service-connected meralgia paresthetica of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124a, Diagnostic Code 8729 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a veteran (the Veteran) who had active duty service from May 2007 to May 2011. This appeal comes before the Board of Veterans’ Appeals (Board) from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is a component of the increased rating claim on appeal in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009) (where there is evidence of unemployability raised by the record during a rating appeal period, the TDIU is an element of an initial rating or increased rating). However, the Veteran has reported that he is a full-time college student, and he does not contend that his service-connected meralgia paresthetica of the left lower extremity has rendered him unable to secure or follow a substantially gainful occupation. Entitlement to a disability rating higher than 0 percent for the service-connected meralgia paresthetica of the left lower extremity. Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017). A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The current appeal arises from a claim of entitlement to service connection for meralgia paresthetica, received at VA on August 13, 2013. In a September 2013 rating decision, VA granted service connection for meralgia paresthetica of the left lower extremity and assigned an initial disability rating of 0 percent under Diagnostic Code 8729, effective August 13, 2013. Under Diagnostic Code 8729, neuralgia of the external cutaneous nerve of the thigh warrants a rating of 10 percent if severe to complete and a rating of 0 percent if mild or moderate. 38 C.F.R. § 4.124a, Diagnostic Codes 8529, 8629, 8729. Meralgia paresthetica is defined as a type of entrapment neuropathy caused by entrapment of the lateral femoral cutaneous nerve at the inguinal ligament, causing paresthesia, pain, and numbness in the outer surface of the thigh in the region supplied by the nerve. See Dorland's Illustrated Medical Dictionary 1153 (31st ed. 2007). The report of a March 2016 VA Peripheral Nerves Examination reveals the Veteran’s report of continuous feelings of numbness and burning to the left lateral thigh. He denied any muscle pain. He reported interruption of his sleep due to the burning pain. There was no pain characterized as constant or intermittent. There was no numbness. Paresthesias and/or dysesthesias were characterized as moderate. Muscle strength with knee extension and ankle plantar/dorsi-flexion was full. Deep tendon reflexes were normal at the knee and ankle. Sensation was normal at the thigh/knee, lower leg/ankle, and foot/toes. Sensation was decreased at the upper anterior thigh. No trophic changes were found. The Veteran’s gait was characterized as normal. A June 2013 EMG was reviewed. The examiner noted that the Veteran most likely had a left lateral femoral cutaneous neuropathy. The rationale was that, although lateral femoral cutaneous nerve condition studies were technically difficult to read, secondary to body habitus, the Veteran clinically fits this picture. The examiner found no electrodiagnostic evidence of an L5 radiculopathy, or peroneal, tibial or sural mononeuropathy. The impact of the condition on the ability to work was characterized as an interruption in sleep due to paresthesias (Record 03/14/2016). On the VA Form 9, the Veteran stated that he was specifically seeking a rating of 10 percent for meralgia paresthetica of the left lower extremity. His argument was centered on the contention that it is not just the surface nerve involved, but that he also has impairment of “the lower nerve” (Record 05/23/2016). After a review of all of the evidence, the Board finds that the Veteran’s meralgia paresthetica of the left lower extremity is manifested by moderate paresthesia or disesthesia causing pain and discomfort in the left lower extremity, which affects the Veteran’s ability to sleep. The Board finds that these symptoms are fully contemplated by the rating schedule, and are fully contemplated by the rating of 0 percent currently assigned. The Board acknowledges the Veteran’s assertion that more than a single nerve is involved. However, he has not pointed to any medical evidence to support this. It is therefore considered lay evidence. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159(a)(2). The Board finds that identifying the specific nerve or nerves involved in a neurological disability is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized medical knowledge, and is not a matter which is capable of lay observation. Accordingly, the Veteran’s lay statements are not competent evidence of involvement of any specific nerve or additional nerves. Here, the March 2016 VA examiner identified the nerve group involved, and based that identification on EMG testing. The examiner’s findings ruled out involvement of the sciatic, peroneal, tibial or sural nerves. These are the only nerve groups pertinent to the lower extremities under the rating schedule which provide compensable ratings for moderate impairment. See 38 C.F.R. § 4.124a, Diagnostic Codes 8720, 8721, 8722, 8723, 8724, 8725, 8727. The specific nerve group identified by the March 2016 examiner provides a 0 percent rating for both mild and moderate impairment. See 38 C.F.R. § 4.124a, Diagnostic Code 8729. The Board acknowledges that the Veteran experiences pain in his left lower extremity, and that this interferes with his ability to sleep. However, pain is the type of symptomatology that would reasonably be contemplated by any rating for the peripheral nerves. Indeed, the rating schedule specifies that peripheral neuralgia is characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve. Such symptoms are to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Thus, even though Diagnostic Code 8529 (paralysis of the external cutaneous nerve of the thigh) contains a 10 percent rating for severe or complete paralysis, the rating schedule does not contemplate the assignment of such a rating in the absence of complete paralysis or severe incomplete paralysis. In sum, the Board finds that the service-connected meralgia paresthetica of the left lower extremity has been manifested by pain, paresthesia, and disesthesia of the external cutaneous nerve of the thigh, which is productive of moderate impairment. The Board further finds that the Veteran’s symptomatology is fully contemplated by the rating schedule. In light of these findings, the Board concludes that a rating higher than 0 percent is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has made no specific allegations as to the inadequacy of the VA examination. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Cramp