Citation Nr: 18150304 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 15-24 356 DATE: November 14, 2018 ORDER An initial rating in excess of 30 percent prior to February 13, 2014 and a disability rating in excess of 70 percent thereafter for PTSD is denied. An initial rating in excess of 20 percent prior to July 21, 2015, and to a disability rating in excess of 30 percent thereafter for peripheral neuropathy (PN) of the right upper extremity (RUE) is denied. An initial rating in excess of 20 percent for PN of the left upper extremity (LUE) is denied. An initial rating in excess of 10 percent for PN of the right lower extremity (RLE) is denied. An initial rating in excess of 10 percent for PN of the left lower extremity (LLE) is denied. REMANDED Entitlement to a disability rating in excess of 10 percent prior to August 11, 2011, and in excess of 20 percent thereafter for diabetes mellitus type II (DM II) is remanded. Entitlement to service connection for Parkinson’s disease is remanded. Entitlement to service connection for atypical chorea/ataxia, to include as secondary to service-connected PTSD, is remanded. Entitlement to a total disability rating for individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. On December 10, 2010, the Veteran filed a claim for service connection for PTSD; there is no prior, unadjudicated claim seeking service connection for this disability. 2. For the initial rating period prior to February 13, 2014, the Veteran’s PTSD was most appropriately characterized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal). 3. As of February 13, 2014, the Veteran’s PTSD is most appropriately characterized by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 4. On February 16, 2011, the Veteran filed a claim for DM II, from which the Veteran’s claims for PN of the bilateral upper and lower extremities stem; there is no prior, unadjudicated claim seeking service connection for these disabilities. 5. For the initial rating period prior to July 21, 2015, the Veteran’s PN of the RUE manifested in numbness in the hands. 6. As of July 21, 2015, the Veteran’s PN of the RUE has been manifested by mild numbness, the absence of light touch sensation, and mild incomplete paralysis of the median nerve. 7. For the entirety of the initial appeal period, the Veteran’s PN of the LUE has been manifested by mild numbness, the absence of light touch sensation, and mild incomplete paralysis of the median nerve. 8. For the entirety of the initial appeal period, the Veteran’s PN of the RLE has been manifested by mild intermittent pain, mild numbness, and mild incomplete paralysis of the sciatic nerve. 9. For the entirety of the initial appeal period, the Veteran’s PN of the LLE has been manifested by mild intermittent pain, mild numbness, and mild incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 30 percent prior to February 13, 2014 and in excess of 70 percent thereafter for PTSD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.159, 3.327, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2018). 2. The criteria for entitlement to an initial rating in excess of 20 percent prior to July 21, 2015 and in excess of 30 percent thereafter for PN of the RUE have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A; 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.159, 3.327, 4.1, 4.3, 4.7, 4.14, 4.69, 4.124a, DC 8515 (2018). 3. The criteria for entitlement to an initial rating in excess of 20 percent for PN of the LUE are not met. 38 U.S.C. §§ 1155, 5103(a), 5103A; 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.159, 3.327, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.69, 4.124a, DC 8515. 4. The criteria for entitlement to an initial rating in excess of 10 percent for PN of the RLE are not met. 38 U.S.C. §§ 1155, 5103(a), 5103A; 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.159, 3.327, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.124a, DC 8621 (2018). 5. The criteria for entitlement to an initial rating in excess of 10 percent for PN of the LLE are not met. 38 U.S.C. §§ 1155, 5103(a), 5103A; 38 C.F.R. §§ 3.102, 3.159, 3.327, 4.1, 4.3, 4.7, 4.14, 4.124a, DC 8621. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from May 1967 to April 1970, with service in the Republic of Vietnam from September 1969 to April 1970. The Board acknowledges that the Veteran submitted an additional Notice of Disagreement (NOD) in May 2014 in which he disputed both the initial ratings and effective dates assigned for service-connected PTSD and peripheral neuropathy of the bilateral upper and lower extremities. To the extent that the Veteran disputed the effective dates of ratings assigned, these will be discussed as part of the initial rating claims, and not as separate claims for an earlier effective date, as the claims are entirely overlapping and the adjudication of the rating claims will encompass all effective date concerns. With regard to all the issues on appeal, with the exception of service connection for Parkinson’s disease, the Veteran did not file a Substantive Appeal in response to the June 2015 Statement of the Case (SOC). Nevertheless, there is no indication that the Regional Office (RO) closed the case for failure to file a timely substantive appeal because the RO readjudicate these issues in an additional SOC in May 2016 and certified these issue to the Board in September 2017. See Percy v. Shinseki, 23 Vet. App. 37, 42-45 (2009). A private attorney revoked his representation and withdrew as the Veteran’s representative for the issues on appeal in October 2017 after the certification of this appeal. The record reflects that written notice was provided to the Board and the Veteran. In August 2018, a notice letter was sent to the Veteran affording him the opportunity to select another representative. He was advised that if he did not respond within 30 days, the Board would assume that he wishes to represent himself and proceed accordingly. As of this date, there has been no response from the Veteran; therefore, the Board will proceed under the assumption that he wishes to represent himself. See 38 C.F.R. § 20.608(a) (2018). As service connection, an initial rating, and an effective date have been assigned for the issues of entitlement to higher initial ratings for PTSD and peripheral neuropathy of the bilateral upper and lower extremities, the notice requirements of 38 U.S.C. § 5103(a) have been met. With regard to the issues on appeal, discussed on the merits below, for higher initial ratings for PTSD and peripheral neuropathy of the bilateral upper and lower extremities, VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim to include where warranted by law, and affording the claimant VA examinations, VA medical opinions, and a hearing before the Board. 38 U.S.C. §§ 5103, 5103A. There is no objective or subjective evidence indicating that there has been a material change in the severity of these service-connected disabilities on appeal since he was last examined in February 2014 for PTSD and July 2015 for peripheral neuropathy. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95; 60 Fed. Reg. 43186 (1995). There is no evidence that additional records have yet to be requested. In sum, there is no evidence of any VA error in notifying or assisting him that reasonable affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Higher Evaluation 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 rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 6. Entitlement to an initial rating in excess of 30 percent prior to February 13, 2014 and a disability rating in excess of 70 percent thereafter for PTSD The Veteran contends that higher initial ratings for PTSD are warranted, to include an earlier effective date for the grant of service connection. In this case, the Veteran submitted his claim requesting service connection for PTSD via a VA Form 21-4138, Statement in Support of Claim, on December 10, 2010. In a May 2013 VA rating decision, the RO granted service connection for PTSD, and assigned a 30 percent rating for the entire appeal period effective from December 10, 2010. 38 C.F.R. § 4.130, DC 9411. During the course of the appeal, in a June 2015 rating decision, the RO combined PTSD with a depressive disorder and assigned a 70 percent rating effective from February 13, 2014. Id. Since the 30 and 70 percent disability ratings are not the maximum ratings available prior to February 13, 2014 or thereafter, the issue has been characterized accordingly. See AB v. Brown, 6 Vet. App. 35 (1993). At the outset, the Veteran contends that an earlier effective date is warranted for the award of service connection for PTSD. However, the law is clear that the effective date is based on the date of receipt of the claim or the date entitlement arose, whichever is later. In this case, the Veteran may have been diagnosed with PTSD prior to December 10, 2010, but he did not file his claim for PTSD until December 10, 2010, the later of the two dates. The Board considered whether any evidence of record dated prior to December 10, 2010, may be construed as a claim, formal or inform, for service connection for PTSD. However, in this case, there is no document of record earlier than the established date of claim that may reasonably be construed as a formal or informal claim, nor did he submit his claim within one year from separation from service. See 38 C.F.R. §§ 3.151(a), 3.155(a). Of note, the mere existence or even receipt of medical records does not establish that the Veteran has filed a claim for service connection. Moreover, as indicated above, no clinical records prior to December 10, 2010, indicate any intent on the part of the Veteran to apply for service connection for PTSD. Where a claimant has not previously been granted service connection, VA’s receipt of medical records cannot be construed as an informal claim. Lalonde v. West, 12 Vet. App. 377, 382 (1999). VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed and the mere presence of medical evidence that a veteran suffers from a disability does not establish intent on the part of the veteran to seek service connection for that disability. Brannon v. West, 12 Vet. App. 32, 34, 35 (1998). Further, the Federal Circuit Court has held that the mere mention of a condition in a medical record, alone, cannot be construed as a claim for service connection. See MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed. Cir. 2006); see also 38 C.F.R. §§ 3.155, 3.157. The relevant regulation requires that a claim, or at least some application that reasonably viewed can be considered a claim, be filed. Here, there was no such claim prior to the currently assigned effective date. As such, the Board considers whether an initial rating in excess of 30 percent from December 10, 2010 to February 12, 2014 and in excess of 70 percent since February 13, 2014 for PTSD is warranted in this case. DC 9411 is governed by a General Rating Formula for Mental Disorders, which provides for the following rating criteria: A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and/or mild memory loss (such as forgetting names, directions, or recent events); A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships; A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships; A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran’s psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Ratings are assigned according to the manifestation of particular symptoms, but the use of a term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the DSM-IV and replace them with references to the updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In this case, the RO certified the Veteran’s appeal to the Board in September 2017; therefore, the DSM-5 applies to this claim. A. Prior to February 13, 2014 Review of the evidentiary record from December 10, 2010 to February 12, 2014 documents the following psychiatric symptomatology of the Veteran’s PTSD. A January 2011 private treatment record reflects that the Veteran had dreams and flashbacks of the events that took place in Vietnam, serious sleep disorder, panic attacks, severe hypervigilance, social isolation, episodes of anger, avoidance of thoughts of war, diminished interest in life along with feelings of detachment, long-term depression, and difficulty concentrating. In March 2011, the Veteran reported that he believed he was still in war at times, yelled and screamed at his wife and kids, and could not eat or sleep. He went for walks outside, would not return home, and would be found miles away from home, cold and with no idea where he was. An April 2011 VA examination report reflects the Veteran’s complaints of “real bad” night sweats,” a short temper, and difficulty remembering things at times. He was fully oriented, well-groomed, and cooperative. He had euthymic mood with full and reactive affect; normal attention, memory, and judgment; chronic sleep impairment; and no suicidal or homicidal intent, hallucinations, or delusions. His symptoms were controlled by medication. A May 2011 private neuropsychological evaluation report reflects the Veteran’s complaints of poor short-term memory, which had worsened in the last five years. He forgot things that he had done and frequently lost and misplaced personal belongings, he had difficulty remembering names, and his wife had to remind him of appointments. He had difficulty with attention and concentration, and with planning and organizing. He lost his train of thought when speaking and had difficulty formulating his thoughts into sentences. He reported an “average” mood with nightmares and flashbacks, was easily startled, avoided situations that reminded him of Vietnam, had mood swings, was irritability, and had good energy level. He traveled in his RV with his wife across the country, and enjoyed playing basketball with his grandchildren and taking walks. He was neatly addressed and adequately groomed; oriented to person and place; partially oriented to date. He was diagnosed with cognitive disorder, not otherwise specified (NOS); chronic PTSD; combined type ADHD; and disorder of written expression. A VA treatment record from June 2011 reflects the Veteran’s report of recurrent and vivid nightmares, insomnia, frequent intrusive thoughts, reliving combat and war zone experiences, occasional flashbacks with auditory and visual hallucinations, significant short-term memory and concentration problems, periods of depressed mood and anhedonia, social withdrawal, hypervigilance, and avoidance behavior related to his combat and war zone experiences. He had few social networks, and tended to socially withdraw and isolate from others. He was diagnosed with chronic PTSD, cognitive disorder NOS, ADHD, and disorder of written expression by history. An August 2011 VA treatment record noted that his symptoms were well-controlled. VA treatment records from December 2011 to March 2012 reflect the Veteran’s report of a mild worsening of PTSD symptoms with more irritable mood, more frequent nightmares, average anxiety, sleeping four to five hours per night, fair energy, and no suicidal or homicidal ideation. He had average rate, volume, and tone of speech; constricted affect that was mood congruent; linear and goal-directed thought process; and fair insight and judgment. An August 2012 VA Agent Orange examination report reflects that the Veteran was neatly dressed, was responsive and cooperative, and responded appropriately. VA treatment records from December 2012 to January 2014 reflect that the Veteran reported that his PTSD symptoms were well-controlled with medications. He denied recent nightmares, avoidance symptoms, increased anxiety, or irritability. He had good grooming and hygiene; well-controlled anxiety and ongoing nightmares; average to normal rate, volume, and tone of speech; “ok” to “great” mood; affect that ranged from constricted to euthymic that was mood congruent; linear, coherent, and goal-directed thought process; no suicidal or homicidal ideations; no auditory or visual hallucinations; no apparent delusions; fair to good insight and judgment; and grossly intact immediate, recent, and remote memory. He was oriented to time, place, person, and situation. Prior to February 13, 2014, the Board finds that an initial rating in excess of 30 percent is not warranted. The evidence as a whole demonstrates that his PTSD was more appropriately characterized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), especially as the symptoms during this period, as described in detail in the factual background above, did not manifest in the frequency, severity, or duration for the next higher rating of 50 percent, which requires occupational and social impairment with reduced reliability and productivity. Specifically, the Veteran had depressed mood, chronic sleep impairment, mild memory loss, and panic attacks. He was stated to have full and reactive affect at his April 2011 VA examination, and was found to have euthymic affect with full range from October 2013 to January 2014. Additionally, although a May 2011 private neuropsychological evaluation report reflects that the Veteran lost his train of thought when speaking and had difficulty formulating his thoughts into sentences, the evidence does not reflect any circumstantial, circumlocutory, or stereotyped speech but rather average/normal rate, volume, and tone of speech. A January 2011 private treatment record noted panic attacks, but did not indicate that they occurred more than once a week. Moreover, although the Veteran reported poor memory in April to June 2011, he was found to have grossly intact immediately, recent, and remote memory from April 2011 to January 2014. The evidence also did not demonstrate that he had difficulty in understanding complex commands, impaired judgment or abstract thinking, or difficulty in establishing and maintaining effective work and social relationships although he tended to socially isolate himself. Regardless of the symptoms above, the Veteran was repeatedly stated that his symptoms were well-controlled by continuous medication, for which a 10 percent rating is appropriate. As such, a 30 percent rating prior to February 13, 2014, is more than adequate based on the nature, severity, and frequency of the Veteran’s PTSD symptoms. B. Since February 13, 2014 Review of the evidentiary record since February 13, 2014 documents the following psychiatric symptomatology of the Veteran’s PTSD. A February 13, 2014, examination report reflects diagnoses of chronic PTSD and depressive disorder due to another medical condition with mixed features, which resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Although the Veteran had more than one mental disorder diagnosed, the examiner stated that it was not possible to differentiate what symptoms were attributable to each diagnosis, or to differentiate what portion of occupational and social impairment was caused by each diagnosis. His symptoms included depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened affect; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a worklike setting; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. A July 2015 VA DM II examination report reflects that the Veteran watched TV, worked on puzzles, played Candy Crush, and went to play bingo at night. VA treatment records from August 2015 to March 2016 reflect that the Veteran had well-controlled anxiety and ongoing nightmares; good grooming and hygiene; normal rate, volume, and tone of speech that was coherent; “good” to “great” mood; euthymic affect with full range and occasional appropriate smiling, joking, and/or laughing; grossly intact attention; grossly intact immediate, recent, and remote memory; linear, logical, coherent, and goal-directed thought process with no circumstantiality, tangentiality, or looseness of associations; good concentration; and good insight and judgment. He was cooperative and pleasant; alert; and oriented to time, place, person, and circumstances. He denied suicidal or homicidal ideations, plans, or intent; and auditory or visual hallucinations. As of February 13, 2014, an initial rating in excess of 70 percent is not warranted as there is no indication of total occupational and social impairment. Specifically, the February 2014 examiner found that the Veteran’s disability resulted in occupational and social impairment with deficiencies in most areas. Additionally, the July 2015 VA DM II examination report reflects that the Veteran still watched TV, worked on puzzles, played Candy Crush, and went to play bingo at night. Although the February 2014 examiner found intermittent inability to perform activities of daily living, there is no evidence of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. As such, the assigned 70 percent disability rating as of February 13, 2014, is appropriate. C. Additional Considerations The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). The Board is aware that the symptoms listed under the next-higher ratings of 50 and 100 percent are essentially examples of the type and degree of symptoms for that rating, and that the Veteran need not demonstrate those exact symptoms to warrant a higher rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Moreover, entitlement to a 50 or 100 percent evaluation for the appropriate appeal periods requires sufficient symptoms of the requirements, or others of similar severity, frequency, or duration, that cause the specific type of occupational and social impairment. See Vazquez-Claudio, 713 F.3d at 117-18. In this case, the Board has considered the next higher ratings for the appeal periods but finds that they are rated appropriately. The signs and symptoms manifested are contemplated by the currently assigned rating of 30 percent prior to February 13, 2014 and of 70 percent thereafter as they do not manifest with the severity required for the next-higher ratings. The Board has considered the Veteran’s reported history of symptomatology related to the service-connected PTSD pursuant to seeking VA compensation benefits and at VA treatment sessions. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, his statements do not rise to a level of competency to identify the specific level of psychiatric impairment according to the appropriate diagnostic codes and relevant rating criteria. In this case, such competent evidence concerning the nature and extent of the Veteran’s disability has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran’s subjective reports of worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board also considered the possibility of additional staged ratings and finds that the scheduler ratings for the service-connected PTSD on appeal have been in effect for appropriate periods on appeal. Accordingly, any additional staged ratings are inapplicable. See Hart, 21 Vet. App. at 505. 7. Entitlement to an initial rating in excess of 20 percent prior to July 21, 2015 and in excess of 30 percent thereafter for PN of the RUE 8. Entitlement to an initial rating in excess of 20 percent for PN of the LUE 9. Entitlement to an initial rating in excess of 10 percent for PN of the RLE 10. Entitlement to an initial rating in excess of 10 percent for PN of the LLE The Veteran contends that higher initial ratings for PN of the bilateral upper extremities are warranted, to include an earlier effective date for the grant of service connection. Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. In this case, on September 8, 2011, the Veteran submitted a copy of a treatment record with “diabetic peripheral neuropathy” highlighted. He subsequently submitted claims for PN of the bilateral upper and lower extremities via a VA Form 21-0820, Report of General Information, on April 27, 2012; and again in a letter submitted on May 31, 2012. In the May 2013 VA rating decision, the RO granted service connection for PN of the RUE and LUE, assigning each at 20 percent disabling, and for PN of the RLE and LLE, assigning each at 10 percent disabling, effective September 8, 2011. See 38 C.F.R. § 4.124a, DC 8514. During the course of the appeal, in the June 2015 rating decision, a Decision Review Officer (DRO) granted earlier effective dates of February 16, 2011, which was the date of the Veteran’s claim for DM II. See 38 C.F.R. § 4.124a, DCs 8514 and 8621. The DRO stated that there was no evidence showing that the Veteran did not have PN of the bilateral upper and lower extremities at that time. As such, it generously awarded effective dates as of the date of that underlying DM II claim. Subsequently, in a May 2016 rating decision, a DRO assigned a 30 percent rating for PN of the RUE effective from July 21, 2015. 38 C.F.R. § 4.124a, DC 8515. Since the 20 and 30 percent disability ratings are not the maximum ratings available prior to July 21, 2015 or thereafter, the issue has been characterized accordingly. See AB, 6 Vet. App. at 35. At the outset, the Veteran contends that earlier effective dates are warranted for the award of service connection for PN of the RUE, LUE, RLE, and RLE. However, the law is clear that the effective date is based on the date of receipt of the claim or the date entitlement arose, whichever is later. In this case, at his July 2015 VA examination, the Veteran reported numbness in the hands and pain and numbness in the legs for the past five years. Although the Veteran may have manifested symptoms of PN in the upper and lower extremities since 2010, he did not file his claims for PN until September 8, 2011, and did not file the underlying DM II claim until February 16, 2011. The later of the two dates (between the date of receipt of the claim and when entitlement arose) is the date of the claim, which was considered by the RO to be February 16, 2011. The Board considered whether any evidence of record dated prior to February 16, 2011, may be construed as a claim, formal or inform, for service connection for PN of the RUE, LUE, RLE, and RLE. However, in this case, there is no document of record earlier than the established date of claim that may reasonably be construed as a formal or informal claim, nor did he submit his claim within one year from separation from service. See 38 C.F.R. §§ 3.151(a), 3.155(a). Of note, the mere existence or even receipt of medical records does not establish that the Veteran has filed a claim for service connection. Moreover, as indicated above, no clinical records prior to February 16, 2011, indicate any intent on the part of the Veteran to apply for service connection for PN. See Lalonde, 12 Vet. App. at 382; Brannon, 12 Vet. App. at 34-35; MacPhee, 459 F.3d at 1327; 38 C.F.R. §§ 3.155, 3.157. Again, the relevant regulation requires that a claim, or at least some application that reasonably viewed can be considered a claim, be filed. Here, there was no such claims prior to the currently assigned effective date. As such, the Board considers whether an initial rating in excess of 30 percent from February 16, 2011 to July 20, 2015 and in excess of 30 percent thereafter for PN of the RUE is warranted in this case, as well as initial ratings in excess of 20 percent for PN of the LUE and in excess of 10 percent for PN of the RLE and LLE is warranted at any time since the date of claim on February 16, 2011. A. PN of the RUE and LUE Under DC 8515 for disability of the median nerve, for mild incomplete paralysis, a 10 percent rating is assigned regardless of whether it is the major or minor hand. For moderate incomplete paralysis, a 30 percent rating is assigned for the major hand, and a 20 percent rating is assigned for the minor hand. For severe incomplete paralysis, a 50 percent rating is assigned for the major hand, and a 40 percent rating is assigned for the minor hand. A 70 percent rating is assigned for complete paralysis of the median nerve on the major side with such manifestations such as the hand inclined to the ulnar side; the index and middle fingers more extended than normal; considerable atrophy of the muscles of the thenar eminence; the thumb in the plane of the hand (ape hand); pronation incomplete and defective; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; the index and middle fingers remain extended; an inability to flex the distal phalanx of thumb; defective opposition and abduction of the thumb, at right angles to the palm; weakened wrist flexion; and pain with trophic disturbances. Complete paralysis of the minor hand is rated as 60 percent disabling. 38 C.F.R. § 4.124a. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. Id. Right- or left-handedness for the purpose of a dominant-side disability rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence shows that the Veteran’s right hand is dominant. Review of the evidentiary record from February 16, 2011 to July 20, 2015 and since July 21, 2015 documents the following symptomatology of the Veteran’s PN of the RUE and LUE. VA treatment records reflect a July 2012 prescription for gabapentin for peripheral neuropathy pain. A July 21, 2015 VA examination report reflects diagnoses of peripheral neuropathy of the bilateral upper extremities. He experienced numbness in the hands for the past five years. His dominant hand was the right one. He had mild numbness in the bilateral upper extremities. Light touch sensation was absent for the hands and fingers bilaterally. The bilateral upper extremities both had mild incomplete paralysis of the median nerve. The evidence reflects that the Veteran reported numbness in the hands since approximately 2010. At the July 2015 VA examination, the examiner found that, although the Veteran had mild incomplete paralysis of the median nerve bilaterally, light touch sensation was absent. In May 2016, the RO stated that the absence of light touch sensation indicated moderate incomplete paralysis. As noted above, PN of the bilateral upper extremities were both initially evaluated under DC 8514, under which mild incomplete paralysis resulted in 20 percent ratings, regardless of major or minor hand; moderate incomplete paralysis resulted in a 30 percent rating for the major hand and 20 percent rating for the minor hand; and severe incomplete paralysis resulted in a 50 percent rating for a major hand and a 40 percent rating for a minor hand. As such, PN of the bilateral upper extremities each was initially assigned a 20 percent rating for mild incomplete paralysis under DC 8514. However, as of July 21, 2015, the RO interpreted the absence of light touch sensation as moderate incomplete paralysis. Accordingly, under DC 8515, a 30 percent rating is warranted for PN of the RUE as it is the major hand as of July 21, 2015. Additionally, although the severity may have increased from mild to moderate, the 20 percent rating continues for PN of the LUE under DC 8515 as it is the minor hand. B. PN of the RLE and LLE DC 8621 provides for neuritis (external popliteal nerve). 38 C.F.R. § 4.124a. As discussed below, the Veteran’s PN of the RLE and LLE were found to involve the sciatic nerve, thus the Board finds that DC 8520 is more appropriate in this case. Under DC 8520, an 80 percent disability rating is assigned for complete paralysis of the sciatic nerve, demonstrated by foot drop, no active movement possible of the muscles below the knee, and knee flexion that is weakened or (very rarely) lost. Lower disability ratings are provided for incomplete paralysis, defined by the Rating Schedule as “a degree of lost or impaired function substantially less than the type picture for complete paralysis given.” A 60 percent disability rating is assigned for severe, incomplete paralysis, with marked muscular atrophy. A 40 percent disability rating is assigned for moderately severe, incomplete paralysis. A 20 percent disability rating is assigned for moderate, incomplete paralysis. Id. The regulation further provides that when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The words “mild,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “mild” and “moderate” by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Review of the evidentiary record since February 16, 2011 documents the following symptomatology of the Veteran’s PN of the RLE and LLE. A March 2011 private abnormal nerve conduction study of the lower extremities was consistent with sensory motor axonal neuropathy, which was consistent with the Veteran’s history of diabetic peripheral neuropathy with a superimposed lumbar radiculopathy at L5. VA treatment records from June and July 2012 reflect a prescription for capsaicin cream for nerve pain in lower legs, and for gabapentin for PN pain. An August 2012 VA Agent Orange examination report reflects the Veteran’s reports of tingling and numbness in the lower legs with restless legs at night. On examination, the Veteran had decreased gross sensation bilaterally in the lower legs and feet. The initial impression was restless leg syndrome and peripheral neuralgia. A July 2015 VA examination report reflects diagnoses of peripheral neuropathy of the bilateral lower extremities. He experienced pain and numbness in the upper thighs, calves, and feet for the past five years. He had mild intermittent pain and mild numbness in the bilateral lower extremities. The bilateral lower extremities both had mild incomplete paralysis of the sciatic nerve. The evidence reflects that the Veteran reported mild intermittent pain and mild numbness in the bilateral lower extremities since approximately 2010. At the July 2015 VA examination, the examiner found that the Veteran had mild incomplete paralysis of the sciatic nerve. As noted above, PN of the bilateral upper extremities were both evaluated under DC 8621. Regardless, the evidence reflects mild incomplete paralysis bilaterally, which warrants a 10 percent rating under both DC 8521 and 8520. C. Additional Considerations The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70. Again, the Board has considered the Veteran’s reported history of symptomatology related to the service-connected PN of the bilateral upper and lower extremities pursuant to seeking VA compensation benefits and at VA treatment sessions. See Layno, 6 Vet. App. at 470. However, his statements do not rise to a level of competency to identify the specific level of psychiatric impairment according to the appropriate diagnostic codes and relevant rating criteria. In this case, such competent evidence concerning the nature and extent of these disabilities has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran’s subjective reports of worsened symptomatology. See Cartright, 2 Vet. App. at 25. Lastly, the Board considered the possibility of additional staged ratings and finds that the scheduler ratings for the service-connected disabilities on appeal have been in effect for appropriate periods on appeal. Accordingly, any additional staged ratings are inapplicable. See Hart, 21 Vet. App. at 505. REASONS FOR REMAND 1. Entitlement to a disability rating in excess of 10 percent prior to August 11, 2011, and in excess of 20 percent thereafter for DM II As noted above, the May 2016 VA rating decision noted that the Veteran’s date of claim for a higher rating for service-connected DM II was on February 16, 2011. During the course of this appeal, a 20 percent disability rating was assigned effective from August 11, 2011. Since the 10 percent and 20 percent disability ratings are not the maximum ratings available from the date of claim on February 16, 2011 to August 10, 2011 or since August 11, 2011, this issue is still on appeal before the Board and characterized accordingly. See AB v. Brown, 6 Vet. App. 35 (1993). As of this date, this issue for the appeal period prior to August 11, 2011 has not been readjudicated by the AOJ. 2. Entitlement to service connection for Parkinson’s disease The claim of entitlement for service connection for Parkinson’s disease is being remanded for an additional VA examination. The Board notes that the Veteran was previously provided a VA examination for Parkinson’s disease in July 2011 and the examiner found that the Veteran did not have a diagnosis or symptoms of Parkinson’s disease. Review of subsequent VA treatment records indicates a possible diagnosis of Parkinson’s disease. As such, an additional VA examination should be provided in order to confirm whether the Veteran has a diagnosis of Parkinson’s disease and to address the nature and etiology of such. 3. Entitlement to service connection for atypical chorea/ataxia, to include as secondary to service-connected PTSD The claim of entitlement for service connection for atypical chorea/ataxia is being remanded for a VA examination. An October 2010 VA treatment record reflects that the Veteran’s ataxia may be a symptom or related to his PTSD. Additionally, in June 2015, the Veteran reported that his chorea may be related to his years of Sinemet use. Unfortunately, although a July 2011 VA examination report noted his ataxia and chorea, the examination evaluated his claimed Parkinson’s disease, not his atypical chorea/ataxia. As such, the Veteran has not yet been afforded a VA examination in order to evaluate the nature and etiology of his atypical chorea/ataxia. 4. Entitlement to a TDIU The Veteran’s claim for a TDIU is inextricably intertwined with the claims remanded herein, and the adjudication of this claim may depend on the outcome of the other remanded claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following actions: 1. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s claimed Parkinson’s disease. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: The Veteran’s service in Vietnam from September 1969 to March 1970 and exposure to herbicide agents. A January 2011 letter from a private licensed professional counselor and certified vocational rehabilitation counselor reflecting that the Veteran was diagnosed with Parkinson’s disease, which appeared to be related to in-service exposure to Agent Orange. The July 2011 VA examination report reflecting that the Veteran did not have a diagnosis or symptoms of Parkinson’s disease or its treatment. A January 2013 VA treatment record reflecting an impression of severe idiopathic Parkinson’s disease for more than 20 years. An April 2013 VA neuropsychology consultation report reflecting that the Veteran met the diagnosis of dementia NOS with Parkinson’s and Alzheimer’s etiologies as the most probable underlying contributors. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: (a.) Confirm whether the Veteran has a current diagnosis of Parkinson’s disease. (b.) If so, provide an opinion as to whether it was at least as likely as not (i.e., probability of 50 percent) that the Veteran’s Parkinson’s disease was incurred during active duty or is otherwise related to it, to include exposure to herbicide agents. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s claimed atypical chorea/ataxia. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: The Veteran’s service in Vietnam from September 1969 to March 1970 and exposure to herbicide agents. A July 2007 VA treatment record noting that the Veteran’s movement disorder started two years ago and had progressively worsened. An August 2007 VA treatment record reflecting a diagnosis of post-toxic chorea and the Veteran’s report that he was exposed to a massive amount of toxins during service. An October 2007 VA treatment record reflecting that the Veteran’s gait ataxia had not progressed a lot since service, suggesting a one-time toxic cerebellar insult. His daughter’s October 2008 statement in which she contended that the Veteran’s symptoms were because “Agent Orange killed some brain cells in his head.” An August 2009 VA treatment record reflecting an impression of atypical ataxia/movements with atypical little progression, which did not appear to be physiological but could not confidently be excluded. An October 2010 VA treatment record noting that the Veteran’s atypical ataxia/movements were not clearly physiological and may be part of his overall PTSD. An April 2013 VA treatment record reflecting that the Veteran appeared to have Sinemet-induced chorea. A June 2015 VA treatment record reflecting the Veteran’s report of being told that he had a diagnosis of “chorea of unknown origin” and contention that his many years of movement abnormalities may have been caused by years of Sinemet use. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: 3. Provide an opinion as to whether it was at least as likely as not (i.e., probability of 50 percent) that the Veteran’s atypical chorea/ataxia was incurred during active duty or is otherwise related to it, to include exposure to herbicide agents. (a.) Provide an opinion as to whether it was at least as likely as not (i.e., probability of 50 percent) that the Veteran’s atypical chorea/ataxia was proximately due to or the result of any of his service-connected disabilities, to include medication taken for such. (b.) Provide an opinion as to whether it was at least as likely as not (i.e., probability of 50 percent) that the Veteran’s atypical chorea/ataxia was aggravated beyond its natural progression by any of his service-connected disabilities, to include medication taken for such. The Veteran is currently service-connected for DM II, PN of the bilateral upper and lower extremities, and PTSD with depressive disorder. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. 5. Then, readjudicate the remaining claims on appeal, to include TDIU and a rating in excess of 10 percent for DM II prior to August 11, 2011. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jane R. Lee