Citation Nr: 18152891 Decision Date: 11/26/18 Archive Date: 11/26/18 DOCKET NO. 09-22 845 DATE: November 26, 2018 ORDER Entitlement to a 40 percent rating from July 12, 2012, for bilateral diabetic retinopathy is granted. Entitlement to a rating in excess of 10 percent prior to June 21, 2011, for right upper extremity diabetic polyneuropathy is denied. Entitlement to a rating in excess of 30 percent from June 21, 2011, for right upper extremity diabetic polyneuropathy is denied. Entitlement to a rating in excess of 10 percent prior to June 21, 2011, for left upper extremity diabetic polyneuropathy is denied. Entitlement to a rating in excess of 20 percent from June 21, 2011, for left upper extremity diabetic polyneuropathy is denied. FINDINGS OF FACT 1. For the period of appeal prior to March 28, 2017, the bilateral diabetic retinopathy is productive of visual acuity no worse than 20/70 bilaterally and visual field no worse than 46 to 60 degrees bilaterally. For the period of appeal from March 28, 2017, the bilateral diabetic retinopathy is productive of visual acuity no worse than 20/40 in the right eye and 20/50 in the left eye, and visual field no worse than 31 to 45 degrees bilaterally. 2. The Veteran’s dominant hand is his right hand. 3. For the period of appeal prior to June 21, 2011, the right upper extremity diabetic polyneuropathy more nearly approximates mild incomplete paralysis. 4. For the period of appeal from June 21, 2011, the right upper extremity diabetic polyneuropathy more nearly approximates moderate incomplete paralysis 5. For the period of appeal prior to June 21, 2011, the left upper extremity diabetic polyneuropathy more nearly approximates mild incomplete paralysis. 6. For the period of appeal from June 21, 2011, the left upper extremity diabetic polyneuropathy more nearly approximates moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a 40 percent rating from July 12, 2012, for bilateral diabetic retinopathy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.79, Diagnostic Code 6080. 2. For the period of appeal prior to June 21, 2011, the criteria for a rating in excess of 10 percent for right upper extremity diabetic polyneuropathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.69, 4.124a, Diagnostic Code 8799-8715. 3. For the period of appeal from June 21, 2011, the criteria for a rating in excess of 30 percent for right upper extremity diabetic polyneuropathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.69, 4.124a, Diagnostic Code 8799-8715. 4. For the period of appeal prior to June 21, 2011, the criteria for a rating in excess of 10 percent for left upper extremity diabetic polyneuropathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.69, 4.124a, Diagnostic Code 8799-8715. 5. For the period of appeal from June 21, 2011, the criteria for a rating in excess of 20 percent for left upper extremity diabetic polyneuropathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.69, 4.124a, Diagnostic Code 8799-8715. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty form May 1968 to December 1969. The Board remanded the claims in November 2015, December 2016, and September 2017. Remand directives included obtaining relevant VA and non-VA treatment records and schedule the Veteran for VA examinations of the bilateral upper extremities and eyes. Treatment records have since been associated with the file (and the Veteran was provided with an opportunity in October 2017 to provide authorization for VA to obtain additional treatment records) and the Veteran underwent VA examinations in March 2017. The Board therefore finds there has been substantial compliance with remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Increased Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 1. Increased rating from July 12, 2012, for diabetic retinopathy. The Veteran has been assigned a 20 percent rating for his bilateral diabetic retinopathy as of July 12, 2012, under Diagnostic Code 6080, for visual field defects. Rating criteria Under Diagnostic Code 6080, visual field defects are rated based on computation of average concentric contraction of visual fields. 38 C.F.R. § 4.76a, Table III. The normal for the 8 principal meridians are as follows: 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up; and 55 degrees up temporally. The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual fields in each of the eight 45-degree principal meridians. The degrees lost are then added together to determine the total number of degrees lost, which are subtracted from 500. The total remaining degrees of the visual field are then divided by eight to represent the average contraction for rating purposes. 38 C.F.R. § 4.76a. Visual field defects are evaluated as follows: A 10 percent evaluation for concentric contraction of visual field with remaining field of 46 to 60 degrees bilaterally or unilaterally; with remaining field of 31 to 45 degrees unilaterally; with remaining field of 16 to 30 degrees unilaterally; loss of superior half of visual field bilaterally or unilaterally; loss of interior half of visual field unilaterally; loss of nasal half of visual field bilaterally or unilaterally; and loss of temporal half of visual field unilaterally. A 20 percent evaluation if assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees unilaterally. A 30 percent evaluation is assigned for concentric contraction of visual field with remaining field of 31 to 45 degrees bilaterally; remaining field of 5 degrees unilaterally; loss of inferior half of visual filed bilaterally; loss of temporal half of visual field bilaterally; and homonymous hemianopsia visual filed defects. A 50 percent rating is assigned for concentric contraction of visual field with remaining field of 16 to 30 degrees bilaterally. A 70 percent rating is assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees bilaterally. A 100 percent rating is assigned for concentric contraction of visual field with remaining field of 5 degrees bilaterally. Visual impairment is also rated based on impairment of visual acuity (excluding developmental errors of refraction). 38 C.F.R. § 4.79, Diagnostic Codes 6061-6066. 38 C.F.R. § 4.76(b) dictates that evaluation of visual acuity should be done on the basis of corrected distance vision with central fixation, unless the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye. A 10 percent rating is warranted only when there is (1) 20/50 vision in one eye with 20/40 or 20/50 vision in the other eye; (2) 20/70 vision in one eye with 20/40 vision in the other eye; or (3) 20/100 vision in one eye with 20/40 vision in the other eye. A 20 percent rating is warranted when there is (1) 20/70 vision in one eye with 20/50 vision in the other eye; (2) 20/100 vision in one eye with 20/50 vision in the other eye; (3) 20/200 vision in one eye with 20/40 vision in the other eye; or (4) 15/200 vision in one eye with 20/40 vision in the other eye. A 30 percent rating is warranted (1) when vision in both eyes is correctable to 20/70; (2) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/50; (4) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/50; (5) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/40; (6) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/40; and (7) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/40. A 40 percent rating is warranted (1) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/70; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/50; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/50; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/50 or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/40. A 50 percent disability rating is warranted (1) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/100; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/70; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/70; or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/50. A 60 percent disability rating is warranted (1) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/100; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/100; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/200; (4) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/100; (5) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/100; or (6) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/70 or 20/100. A 70 percent disability rating is warranted (1) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/200; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/200; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/200; (4) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/200; (5) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/200; or (6) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/200. An 80 percent disability rating is warranted (1) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 15/200; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 15/200; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 15/200; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 15/200; or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 15/200. A 90 percent disability rating is warranted only (1) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 10/200; (2) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 10/200; (3) when vision in one eye is no more than light perception and vision in the other eye is correctable to 10/200; or (4) when there is anatomical loss of one eye and vision in the other eye is correctable to 10/200. A 100 percent disability rating is warranted only (1) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 5/200; (2) when vision in one eye is no more than light perception and vision in the other eye is correctable to 5/200; (3) when there is anatomical loss of one eye and vision in the other eye is correctable to 5/200; (4) when there is no more than light perception in both eyes; or (5) when there is anatomical loss of both eyes. To determine the rating for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service-connected, separately rate the visual acuity and visual field defect, expressed as a level of visual acuity, and combine them under the provisions of § 4.25. Analysis The Board finds that, resolving all reasonable doubt in favor of the Veteran, a 40 percent rating for the bilateral diabetic retinopathy is warranted from July 12, 2012. In a July 2012 VA examination, the Veteran was noted to have bilateral diabetic retinopathy and cataracts. His corrected near and distance vision was 20/50 bilaterally. His pupils were equal in size, round, and reactive to light, and there was no afferent pupillary defect present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, blindness of either eye, a corneal irregularity that resulted in severe irregular astigmatism, diplopia (double vision), or a scotoma. A Goldman Visual Field test showed bilateral visual field contractions. The right eye showed: temporally 48 degrees, down temporally 70 degrees, down 51 degrees, down nasally 48 degrees, nasally 50 degrees, up nasally 42 degrees, up 36 degrees, and up temporally 41 degrees. Total field of vision was 386 degrees, with an average contraction of 48 degrees. The left eye showed: temporally 75 degrees, down temporally 80 degrees, down 50 degrees, down nasally 48 degrees, nasally 52 degrees, up nasally 51 degrees, up 46 degrees, and up temporally 51 degrees. Total field of vision was 453 degrees, with an average contraction of 57 degrees. In an August 2012 eye appointment at Kaiser, the Veteran’s glasses prescription was increased. His corrected vision was 20/40 bilaterally. VA treatment records indicate that in December 2012, the Veteran’s corrected vision was 20/30-1 in one eye and 20/60-2 in the other. He was noted to have proliferative diabetic retinopathy (PDR) bilaterally, status post-panretinal photocoagulation procedure (PRP) and injections; bilateral cataracts that were not visually significant; and epiretinal membrane of the right eye that was not visually significant. In a follow-up appointment a few days later, the Veteran’s corrected visual acuity was noted to be 20/40 bilaterally. In October 2013, the Veteran reported worsening vision for the past month. His corrected vision was noted to be 20/60 bilaterally. In November 2013, he had a left eye focal macular laser photocoagulation procedure to treat a macular edema. In February 2014, the Veteran reported having no changes in his visual acuity, which was measured as 20/60 in one eye and 20/50-2 in the other. In April 2014, The Veteran again reported having stable vision bilaterally. His visual acuity was measured as 20/50 bilaterally. In July 2014, the Veteran requested new glasses. His prescription was increased such that his corrected right eye visual acuity was 20/50 and his left eye was 20/40-2. In March 2015, the Veteran reported that he had woken up the day before with black spots and webs in the left eye, which had progressed to no vision in the eye that day. He was found to have a left eye vitreous hemorrhage. In April 2015, the Veteran had a left eye intravitreal ranibizumab/Lucentis injection. In a follow-up appointment in June 2015, the Veteran reported minimal improvement in the left eye after the injection. His corrected vision was noted to be 20/70. In early July 2015, the Veteran had another left eye intravitreal ranibizumab/Lucentis injection. Treatment records indicate that a vitrectomy had also been planned for early in July 2015, but was postponed because the hemorrhage was clearing. The Veteran testified in a July 2015 Board hearing that his retinopathy symptoms included fluctuating vision, and as such, his rating should not have been decreased from 30 percent to 20 percent in 2011. In addition to fluctuating vision, his other symptoms included lack of balance, lack of depth perception, and “looking through almost fog sometimes.” The day after the Board hearing, in late July 2015, the Veteran had a left eye cataract extraction with intraocular lens implantation and limbal relaxion incisions. In August 2015, the Veteran’s prescription was increased such that his right eye was 20/60 and left eye was 20/40. In October 2015, the Veteran had a right eye cataract extraction with intraocular lens implantation and limbal relaxion incisions. In a November 2015 follow-up appointment, his corrected right eye visual acuity was 20/40-2. In March 2016, the Veteran’s right eye corrected vision was 20/40-1 and left eye was 20/50-1. He was noted to be doing “great” since his cataract surgeries. In August and December 2016, the Veteran’s corrected bilateral vision was 20/40. In December 2016, he was noted to have a new left eye vitreal hemorrhage. He was given precautions to sleep with his head elevated and not engage in any strenuous activity. In January 2017, the Veteran had a left eye aflibercept injection due to “retinal circulatory problems due to wet age-related macular degeneration.” In February 2017, the Veteran had a pars plana vitrectomy (PPV) of the left eye. A day after the PPV surgery, the Veteran reported that he was doing well and had no pain. He was instructed to refrain from heavy lifting, behind, or straining exercise, to wear glasses during the day, and shield his eyes at night. In a follow-up appointment approximately one week later, the Veteran reported that his vision was much improved. His right eye was 20/50 and the left eye was 20/60-1. The Veteran had a VA contract examination on March 28, 2017. The examiner indicated that he did not review the Veteran’s claims file. The Veteran’s corrected near and distance vision was 20/40 or better bilaterally. His pupils were equal in size, round, and reactive to light, and there was no afferent pupillary defect present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, blindness of either eye, a corneal irregularity that resulted in severe irregular astigmatism, diplopia (double vision), or a scotoma. The examiner indicated that the Veteran did not have a contraction or loss of visual field in either eye. However, a Goldman Visual Field test showed bilateral visual field contractions. The right eye showed: temporally 46 degrees, down temporally 50 degrees, down 46 degrees, down nasally 50 degrees, nasally 50 degrees, up nasally 28 degrees, up 30 degrees, and up temporally 39 degrees. Total field of vision was 339 degrees, with an average contraction of 42 degrees. The left eye showed: temporally 45 degrees, down temporally 47 degrees, down 35 degrees, down nasally 50 degrees, nasally 60 degrees, up nasally 40 degrees, up 33 degrees, and up temporally 40 degrees. Total field of vision was 350 degrees, with an average contraction of 44 degrees. Finally, the examiner also indicated that the Veteran’s retinal hemorrhages constituted incapacitating episodes lasting at least six weeks, as the Veteran was not permitted to do anything physical to avoid further retinal bleeding. In July 2017, the Veteran’s corrected vision was noted to be 20/40 in the right eye and 20/50 in the left eye. In sum, the evidence is in equipoise on whether a 40 percent rating is warranted from July 12, 2012. For the period of appeal prior to March 28, 2017, the bilateral diabetic retinopathy is productive of visual acuity no worse than 20/70 bilaterally, which warrants a 30 percent rating for impairment of visual acuity under Diagnostic Code 6066, and visual field no worse than 46 to 60 degrees bilaterally, which warrants a 10 percent rating under Diagnostic Code 6080. As discussed above, when both decreased visual acuity and visual field defect are present, they are separately rated and expressed as a level of visual acuity, and then combined under the provisions of § 4.25. Here, a visual field no worse than 46 to 60 degrees bilaterally is equated with 20/50 vision bilaterally, which warrants a 10 percent rating. These ratings combined warrant a 40 percent rating for the diabetic retinopathy. The Board notes that for the period from August 2015 to February 2017, the Veteran’s visual acuity was noted to be better than 20/70 in both eyes, which would indicate a rating less than 40 percent is warranted. In light of this, the Board considered staging the appeal. However, the Board also notes that during this period of the appeal, the Veteran had a laser procedure on his left eye (November 2013), two left eye Lucentis injections (April and July 2015), bilateral cataract extractions with intraocular lens implantations (July and October 2015), left eye aflibercept injection (January 2017), and a left eye pars plana vitrectomy (February 2017). Given these multiple procedures and the fluctuation in the disability over this period and affording the Veteran the benefit of the doubt, the 40 percent rating will be continued during this period of appeal. For the period of appeal from March 28, 2017, the bilateral diabetic retinopathy is productive of visual acuity no worse than 20/40 in the right eye and 20/50 in the left eye, which warrants a 10 percent rating for impairment of visual acuity under Diagnostic Code 6066, and visual field no worse than 31 to 45 degrees bilaterally, which warrants a 30 percent rating under Diagnostic Code 6080. Visual field no worse than 31 to 45 degrees bilaterally is equated with 20/70 vision bilaterally, which warrants a 30 percent rating. These ratings combined warrant a 40 percent rating for the diabetic retinopathy. Finally, the Board acknowledges that the March 2017 VA examiner indicated that the retinal hemorrhages constituted incapacitating episodes because the Veteran was not permitted to do anything physical to avoid further retinal bleeding. However, under the rating criteria in effect prior to May 13, 2018, an “incapacitating episode” required prescribed bed rest. In this case, the Veteran was not prescribed bed rest for his vitreous hemorrhage, but rather was simply told to elevate his head in bed and refrain from strenuous activity. The rating criteria were changed effective May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Here, the left eye vitreous hemorrhages were before May 13, 2018. As such, a higher rating based on incapacitating episodes is not warranted. 2. Increased ratings for bilateral upper extremities diabetic polyneuropathy. The Veteran’s bilateral upper extremities diabetic polyneuropathy is rated under Diagnostic Code 8799-8715. The RO assigned initial 10 percent ratings, a 30 percent for the right upper extremity from June 21, 2011, and a 20 percent rating for the left upper extremity from June 21, 2011. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. Here, the hyphenated diagnostic code indicates that indicating that it is rated as analogous to a disease of the peripheral nerves (Diagnostic Code 8799) under the criteria for neuralgia of the median nerve (Diagnostic Code 8715). Rating criteria Neuralgia of the median nerve is rated based on the criteria for paralysis of the median nerve. For paralysis of the median nerve, mild incomplete paralysis warrants a 10 percent rating; moderate incomplete paralysis warrants a 20 percent rating for the minor hand and a 30 percent rating for the major hand; and severe incomplete paralysis warrants a 40 percent rating for the minor hand and a 50 percent rating for the major hand. Complete paralysis warrants a 70 percent rating for the major hand and a 60 percent rating for the minor hand, and is evidenced by the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscle 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, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm, flexion of wrist weakened; and pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Period of appeal prior to June 21, 2011 The Board finds that for the period of appeal prior to June 21, 2011, ratings in excess of 10 percent for the bilateral upper extremities diabetic polyneuropathy are not warranted. In a January 2006 VA examination, the Veteran reported feeling numbness and tingling in his fingers of both hands. On examination, the Veteran’s motor and sensory function of the bilateral upper extremities were normal. He was noted to have neuralgias of the fingers of both hands. In an August 2006 VA examination, the Veteran reported that he had a progressive loss of strength in the arms. On examination, motor and reflex function were within normal limits. Sensor function was abnormal with reduced sensation to touch and vibration distally in both upper extremities. He was noted to have diabetic polyneuropathy of the bilateral upper extremities with subjective bilateral numbness and paresthesia and objective bilateral reduced sensation distally. In a March 2009 VA examination, the Veteran reported having numbness and tingling in his fingers. On examination, the Veteran’s motor function and reflexes were normal. He was noted to have sensory loss in the bilateral fingers. VA treatment records dated between August 2005 and June 2011 contain documentation of neuropathy of the bilateral lower extremities, but are silent for mention of complaints or treatment for neuropathy of the bilateral upper extremities. Treatment records from Kaiser note that the Veteran had a diagnosis of peripheral neuropathy in December 2008, but do not specify whether the diagnosis applies to the upper and/or lower extremities. In sum, ratings in excess of 10 percent are not warranted for this period of appeal. To warrant higher ratings, the evidence must show moderate incomplete paralysis of the minor hand (20 percent rating) or moderate incomplete paralysis of the major hand (30 percent rating). Here, the polyneuropathy is not specifically noted to be mild, moderate, or severe, but the Board finds it significant that six years’ worth of treatment records are silent for mention of complaints or treatment for the condition. Moreover, three VA examiners found the Veteran’s motor function and reflexes to be normal. The Board equates such findings to constitute no more than mild incomplete paralysis. Thus, the record indicates that ratings in excess of 10 percent for this period of appeal are not warranted. Period of appeal from June 21, 2011 The Board finds that for the period of appeal from June 21, 2011, a rating in excess of 30 percent for the right upper extremity and in excess of 20 percent for the left upper extremity are not warranted. In a June 21, 2011, VA examination, the Veteran reported progressive loss of strength in his arms, as well as tingling and numbness of the hands. On examination, motor function was normal. Sensory function was decreased bilaterally. Reflex testing of the bilateral biceps, triceps, brachioradialis, and fingers all showed results of 1+. In a July 2012 VA examination, the Veteran indicated that the condition began with pain in his hands and had progressively worsened. His dominant hand was noted to be his right hand. Symptoms included bilateral mild constant pain, right upper extremity mild intermittent pain and paresthesias/dysesthesias, and left upper extremity moderate intermittent pain and paresthesias/dysesthesias. There was no numbness of either upper extremity, and muscle strength and reflex testing were normal bilaterally. Results of a sensory examination were normal in the shoulder area and inner/outer forearms bilaterally, and decreased in the hands/fingers. The examiner indicated that the Veteran had bilateral mild incomplete paralysis of the radial, median and ulnar nerves. VA treatment records first indicate a diagnosis of peripheral neuropathy of the bilateral upper extremities with tingling/numbness in February 2013. A Kaiser treatment record dated in September 2014 notes that sensation in the bilateral upper extremities was intact to light touch and pin prick. The Veteran was again noted to have peripheral neuropathy of the bilateral upper extremities with intermittent tingling/numbness in a December 2014 and September 2015 VA treatment records. In the July 2015 Board hearing, the Veteran testified that his upper extremities pain was not as severe as his lower extremities, and that it occurred when he tripped something or did work around the house. He stated that he had numbness in his hands and sometimes could not effectively grab things. In a March 2017 VA examination, the Veteran reported “mild problem[s] in arms.” He was noted to be right-hand dominant. The examiner indicated the Veteran had right upper extremity mild constant pain, left upper extremity moderate constant pain, bilateral upper extremity mild paresthesias/dysesthesias, right upper extremity mild numbness, and left upper moderate numbness. Results of muscle strength testing and dep tendon reflexes were normal. The Veteran was noted to have mild incomplete paralysis of the radial and median nerves. VA treatment records dated in September 2016 and March 2017 note neuropathy in the lower extremities and are silent for complaints or treatment of neuropathy in the upper extremities. (Continued on the next page)   In sum, increased ratings are not warranted for this period of appeal. To warrant a higher 50 percent rating for the right upper extremity and/or a 40 percent rating for the left upper extremity, the evidence must show severe incomplete paralysis. Here, VA examiners in July 2012 and March 2017 both found that the Veteran had, at worst, right upper extremity mild constant pain, mild intermittent pain, mild paresthesias/dysesthesias, and mild numbness; and left upper extremity moderate constant pain, moderate intermittent pain, mild paresthesias/dysesthesias, and moderate numbness. Moreover, both examiners indicated the Veteran had mild incomplete paralysis of the radial and median nerves, and the July 2012 examiner also found that the Veteran had mild incomplete paralysis of the ulnar nerves. The Board equates such findings to constitute no more than moderate incomplete paralysis in both upper extremities. Thus, the record indicates that ratings in excess of 30 percent for the right upper extremity and 20 percent for the left upper extremity are not warranted for this period of appeal. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Nelson, Counsel