Citation Nr: 18153812 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 15-45 038 DATE: November 29, 2018 ORDER Entitlement to a rating greater than 20 percent for type 2 diabetes mellitus (diabetes) from April 12, 2013 is denied. Entitlement to a rating greater than 30 percent for nephropathy with hypertension, associated with diabetes, from April 12, 2013 is denied. Entitlement to a rating greater than 20 percent from April 12, 2013, and greater than 10 percent from August 15, 2017 for left lower extremity diabetic neuropathy affecting the sciatic nerve, is denied. Entitlement to a rating greater than 10 percent from April 12, 2013, greater than 20 percent from September 23, 2015, and greater than 10 percent from August 15, 2017 for right lower extremity diabetic neuropathy affecting the sciatic nerve, is denied. Entitlement to a rating greater than 30 percent for posttraumatic stress disorder (PTSD) prior to September 23, 2015 is denied. Entitlement to a rating of 50 percent, but no greater, for PTSD for the period from September 23, 2015 to August 12, 2017 is granted. REMANDED The issue of entitlement to service connection for benign prostatic hyperplasia (BPH) is remanded. The issue of entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) prior to August 12, 2017 is remanded. FINDINGS OF FACT 1. At no time during the period on appeal has the appellant’s type 2 diabetes mellitus required insulin. Further, it has not caused episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations or twice a month or more visits to a diabetic care provider. 2. At no time during the period on appeal has the appellant’s nephropathy with hypertension, associated with type 2 diabetes mellitus, manifested with symptoms requiring regular dialysis, persistent edema or albuminuria, constant albuminuria with some edema, definite decrease in kidney function, transient or slight edema, or hypertension with diastolic blood pressure predominantly 120 or more. 3. At no time during the period on appeal has the appellant’s diabetic neuropathy of the left lower extremity affecting the sciatic nerve manifested with symptoms of complete paralysis of the sciatic nerve, or more than mild incomplete paralysis. 4. At no time during the period on appeal has the appellant’s diabetic neuropathy of the right lower extremity affecting the sciatic nerve manifested with symptoms of complete paralysis of the sciatic nerve, or more than mild incomplete paralysis. 5. Prior to September 23, 2015, the appellant was not receiving any treatment or medication to treat his PTSD symptoms. During the period prior to September 23, 2015, the appellant’s PTSD manifested with symptoms of chronic sleep impairment, with low levels of anxiety and depression, and an absence of clinically significant mental health issues. It was noted that his disability was at the same level it was in 2007 when he retired from his career with the Post Office. The appellant was noted to have some difficulty getting along with other people in close settings with good attention and concentration and no particular memory problems. It was also observed that he socializes well, and had recently made new friends after a move. All these symptoms caused occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. 6. From September 23, 2015, the appellant’s PTSD manifested with symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, impaired abstract thinking, disturbances of mood or motivation, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a worklike setting. The appellant also had other symptoms of discouragement about the future, a negative view of the past, present and self, feelings of guilt, some crying, restlessness, less interest in others, problems making decisions, lower energy, reduced sleep, increased irritability, and fatigue. His disability at the time was chronic with a poor prognosis if left untreated. The appellant’s symptoms were noted to have the potential to create interference or impose work restrictions in work areas such as those associated with jobs having much cognitive demand and those with much social or collegial contact. His overall capacity for work was described as limited. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating greater than 20 percent for type 2 diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.119, Diagnostic Code 7913. 2. The criteria for entitlement to a rating greater than 30 percent for nephropathy with hypertension, associated with type 2 diabetes mellitus, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.104, Diagnostic Code 7101, 4.115, Diagnostic Code 7541. 3. The criteria for entitlement to a rating greater than 20 percent from April 12, 2013 for left lower extremity diabetic neuropathy, affecting the sciatic nerve, and greater than 10 percent from August 15, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10,.4.124, Diagnostic Code 8520. 4. The criteria for entitlement to a rating greater than 10 percent from April 12, 2013, greater than 20 percent from September 23, 2015, and greater than 10 percent from August 15, 2017 for right lower extremity diabetic neuropathy, affecting the sciatic nerve, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10,.4.124, Diagnostic Code 8520. 5. The criteria for entitlement to a rating greater than 30 percent for the period before September 23, 2015 for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10,.4.130, Diagnostic Code 9411. 6. The criteria for entitlement to a 50 percent rating, for PTSD for the period from September 23, 2015 to August 12, 2017 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10,.4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty from July 1969 to July 1971. This matter comes to the Board of Veterans’ Appeals (Board) from rating decisions by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). In a February 2014 rating decision, the RO denied a rating in excess of 30 percent for nephropathy with hypertension, a rating in excess of 30 percent for PTSD with explosive disorder, a rating in excess of 20 percent for diabetes mellitus, a rating in excess of 10 percent for right lower extremity neuropathy, and a rating in excess of 20 percent for left lower extremity neuropathy. In an October 2015 rating decision, the RO denied service connection for BPH. Before the appeal was certified to the Board, in a November 2015 rating decision, the RO increased the rating for right lower extremity diabetic neuropathy to 20 percent, effective September 23, 2015. In an October 2017 rating decision, the RO granted a 70 percent rating for the appellant’s service-connected psychiatric disability, TDIU, and special monthly compensation based on housebound criteria, all from August 12, 2017. In briefing since the October 2017 rating decision, in May 2018 and August 2018, the appellant’s attorney limited appeal of his psychiatric rating to the period prior to the August 12, 2017 grant of a 70 percent rating. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on the veteran’s average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body to function under the ordinary conditions of daily life, including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of an initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). 1. Entitlement to a rating greater than 20 percent for type 2 diabetes mellitus from April 12, 2013 is denied. The appellant contends that his type 2 diabetes mellitus is more disabling than currently rated, which is currently 20 percent. After a review of the evidence of record, the Board finds that the preponderance of the evidence does not warrant a rating greater than 20 percent for the appellant’s type 2 diabetes mellitus. The ratings for diabetes mellitus are found under Diagnostic Code 7913. 38 C.F.R. § 4.119. Under these rating criteria, a 40 percent rating is assigned when diabetic symptoms require insulin, restricted diet, and regulation of activities for management. A 60 percent rating is assigned when diabetic symptoms also include episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations a year or twice a month visits to a diabetic care provider, and complications that would not be compensable if separately evaluated. A 100 percent rating requires more than one daily injection of insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization at least 3 times per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. Id. The appellant underwent VA examinations to assess the severity of his type 2 diabetes mellitus in February 2014, September 2015, and August 2017. At none of these examinations was the appellant noted to be taking insulin injections for the management of his diabetes. While he did have a restricted diet and a regulation of activities, his condition was treated with oral medication. Further, at no time did the appellant receive treatment for ketoacidosis or hypoglycemic reactions requiring hospitalization or regular visits to his diabetic care provider more than twice per month. He also had no loss of weight or strength due to his disability. The Board has also reviewed the appellant’s VA treatment records; however, they confirm that, while he receives regular check-ups where his diabetes is discussed, he does not take insulin to manage the condition, and has neither required hospitalization related to the disability, nor required more than two monthly visits to a diabetic care provider. Applying this to the rating criteria, the Board finds the preponderance of the evidence does not support a rating greater than 20 percent for service connected type 2 diabetes mellitus as there is no evidence of the appellant requiring insulin injections for management of his symptoms, or the kind of serious regular treatment contemplated by the rating criteria. The Board has considered the appellant’s contention, as raised in his April 2014 notice of disagreement, that he has urinary frequency issues due to his type 2 diabetes mellitus; however, his September 2015 examination and his August 2017 examination both attribute the appellant’s urinary frequency issues to his non-service connected BPH. Although in some cases a layperson is competent to offer an opinion addressing the etiology of a disorder, the Board finds that, in this case, the determination of the origin of the appellant’s urinary frequency symptoms, and generally the severity of his type 2 diabetes mellitus, are medical questions not subject to lay expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The disease involves a pathological process that is not readily observable to a layperson. The Board finds that due to the non-observable nature of the pathology, the issue of the severity of the appellant’s urinary frequency symptoms is a medical question requiring medical training, expertise, and experience. Therefore, the Board finds that the medical opinion provided in the September 2015 and August 2017 examinations outweigh the appellant’s lay opinion. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). As such, the Board finds no basis on which to award a rating greater than 20 percent for the appellant’s type 2 diabetes mellitus. Neither the appellant, nor his representative, have presented any evidence or argument that would demonstrate otherwise. Therefore, the Board finds that preponderance of the evidence is against the appellant’s claim of entitlement to a rating greater than 20 percent for service connected type 2 diabetes mellitus and the claim is denied. 2. Entitlement to a rating greater than 30 percent for nephropathy with hypertension, associated with type 2 diabetes mellitus, from April 12, 2013 is denied. The appellant contends that his 30 percent rating for nephropathy with hypertension should be increased. After a review of the record, the Board finds that the preponderance of evidence does not support a rating greater than 30 percent for this disability. Renal complications caused by diabetes mellitus are rated under 38 C.F.R. § 4.115a for renal dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7541. Under 38 C.F.R. § 4.115a, renal dysfunction is rated as 60 percent disabling with constant albuminuria with some edema, or definite decrease in kidney function, or hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is assigned for symptoms of persistent edema and albuminuria, with BUN 40 to 80mg% or, creatine 4 to 8 mg%, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent disability rating is assigned for symptoms requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria, or BUN more than 80mg%, or creatine more than 8mg%, or markedly decreased function of kidney or other organ systems, especially the cardiovascular system. Under Diagnostic Code 7101, hypertension is rated as 10 percent disabling if it requires continuous medication and the claimant has a history of a diastolic blood pressure predominantly 100 more, the claimant predominantly has a diastolic blood pressure 100 or more, or a systolic pressure predominantly 150 or more. A 40 percent evaluation is assigned if the diastolic blood pressure is predominantly 120 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The appellant underwent VA examinations for this condition in February 2014, September 2015, and August 2017. All three examinations indicated the appellant’s disability was controlled with medication and that he was not experiencing any new symptoms. At no point had he had any episodes of renal dysfunction, and beyond medication, he had not had any treatment for the condition. The September 2015 examination indicated that his diagnosis was based on one episode of microalbuminuria in 2009. Since that time, all his laboratory test results had been normal with respect to this issue. The appellant’s August 2017 examination also included testing for the appellant’s hypertension. His blood pressure readings at that examination were 150/90, 150/105, and 140/95. This examination also noted that the appellant requires continuous medication for the management of his hypertension. The appellant’s VA treatment records do not demonstrate any edema, microalbuminuria, dialysis, decrease in kidney function, or diastolic blood pressure predominantly greater than 120. Applying the rating criteria to the competent medical evidence of record, the Board finds that the criteria for a higher rating are not met. The appellant’s disability does not require dialysis, he has no active or recurring edema or albuminuria, he does not have elevated creatine levels, and his diastolic blood pressure is not predominantly greater than 120. As such, the evidence does not support a higher rating. The Board has considered the appellant’s belief that his disability is more disabling than currently rated; however, the Board notes that neither the appellant, nor his attorney representative, have presented any competent or objective evidence to support this belief. Although in some cases a layperson is competent to offer an opinion addressing the etiology of a disorder, the Board finds that, in this case, the determination of the severity of the appellant’s nephropathy with hypertension is a medical question not subject to lay expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The condition involves a pathological process that is not readily observable to a layperson. The Board finds that due to the non-observable nature of the pathology, the issue of the severity of the appellant’s disability is a medical question requiring medical training, expertise, and experience. Therefore, the Board finds that the medical opinion provided in the VA examinations outweighs the appellant’s lay opinion. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). As such, the Board finds no basis on which to award a rating greater than 30 percent for the appellant’s diabetic nephropathy with hypertension. Neither the appellant, nor his representative, have presented any evidence or argument that would demonstrate otherwise. Therefore, the Board finds that preponderance of the evidence is against the appellant’s claim of entitlement to a rating greater than 30 percent for service connected diabetic nephropathy with hypertension and the claim is denied. 3. Entitlement to a rating greater than 20 percent prior to August 15, 2017, and greater than 10 percent from August 15, 2017 for left lower extremity diabetic neuropathy affecting the sciatic nerve, is denied. The appellant contends that his left lower extremity diabetic neuropathy, affecting the sciatic nerve, is more disabling than the current staged rating for the disability. After a review of the evidence of record, the Board finds the preponderance of the evidence does not support the assignment of a rating greater than 20 percent for any period on appeal, and does not support the assignment of a rating greater than 10 percent for the period from August 15, 2017. As a procedural note, in an October 2017 rating decision, the RO assigned a staged rating for the appellant’s disability, in the form of a reduction from the assigned 20 percent rating to 10 percent. The appellant’s disability was rated as 20 percent disabling prior to August 15, 2017 due to a finding of moderate symptoms associated with incomplete paralysis of the sciatic nerve, as caused by diabetes. During the August 15, 2017 VA examination, the evidence indicated an improvement in symptoms, with mild symptoms associated with incomplete paralysis of the sciatic nerve as caused by diabetes. As such, the RO initiated a reduction in the rating for this disability. As the reduction did not reduce the appellant’s overall disability rating, the RO was not required to provide notice or follow the procedures generally required for a rating reduction. 38 C.F.R. § 3.105. The Board also notes that a new separate rating was assigned for diabetic neuropathy of the left femoral nerve. A notice of disagreement has not been received by VA with regards to that separate disability, and it is not on appeal. Impairments of the sciatic nerve are rated under Diagnostic Codes 8520, 8620, and 8720. 38 C.F.R. § 4.124a. A 10 percent rating is assigned for mild symptoms. A 20 percent rating for moderate symptoms. A 40 percent rating for moderately severe symptoms. A 60 percent rating for severe symptoms with marked muscular atrophy. An 80 percent rating is assigned for complete paralysis of the nerve resulting in a foot that dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or lost. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than complete paralysis. When the involvement is wholly sensory, the rating should be for the mild, or at the most, the moderate degree. Turning to the evidence of record, the appellant underwent VA examinations to determine the severity of his lower extremity diabetic neuropathy in February 2014, September 2015, and August 2017. During his February 2014 VA examination, the appellant demonstrated symptoms of mild lower extremity paresthesias or dysesthesias. There were no reports of constant or even intermittent pain. He had normal muscle strength in both lower extremities, normal reflexes, normal sensation, and no evidence of muscle atrophy or any trophic changes. While he was noted to have lower extremity diabetic peripheral neuropathy, both of his lower extremity nerves were found to be normal, with no indication of incomplete paralysis. During his September 2015 VA examination, the appellant demonstrated symptoms of moderate lower extremity numbness and paresthesias or dysesthesias. There were no reports of constant or even intermittent pain. He had normal muscle strength, absent reflexes in the ankles, some decreased sensation in the ankles and feet, absent vibration sensation, and absent cold sensation. There was no evidence of any muscle atrophy or trophic changes. The diagnosis was moderate incomplete paralysis of the sciatic nerve in both lower extremities based on a review of these symptoms. During his August 2017 VA examination, the appellant demonstrated symptoms of mild paresthesias or dysesthesias of the lower extremities. There were no reports of constant or even intermittent pain. He had decreased vibration sensation, but otherwise normal sensation with no evidence of reduced muscle strength or reflexes, muscle atrophy, or trophic changes in the lower extremities. The diagnosis was mild incomplete paralysis of the sciatic nerve in both lower extremities due to diabetic neuropathy based on a review of these symptoms. The appellant’s VA treatment records do not contain any evidence the appellant sought regular treatment for his diabetic neuropathy. The record does include an assortment of buddy statements from the appellant’s former coworkers which generally describe the difficulty he had with his hands and feet towards the end of his career at the United States Postal Service in 2006, outside the period on appeal. While these statements do support that the appellant had a current disability, they do not speak to the severity of the appellant’s disability during the period on appeal, nor is there any indication that the individuals offering the lay opinion are competent to provide an assessment on the severity of the appellant’s diabetic neuropathy. Considering all the relevant evidence of record, the Board finds the preponderance of the evidence is against the assignment of rating greater than 20 percent prior to August 15, 2017, and greater than 10 percent from August 15, 2017. The Board finds that a preponderance of the evidence does not equate the criteria necessary for a rating greater than 20 percent for any of the period on appeal. There is no evidence of reduced muscle strength in the appellant’s lower extremities at any point during the appellate period. There are no trophic changes to the skin, and the appellant’s symptoms have never included muscle atrophy, which is an indicator of disuse. Ultimately the examiner found that the appellant’s symptoms were moderate as there did not appear to be any reduced functionality in the appellant’s feet resulting in diminished capacity. During the period prior to August 15, 2017, the appellant had two separate examinations which concluded he had diabetic neuropathy, although the examinations disagreed as to whether the appellant had any paralysis of the sciatic nerve. The February 2014 examination, noted symptoms consistent with only a 10 percent rating, while the September 2015 examination noted symptoms consistent with a 20 percent rating. As there is doubt as to which of two evaluations should be applied for this period, the Board grants the higher evaluation for this portion of the appeal period. 38 C.F.R. § 4.7. The examination in August 2017 demonstrated an improvement in the appellant’s disability. The symptoms in the left lower extremity were described as mild, and there was a decrease in the number of symptoms found on objective sensation testing. As such, the Board finds that a 10 percent rating is warranted for the period from August 15, 2017. The Board has considered the appellant’s contention that his disability is worse than currently rated. Although in some cases a layperson is competent to offer an opinion addressing the severity of a disorder, the Board finds that, in this case, the determination of the severity of the appellant’s diabetic neuropathy is a medical question not subject to lay expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The condition involves a pathological process that is not readily observable to a layperson. The Board finds that due to the non-observable nature of the pathology, the issue of the severity of the appellant’s diabetic neuropathy is a medical question requiring medical training, expertise, and experience. Therefore, the Board finds that the medical opinions provided in the VA examinations outweigh the appellant’s lay opinion. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). As such, the Board finds no basis on which to award a rating greater than 20 percent for the appellant’s diabetic neuropathy of the left lower extremity affecting the sciatic nerve, prior to August 15, 2017, and greater than 10 percent from August 15, 2017. Neither the appellant, nor his representative, have presented any evidence or argument that would demonstrate otherwise. Therefore, the Board finds that preponderance of the evidence is against the appellant’s claim of entitlement to a rating greater than 20 percent for service connected diabetic neuropathy of the left lower extremity affecting the sciatic nerve, prior to August 15, 2017 and greater than 10 percent from August 15, 2017 and the claim is denied. 4. Entitlement to a rating greater than 10 percent prior to September 23, 2015, greater than 20 percent from September 23, 2015, and greater than 10 percent from August 15, 2017 for right lower extremity diabetic neuropathy affecting the sciatic nerve, is denied. The appellant contends that his left lower extremity diabetic neuropathy, affecting the sciatic nerve, is more disabling than the current staged rating for the disability. After a review of the evidence of record, the Board finds the preponderance of the evidence does not support the assignment of a rating greater than 10 percent for the period prior to September 23, 2015, greater than 20 percent from September 23, 2015, and does not support the assignment of a rating greater than 10 percent for the period from August 15, 2017. As a procedural note, in an October 2017 rating decision, the RO assigned a staged rating for the appellant’s disability, in the form of a reduction from the assigned 20 percent rating to 10 percent. The appellant’s disability was rated as 20 percent disabling prior to August 15, 2017 due to moderate symptoms associated with incomplete paralysis of the sciatic nerve as caused by diabetes. During the August 15, 2017 VA examination, the evidence indicated mild symptoms associated with incomplete paralysis of the sciatic nerve as caused by diabetes, and as such, the RO initiated a reduction in the rating for this disability. As the reduction did not reduce the appellant’s overall disability rating, the RO was not required to provide notice or follow the procedures generally required for a rating reduction. 38 C.F.R. § 3.105. The Board also notes that a new separate rating was assigned for diabetic neuropathy of the right femoral nerve. A notice of disagreement has not been issued with regards to that separate disability, and it is not on appeal. Impairments of the sciatic nerve are rated under Diagnostic Codes 8520, 8620, and 8720. 38 C.F.R. § 4.124a. A 10 percent rating is assigned for mild symptoms. A 20 percent rating for moderate symptoms. A 40 percent rating for moderately severe symptoms. A 60 percent rating for severe symptoms with marked muscular atrophy. An 80 percent rating is assigned for complete paralysis of the nerve resulting in a foot that dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or lost. Turning to the evidence of record, the appellant underwent VA examinations to determine the severity of his lower extremity diabetic neuropathy in February 2014, September 2015, and August 2017. During his February 2014 VA examination, the appellant demonstrated symptoms of mild lower extremity paresthesias or dysesthesias. There were no reports of constant or even intermittent pain. He had normal muscle strength in both lower extremities, normal reflexes, normal sensation, and no evidence of muscle atrophy or any trophic changes. While he was noted to have lower extremity diabetic peripheral neuropathy, both of his lower extremity nerves were found to be normal, with no indication of incomplete paralysis. During his September 2015 VA examination, the appellant demonstrated symptoms of moderate lower extremity numbness and paresthesias or dysesthesias. There were no reports of constant or even intermittent pain. He had normal muscle strength, absent reflexes in the ankles, some decreased sensation in the ankles and feet, absent vibration sensation, and absent cold sensation. There was no evidence of any muscle atrophy or trophic changes. The diagnosis was moderate incomplete paralysis of the sciatic nerve in both lower extremities. During his August 2017 VA examination, the appellant demonstrated symptoms of mild paresthesias or dysesthesias of the lower extremities. There were no reports of constant or even intermittent pain. He had decreased vibration sensation, but otherwise normal sensation with no evidence of reduced muscle strength or reflexes, muscle atrophy or trophic changes in the lower extremities. The diagnosis was mild incomplete paralysis of the sciatic nerve in both lower extremities due to diabetic neuropathy. The appellant’s VA treatment records do not contain any evidence the appellant sought regular treatment for his diabetic neuropathy. The record does include an assortment of buddy statements from the appellant’s former coworkers which generally describe the difficulty he had with his hands and feet towards the end of his career at the United States Postal Service. While these statements do support that the appellant had a current disability, they do not speak to the severity of the appellant’s disability, nor is there any indication that the individuals offering the lay opinion are competent to provide an assessment on the severity of the appellant’s diabetic neuropathy. Considering all the relevant evidence of record, the Board finds the preponderance of the evidence is against the assignment of a rating greater than 10 percent prior to September 23, 2015, greater than 20 percent for the period from September 23, 2015 to August 15, 2017, and greater than 10 percent for the period from August 15, 2017. During the period prior to the September 23, 2015 VA examination, the appellant symptoms of right lower extremity diabetic neuropathy did not manifest to a degree which warranted a 20 percent rating. The condition was not found to have moderate symptoms prior to this date. As such, a 10 percent rating is appropriate for evidence of mild incomplete paralysis of the sciatic nerve. During the period from September 23, 2015 to August 15, 2017, the appellant’s symptoms were not described as moderately severe. There is no evidence of reduced muscle strength in the appellant’s lower extremities at any point during the appellate period. There was also no evidence of any trophic changes to the skin, or muscle atrophy, indicating disuse, during the period on appeal. As the appellant’s symptoms were categorized as moderate incomplete paralysis of the sciatic nerve, the Board finds that a 20 percent rating is appropriate for this period. The examination in August 2017 demonstrated an improvement in the appellant’s disability. The symptoms in the right lower extremity were described as mild, and there was a decrease in the number of symptoms found on objective sensation testing. As such, the Board finds that a 10 percent rating is warranted for the period from August 15, 2017. The Board has considered the appellant’s contention that his disability is worse than currently rated. Although in some cases a layperson is competent to offer an opinion addressing the severity of a disorder, the Board finds that, in this case, the determination of the severity of the appellant’s diabetic neuropathy is a medical question not subject to lay expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The condition involves a pathological process that is not readily observable to a layperson. The Board finds that due to the non-observable nature of the pathology, the issue of the severity of the appellant’s diabetic neuropathy is a medical question requiring medical training, expertise, and experience. Therefore, the Board finds that the medical opinions provided in the VA examinations outweigh the appellant’s lay opinion. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). As such, the Board finds no basis on which to award a rating greater than 10 percent prior to September 23, 2015, a rating greater than 20 percent rating from September 23, 2015, or a rating greater than 10 percent from August 15, 2017. Neither the appellant, nor his representative, have presented any evidence or argument that would demonstrate otherwise. Therefore, the Board finds that the preponderance of the evidence is against the appellant’s claim of entitlement to a rating greater than 10 percent prior to September 23, 2015 for service connected diabetic neuropathy of the right lower extremity affecting the sciatic nerve, a rating greater than 20 percent prior to August 15, 2017 and greater than 10 percent from August 15, 2017 and the claim is denied. 5. Entitlement to a rating greater than 30 percent for PTSD prior to September 23, 2015 is denied. The appellant contends that his psychiatric disability is worse than currently rated. After a review of the evidence of record, the Board finds that prior to September 23, 2015, the appellant’s psychiatric disability does not warrant a rating greater than 30 percent. Psychiatric disabilities are rated based on the criteria presented under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. A 30 percent rating is assigned when there is occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss. A 50 percent rating is assigned when there is 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; difficulty establishing effective work and social relationships. A 70 percent rating is assigned 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; inability to establish and maintain effective relationships. A 100 percent evaluation is assigned when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. The appellant underwent a VA examination for his psychiatric disability in February 2014. At that examination, the appellant’s PTSD was noted to cause chronic sleep impairment. Diagnostic testing revealed low levels of anxiety and depression and “mild PTSD…with a tendency to depression.” After reviewing the evidence of record, the examiner determined that the appellant’s PTSD was at the same level as when he was last evaluated 5 years prior and had not increased in severity since his retirement from work in 2007. The examiner noted the appellant socializes well, but has some difficulty getting along with people. As such, the examiner found that the appellant’s disability caused occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. There is no other medical evidence from this period which indicates the appellant experienced symptoms more severe than those described in the February 2014 VA examination. The appellant was not receiving regular treatment for his PTSD at the time. Further, the Board notes that in a May 2018 brief by the appellant’s attorney representative, it appears to be conceded that an increase in the appellant’s psychiatric disability can be pinpointed to his VA examination on September 23, 2015. While this is inconsistent with an August 2018 brief from the appellant’s attorney representative, in which he claims that the appellant’s 70 percent rating should be applied to the entire period on appeal, the Board finds no evidence on which to support any rating greater than 30 percent prior to September 23, 2015. As such, after a full review of the evidence of record, the Board finds that prior to September 23, 2015, the appellant’s PTSD symptoms were most consistent with the 30 percent rating criteria for psychiatric disabilities. Therefore, the Board concludes that a rating greater than 30 percent is not warranted for the period prior to September 23, 2015. 6. Entitlement to a rating of 50 percent, but no greater, for PTSD for the period from September 23, 2015 to August 12, 2017 is granted. The appellant contends that his psychiatric disability is more disabling than currently rated. In a May 2018 brief, the appellant, through his attorney representative, argued that he is entitled to a 50 percent rating for PTSD for the period from September 23, 2015 to August 12, 2017. In a later August 2018 brief, the appellant’s attorney representative argued that the appellant should be awarded a 70 percent rating prior to August 12, 2017. After a review of the evidence of record, the Board finds that a staged rating is appropriate in this instance and that a 50 percent rating, but not greater, is warranted for the period from September 23, 2015 to August 12, 2017. The appellant underwent a VA examination on September 23, 2015 where he was noted with symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, impaired abstract thinking, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances including work or a worklike setting. The appellant also had symptoms of discouragement about the future, negative views of the past, present and himself, feelings of guilt with periods of crying, restlessness, less interest in others, problems making decisions, low energy, reduced sleep, increased irritability, and fatigue. The appellant appeared for the examination well-groomed, and presented with a cooperative manner, normal speech, an anxious attitude, and thought processes which were normal but contained intrusive recollections. The examiner assessed that the appellant’s symptoms had the potential to create interference or impose work restrictions in work areas such as those associated with jobs having much cognitive demand and those with much social or collegial contact. It was noted that the appellant was neither taking any medications for his disability, nor receiving any regular treatment for his psychiatric illness. The appellant reported that he had been married for 44 years at the time of this examination, and that his marital relationship was “pretty good.” There was no mention of any estrangement or difficulties with immediate family members. He did note some increased tension with his coworkers when he worked at the post office; however, the Board notes that multiple former coworkers of the appellant from his time at the post office submitted statements in support of his claim, and not one mentioned any difficulty with the appellant’s attitude or demeanor. The record does not contain any indication that the appellant was receiving any regular treatment for his disability during this period, and as such, there is no other relevant medical evidence of record to examine. Reviewing the appellant’s symptoms, the Board notes that he was found to have symptoms which are contemplated by and included in the 30, 50, and 70 percent rating criteria. Considering all the appellant’s symptoms, the Board finds that his symptoms most nearly approximate the 50 percent rating criteria. The Board notes, that while the appellant’s disability was found to interfere with his occupational capacity, it was not found, at the time of this examination, to have a major impact on his social functioning. The symptoms demonstrate reduced reliability and productivity but do not rise to the level of occupational and social impairment with deficiencies in most areas, as at the time, the appellant’s disability seems to be more limiting towards his occupational capacity, and less limiting of his social capacity. This is supported by a lack of reporting of social issues and issues with the family. At the time of the September 2015 examination, the appellant still maintained good relationships with his family members and did not endorse recent symptoms of occupational interference, as he had retired due to the difficulties caused by his diabetes. While the examiner did note the appellant experienced “difficulty adapting to stressful circumstances,” a symptom found in the 70 percent rating criteria, the symptoms noted for the appellant were predominantly from the 50 percent rating criteria. Further, while the appellant was noted with this symptom, there is no indication that it alone, or in combination with his other symptoms, caused occupational and social impairment with deficiencies in most areas. By all accounts, the appellant, while suffering from significant symptoms, was not substantially limited in his social and family life, and due to his retirement from work, which as discussed below was largely due to symptoms of diabetic neuropathy, there is no evidence his symptoms caused occupational impairment, with deficiencies in most areas. While the evidence does demonstrate a significant increase in the appellant’s symptoms, these were first noted and recorded in an August 2017 VA examination. As such, while the increase in the appellant’s symptoms may have occurred prior to that examination, the increase can only be granted from the date VA obtained evidence of the increase in the severity of symptomatology. For the period prior to August 2017, there is no evidence the appellant was suffering from psychiatric symptoms approximately equivalent to the 70 percent rating criteria. After a full review of the evidence of record, the Board finds that the appellant’s symptoms most nearly approximate the criteria for a 50 percent rating for his psychiatric disability. As noted above, this is the rating the appellant’s attorney representative initially argued the appellant should be entitled to, based on his psychiatric symptomatology, although a later brief presented a different argument. As such, the Board concludes that a rating of 50 percent, but not greater, is warranted for the period from September 23, 2015 and August 12, 2017. REASONS FOR REMAND 1. Entitlement to service connection for BPH is remanded. A remand is warranted for an additional medical inquiry into this claim. The appellant contends that his BPH is related to his active service. He has asserted that the condition was directly caused by exposure to herbicide agents while he was deployed in the Republic of Vietnam. He has alternatively claimed that the disability is secondary to, or aggravated beyond its normal progression by his service connected diabetes mellitus. A September 2017 VA examination addressed the issue of secondary service connection. But the report does not address direct service connection between BPH and herbicide exposure. As pointed out by the appellant’s attorney representative, even when a disability is not subject to service connection on a presumptive basis for presumed exposure to herbicide agents under 38 C.F.R. § 3.309, the disability may still be granted service connection for exposure to herbicides on a direct basis. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Board cannot make a fully-informed decision on the issue of entitlement to service connecion for BPH because no VA examiner has opined whether the appellant’s BPH was directly caused by his presumed exposure to herbicides. As such, remand is necessary in order to obtain an addendum opinion on this contention of the appellant’s. 2. Entitlement to a TDIU prior to August 12, 2017 is remanded. This issue must be remanded as well because it is intertwined with the remanded service connection claim. Further, the RO should readjudicate the claim in light of the increase in rating for PTSD granted in this decision. The matter is REMANDED for the following action: Obtain an addendum opinion which addresses whether the appellant’s BPH is at least as likely as not (i.e., probability of 50 percent or greater) related to his presumed herbicide exposure during service in Vietnam. Please explain in detail any opinion provided. CHRISTOPHER MCENTEE Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kleponis, Associate Counsel