Citation Nr: 18154409 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 17-04 083 DATE: November 29, 2018 ORDER New and material evidence having been received, the claim of service connection for a skin disability is reopened. New and material evidence has not been received; as such, the application to reopen a claim of entitlement to service connection for hypertension is denied. New and material evidence has not been received; as such, the application to reopen a claim of entitlement to service connection for peripheral vascular disease of the lower extremities is denied. Service connection for a heart disability is granted. Entitlement to an effective date earlier than February 25, 2013, for the grant of service connection for bilateral hearing loss is denied. Entitlement to an effective date earlier than February 25, 2013, for the grant of service connection for tinnitus is denied. Entitlement to an effective date earlier than October 29, 2010, for the grant of service connection for diabetes mellitus is denied. Entitlement to an effective date earlier than October 29, 2010, for the grant of service connection for peripheral neuropathy of the left upper extremity is denied. Entitlement to an effective date earlier than October 29, 2010, for the grant of service connection for peripheral neuropathy of the right upper extremity is denied. Entitlement to an effective date earlier than October 29, 2010, for the grant of service connection for peripheral neuropathy of the left lower extremity is denied. Entitlement to an effective date earlier than October 29, 2010, for the grant of service connection for peripheral neuropathy of the right lower extremity is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to a disability rating in excess of 10 percent for tinnitus is denied. Entitlement to a disability rating in excess of 10 percent for diabetes mellitus from October 29, 2010 to June 22, 2015 is denied. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus on and after June 23, 2015 is denied. Entitlement to a 30 percent disability rating for peripheral neuropathy of the left upper extremity is granted. Entitlement to a 40 percent disability rating for peripheral neuropathy of the right upper extremity is granted. Entitlement to a 20 percent disability rating for peripheral neuropathy of the left lower extremity is granted, effective August 20, 2015. Entitlement to a 20 percent disability rating for peripheral neuropathy of the right lower extremity is granted, effective August 20, 2015. Entitlement to a disability rating of 70 percent, but no more, for posttraumatic stress disorder (PTSD) is granted on and after March 9, 2015, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Service connection for a skin disability is remanded. FINDINGS OF FACT 1. The Veteran’s claim for service connection for dermatitis was denied in a May 2006 rating decision on the basis that the evidence failed to establish a nexus to service. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 2. The Veteran’s request to reopen his claim for service connection for dermatitis was denied in an August 2012 rating decision on the basis of a lack of new and material evidence. 3. Evidence received in September 2012 raises a substantial possibility of substantiating the claim of service connection for a skin disability. Because this was within one year of the August 2012 rating decision, it has not become final. 4. The Veteran’s claim for service connection for hypertension was denied in an August 2012 rating decision on the basis failed to establish a nexus to service. The Veteran responded by submitting additional evidence and the claim was again denied in a February 2013 rating decision on the same basis. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 5. The evidence received since the February 2013 denial, by itself or when considered with previous evidence of record, does not relate to an unestablished fact necessary to substantiate the claim for service connection for hypertension, and therefore does not raise a reasonable possibility of substantiating the claim for service connection for hypertension. 6. The Veteran’s claim for service connection for peripheral vascular disease of the lower extremities was denied in a May 2006 rating decision on the basis that it failed to establish a nexus to service. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 7. The Veteran’s request to reopen his claim for service connection for peripheral vascular disease of the lower extremities was denied in an August 2012 rating decision on the basis of a lack of new and material evidence. The Veteran responded by submitting additional evidence and the claim was again denied in a February 2013 rating decision on the same basis. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 8. The evidence received since the February 2013 denial, by itself or when considered with previous evidence of record, does not relate to an unestablished fact necessary to substantiate the claim for service connection for peripheral vascular disease of bilateral lower extremities, and therefore does not raise a reasonable possibility of substantiating the claim for service connection for peripheral vascular disease of bilateral lower extremities. 9. The Veteran served in the Republic of Vietnam during the Vietnam Era and was therefore presumptively exposed to herbicide agents. 10. The Veteran has a current diagnosis of ischemic heart disease. 11. There is no indication of a claim of service connection for bilateral hearing loss prior to February 25, 2013. 12. There is no indication of a claim of service connection for tinnitus prior to February 25, 2013. 13. There is no indication of a claim of service connection for diabetes mellitus prior to October 29, 2010. 14. There is no indication of a claim of service connection for peripheral neuropathy of the left upper extremity prior to October 29, 2010. 15. There is no indication of a claim of service connection for peripheral neuropathy of the right upper extremity prior to October 29, 2010. 16. The Veteran’s claim for service connection for continuing rash, scaling and burning in extremities was denied in a May 2006 rating decision. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year, and it became final. 17. VA received a claim for service connection for peripheral neuropathy in both lower extremities on October 29, 2010. The November 2016 rating decision resulting from that claim granted service connection for peripheral neuropathy of the left lower extremity. There is no indication of an attempt to reopen the claim between May 2006 and October 29, 2010. 18. VA received a claim for service connection for peripheral neuropathy in both lower extremities on October 29, 2010. The November 2016 rating decision resulting from that claim granted service connection for peripheral neuropathy of the right lower extremity. There is no indication of an attempt to reopen the claim between May 2006 and October 29, 2010. 19. During the period on appeal, the Veteran’s bilateral hearing loss was not manifested by worse than a Level II hearing loss in the right ear and a Level I hearing loss in the left ear. 20. The Veteran’s service-connected tinnitus is already assigned the maximum schedular rating authorized under Diagnostic Code 6260. 21. From October 29, 2010 to June 22, 2015, the Veteran’s diabetes mellitus was manifested by a need for restricted diet, but not by a need for insulin or oral hypoglycemic medication. 22. On and after June 23, 2015, the Veteran’s diabetes mellitus has manifested as a need for regular oral hypoglycemic medication and a restricted diet, but not by avoidance of strenuous occupational and recreational activities. 23. Throughout the period on appeal, the Veteran’s peripheral neuropathy of the left upper extremity has manifested by moderate incomplete paralysis of all radicular groups, but not severe incomplete paralysis. 24. Throughout the period on appeal, the Veteran’s peripheral neuropathy of the right upper extremity has manifested by moderate incomplete paralysis of all radicular groups, but not severe incomplete paralysis. 25. Throughout the period on appeal, the Veteran’s peripheral neuropathy of the left lower extremity has manifested by moderate incomplete paralysis of the sciatic nerve, but not severe incomplete paralysis. 26. Throughout the period on appeal, the Veteran’s peripheral neuropathy of the right lower extremity has manifested by moderate incomplete paralysis of the sciatic nerve, but not severe incomplete paralysis. 27. Throughout the period on appeal, the Veteran’s PTSD has been manifested by occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 28. The Veteran’s service-connected disabilities have met the percentage requirements for the award of a schedular TDIU, and the evidence indicates that the nature and severity of these disabilities prevent him from performing gainful employment for which his education and occupational experience would otherwise qualify him. CONCLUSIONS OF LAW 1. The May 2006 rating decision is final with regard to the issue of service connection for dermatitis. New and material evidence sufficient to reopen the claim of service connection for a skin disability has been received. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2017). 2. The February 2013 rating decision is final with regard to the issue of service connection for hypertension. New and material evidence has not been received to reopen a claim for service connection for hypertension. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 3. The February 2013 rating decision is final with regard to the issue of service connection for peripheral vascular disease of the lower extremities. New and material evidence has not been received to reopen a claim for service connection for peripheral vascular disease of bilateral lower extremities. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 4. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for a heart disability have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 5. The criteria for entitlement to an effective date prior to February 25, 2013, for the grant of service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105 (2012); 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103 (2017). 6. The criteria for entitlement to an effective date prior to February 25, 2013, for the grant of service connection for tinnitus are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 7. The criteria for entitlement to an effective date prior to October 29, 2010, for the grant of service connection for diabetes mellitus are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 8. The criteria for entitlement to an effective date prior to October 29, 2010, for the grant of service connection for peripheral neuropathy of the left upper extremity are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 9. The criteria for entitlement to an effective date prior to October 29, 2010, for the grant of service connection for peripheral neuropathy of the right upper extremity are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 10. The criteria for entitlement to an effective date prior to October 29, 2010, for the grant of service connection for peripheral neuropathy of the left lower extremity are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 11. The criteria for entitlement to an effective date prior to October 29, 2010, for the grant of service connection for peripheral neuropathy of the right lower extremity are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 12. During the period on appeal, the criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100 (2017). 13. There is no legal basis for the assignment of a schedular rating in excess of 10 percent for tinnitus. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.87, Diagnostic Code 6260 (2017). 14. From October 29, 2010 to June 22, 2015, the criteria for a rating in excess of 10 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.119, Diagnostic Code 7913 (2017). 15. On and after June 23, 2015, the criteria for a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.119, Diagnostic Code 7913. 16. On and after October 29, 2010, the criteria for a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.124a, Diagnostic Code 8513 (2017). 17. On and after October 29, 2010, the criteria for a rating in excess of 20 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.124a, Diagnostic Code 8513. 18. Effective August 20, 2015, the criteria for a 20 percent rating for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.124a, Diagnostic Code 8520 (2017). 19. Effective August 20, 2015, the criteria for a 20 percent rating for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.124a, Diagnostic Code 8520. 20. With resolution of reasonable doubt in the Veteran’s favor, on and after March 9, 2015, the criteria for a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2017). 21. With resolution of reasonable doubt in the Veteran’s favor, the criteria for the award of a TDIU have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Navy from October 1965 to September 1969, including service in the Republic of Vietnam during the Vietnam Era. These matters are on appeal from January 2012, October 2013, July 2015, September 2015, and November 2016 rating decisions. As described in further detail below, the Veteran’s attorney has contended in a March 2017 statement that the Veteran is unemployable as a result the combined effect of his service-connected disabilities. The Board finds that the issue of entitlement to a TDIU has been raised by the March 2017 statement in connection with the claims on appeal for increased ratings. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor his attorney have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (2017). In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Skin Disability – New and Material Evidence The Veteran contends that he has a skin disability that is etiologically related to his active duty service. In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured to that claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence is neither cumulative nor redundant of evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). However, evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343, 1347 (Fed. Cir. 2000). In deciding whether new and material evidence has been submitted, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is generally “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Until the Veteran meets his threshold burden of submitting new and material evidence sufficient to reopen his claim of entitlement to service connection, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). The Veteran was denied service connection for dermatitis in a May 2006 rating decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the rating decision. Therefore, the May 2006 rating decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the May 2006 denial was a lack of evidence of a nexus to service. The Veteran’s request to reopen his claim for service connection for dermatitis was denied in an August 2012 rating decision. The basis for the August 2012 denial was a lack of new and material evidence. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in August 2012, that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has a skin disability as a result of active duty service. The evidence that was of record at the time of the August 2012 rating decision included the Veteran’s service treatment records, VA and private treatment records, VA and private treatment records, and lay statements. Since the August 2012 rating decision, the Veteran has provided a September 2012 private examination. The examiner opined that it is at least as likely as not that the Veteran’s skin disability is due to his service-connected diabetes mellitus. As the record now contains more evidence pertinent to the issue of nexus to service than it did in August 2012, the Board finds that new and material evidence has been received which pertains to previously unestablished facts necessary to support the claim. As this evidence raises a reasonable possibility of substantiating the claim, satisfying the criteria of 38 C.F.R. § 3.156(a) for new and material evidence, the claim is reopened. Because this evidence was submitted within one year of the August 2012 rating decision, that rating decision has not become final and the new evidence is considered as having been filed in connection with the claim denied in August 2012. 38 C.F.R. § 3.156(b) (2017). 2. Hypertension – New and Material Evidence The Veteran contends that he has hypertension that is etiologically related to his active duty service. The Veteran was denied service connection for hypertension in an August 2012 rating decision. He submitted additional evidence and the claim was denied again in a February 2013 rating decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the February 2013 rating decision. Therefore, the August 2012 and February 2013 rating decisions are final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the August 2012 and February 2013 denials was a lack of evidence of nexus to service. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in February 2013 that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has hypertension as a result of active duty service. The evidence that was of record at the time of the February 2013 rating decision included the Veteran’s service treatment records, VA and private treatment records, and VA and private examination reports. Since the February 2013 rating decision, the Veteran has not presented any non-cumulative evidence which indicates that there is a nexus between any current hypertension and any injury or illness in service. Because the evidence received since the last final decision is cumulative of the evidence already of record and does not provide a reasonable possibility of substantiating the claim, the Veteran has not submitted and VA has not otherwise received new and material evidence and the claim of entitlement to service connection for hypertension is not reopened. 3. Peripheral Vascular Disease of the Lower Extremities – New and Material Evidence The Veteran contends that he has peripheral vascular disease of bilateral lower extremities that is etiologically related to his active duty service. The Veteran was denied service connection for peripheral vascular disease of bilateral lower extremities in a May 2006 rating decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the rating decision. Therefore, the May 2006 rating decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the May 2006 denial was a lack of evidence of a nexus to service. The Veteran’s request to reopen his claim for service connection for peripheral vascular disease of bilateral lower extremities was denied in an August 2012 rating decision. The basis for the August 2012 denial was a lack of new and material evidence. He submitted additional evidence and the claim was denied again in a February 2013 rating decision. Although the Agency of Original Jurisdiction (AOJ) referred to the claim as “reopened,” it specifically found that the additional evidence submitted was not new and material. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the February 2013 rating decision. Therefore, the August 2012 and February 2013 rating decisions are final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in February 2013 that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has peripheral vascular disease of bilateral lower extremities as a result of active duty service. The evidence that was of record at the time of the February 2013 rating decision included the Veteran’s service treatment records, VA and private treatment records, and VA and private examination reports. Since the February 2013 rating decision, the Veteran has not presented any non-cumulative evidence which indicates that there is a nexus between any current peripheral vascular disease of bilateral lower extremities and any injury or illness in service. Because the evidence received since the last final decision is cumulative of the evidence already of record and does not provide a reasonable possibility of substantiating the claim, the Veteran has not submitted and VA has not otherwise received new and material evidence and the claim of entitlement to service connection for peripheral vascular disease of bilateral lower extremities is not reopened. 4. Heart Disability – Service Connection The Veteran contends that he has ischemic heart disease as a result of exposure to herbicides in Vietnam. Because the Veteran’s service records indicate service in the Republic of Vietnam from January 1967 to April 1968, he is presumed to have been exposed to herbicides. 38 C.F.R. § 3.307. Certain diseases are deemed associated with herbicide exposure under current law. The list of those diseases includes ischemic heart disease. 38 C.F.R. § 3.309(e). The Veteran has provided an April 2011 private examination in which the examiner diagnosed ischemic heart disease. The Board therefore finds that it is at least as likely as not that the Veteran has ischemic heart disease, which is presumptively service-connected. Accordingly, service connection for a heart disability is granted on this basis. Effective Dates Unless specifically provided otherwise by statute, the effective date of an award for compensation benefits based on (1) an original claim, (2) a claim reopened after final adjudication, or (3) a claim for increase, is the date VA received the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400; Lalonde v. West, 12 Vet. App. 377, 382 (1999). With regard to a claim for increase, the effective date can be up to one year earlier than the date of the claim if it is factually ascertainable, based on all evidence of record, that an increase in disability occurred within one year of the date of claim. 38 C.F.R. § 3.400. 5. Bilateral Hearing Loss – Effective Date The Veteran contends that he should be granted an effective date earlier than February 25, 2013, for service connection for bilateral hearing loss. The Veteran first submitted a claim for entitlement to service connection for bilateral hearing loss on February 25, 2013. The Board has reviewed the claims file for any document, submitted before the Veteran’s February 25, 2013, claim, that could be considered a claim for service connection. Lalonde, 12 Vet. App. at 381. Prior to March 24, 2015, a “claim” was defined as “a formal or informal communication in writing requesting a determination of entitlement[,] or evidencing a belief in entitlement, to a benefit.” 38 C.F.R. § 3.1(p) (2015). Any communication or action that (1) indicates an “intent to apply for one or more [VA] benefits” and (2) “identif[ies] the benefit sought” may be considered an informal claim. 38 C.F.R. § 3.155(a) (2015). The Board has found no communication from the Veteran to VA that could be construed as a claim of entitlement to service connection for bilateral hearing loss prior to the claim submitted on February 25, 2013. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than February 25, 2013, for service connection for bilateral hearing loss, which is the date of the claim that led to the grant of service connection. 6. Tinnitus – Effective Date The Veteran contends that he should be granted an effective date earlier than February 25, 2013, for service connection for tinnitus. The Veteran first submitted a claim for entitlement to service connection for tinnitus on February 25, 2013. The Board has reviewed the claims file for any document, submitted before the Veteran’s February 25, 2013, claim, that could be considered a claim for service connection. The Board has found no communication from the Veteran to VA that could be construed as a claim of entitlement to service connection for tinnitus prior to the claim submitted on February 25, 2013. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than February 25, 2013, for service connection for tinnitus, which is the date of the claim that led to the grant of service connection. 7. Diabetes Mellitus – Effective Date The Veteran contends that he should be granted an effective date earlier than October 29, 2010, for service connection for diabetes mellitus. The Veteran first submitted a claim for entitlement to service connection for diabetes on February 23, 2011. In a November 2012 rating decision, VA granted service connection for diabetes mellitus, type II, and assigned an effective date of February 23, 2011. Later, in a November 2016 rating decision granting service connection for peripheral neuropathy as secondary to the Veteran’s service-connected diabetes mellitus, VA liberally interpreted the Veteran’s October 29, 2010 claim for entitlement to service connection for peripheral neuropathy to include a claim for entitlement to service connection for diabetes mellitus and changed the effective date of service connection to reflect this. The Board has reviewed the claims file for any document, submitted before the Veteran’s October 29, 2010, claim, that could be considered a claim for service connection. The Board has found no communication from the Veteran to VA that could be construed as a claim of entitlement to service connection for diabetes mellitus prior to the claim submitted on October 29, 2010. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than October 29, 2010, for service connection for diabetes mellitus, which is the date of the earliest claim that VA has interpreted to include a claim for service connection for diabetes mellitus. 8. Peripheral Neuropathy –Upper Extremities – Effective Date The Veteran contends that he should be granted an effective date earlier than October 29, 2010, for service connection for peripheral neuropathy of the upper extremities. The Veteran first submitted a claim for entitlement to service connection for peripheral neuropathy of the upper and lower extremities on October 29, 2010. The Board has reviewed the claims file for any document, submitted before the Veteran’s October 29, 2010, claim, that could be considered a claim for service connection. The Board has found no communication from the Veteran to VA that could be construed as a claim of entitlement to service connection for peripheral neuropathy of either upper extremity prior to the claim submitted on October 29, 2010. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than October 29, 2010, for service connection for peripheral neuropathy of either upper extremity, which is the date of the claim that led to the grant of service connection. 9. Peripheral Neuropathy –Lower Extremities – Effective Date The Veteran contends that he should be granted an effective date earlier than October 29, 2010, for service connection for peripheral neuropathy of the lower extremities. The Veteran first submitted a claim for entitlement to service connection for continuing rash, scaling and burning in his extremities in March 2006. Elsewhere in the claim, the Veteran clarified that the reference to burning in his extremities referred to pain in his legs. The Board liberally interprets this as including a claim for service connection for peripheral neuropathy of the lower extremities. VA denied that claim in May 2006 and the Veteran did not submit a notice of disagreement or additional evidence within the one year period following the decision. The decision became final and not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. The Board has reviewed the claims file for any document, submitted after the May 2006 rating decision but before the Veteran’s October 29, 2010, claim, that could be considered a claim for service connection for peripheral neuropathy of the lower extremities. The Board has found no communication from the Veteran to VA that could be construed as a request to reopen the claim of entitlement to service connection for peripheral neuropathy of the lower extremities prior to the claim submitted on October 29, 2010. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. In order for the Veteran to be awarded an effective date based on the claim that was denied in the May 2006 rating decision, he has to show clear and unmistakable error (CUE) in the prior denial as a collateral attack. Flash v. Brown, 8 Vet. App. 332, 340 (1995). Neither the Veteran nor his attorney have raised CUE to overcome the finality of the May 2006 rating decision denying service connection. Any claim of CUE must be pled with specificity. See Andre v. Principi, 301 F.3d 1354 (Fed. Cir. 2002). This specific allegation must assert more than merely disagreement with how the facts of the case were weighed or evaluated. Persuasive reasons must be given as to why the result would have been manifestly different but for the alleged error. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than October 29, 2010, for service connection for peripheral neuropathy of either lower extremity, which is the date of the claim that led to the grant of service connection. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017). 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. “Staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claims for higher initial evaluations with the exception of the PTSD claim, the Board has considered all evidence of severity since the effective dates for the awards of service connection for those claims. Fenderson v. West, 12 Vet. App. 119 (1999). With regard to the PTSD claim, when entitlement to compensation has already been established and an increased rating is at issue, the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. at 509; see also 38 U.S.C. § 5110(b)(2) (2012); 38 C.F.R. § 3.400(o)(2) (2017). 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. 10. Bilateral Hearing Loss – Increased Rating The Veteran contends that his service-connected bilateral hearing loss warrants a compensable rating. It is currently service-connected with a noncompensable rating on and after February 25, 2013. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. §§ 3.385, 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). In September 2013, the Veteran was afforded a VA examination. The examiner diagnosed bilateral sensorineural hearing loss. The hearing examination results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 55 60 LEFT 20 15 25 55 60 The pure tone average in the right ear was 38 and the pure tone average in the left ear was 39. Speech recognition was 96 percent in the right ear and 98 percent in the left ear. The examiner noted the Veteran’s report of functional impact in the form of needing to ask people to repeat themselves. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The findings from the September 2013 VA examination require the use of Table VI for each ear. Applying the findings to that table yields findings of Level I hearing loss in each ear. 38 C.F.R. § 4.85, Diagnostic Code 6100. Where hearing loss is at Level I in each ear, a noncompensable rating is assigned under Table VII. Id. In August 2015, the Veteran was afforded an additional VA examination. The examiner diagnosed bilateral sensorineural hearing loss. The hearing examination results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 30 60 70 LEFT 25 10 25 65 70 The pure tone average in the right ear was 44 and the pure tone average in the left ear was 43. Speech recognition was 86 percent in the right ear and 92 percent in the left ear. The examiner noted the Veteran’s report of functional impact in the form of needing to ask people to repeat themselves. 38 C.F.R. § 4.10; Martinak, 21 Vet. App. 447. The findings from the August 2015 VA examination require the use of Table VI for each ear. Applying the findings to that table yields findings of Level II hearing loss the right ear and Level I hearing loss in the left ear. 38 C.F.R. § 4.85, Diagnostic Code 6100. Where hearing loss is at Level II in one ear and Level I in the other ear, a noncompensable rating is assigned under Table VII. Id. Other than his statements during the VA examinations cited above, the Veteran has not offered any lay statements as to the severity of his hearing loss during the period on appeal. To the extent that those statements and the fact that he appealed the assigned rating constitute assertions that his hearing loss is worse than its currently assigned noncompensable rating, he is competent to report a decrease in hearing acuity and his statements during the examination are credible. The Board acknowledges the Veteran’s complaints regarding the impact of hearing loss on his daily life, but his lay assertions do not constitute competent evidence to indicate that his hearing disability is worse than has been recorded in his VA examination or that hearing loss has functionally affected the Veteran in any more severe ways than have been discussed in the record and were already considered by medical professionals. The competence of a lay person to provide a medical opinion must be determined on a case by case basis. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran in this case is not competent to make such a conclusion. Determining the severity of hearing loss involves using specialized equipment and interpreting audiological test results. The record does not show that the Veteran possesses the training or experience needed to accomplish these actions. The probative value of his assertions is low. The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, difficulty hearing speech, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Martinak, 21 Vet. App. 447. In brief, the medical examination findings are of greater probative value than the Veteran’s allegations regarding the severity of his hearing loss and the nature of any functional impairment is adequately reflected by those medical findings. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable rating for hearing loss. 11. Tinnitus – Increased Rating The Veteran contends that his tinnitus warrants a higher rating than that currently assigned. It is currently rated under 38 C.F.R. § 4.87, Diagnostic Code 6260, with a 10 percent rating on and after February 25, 2013. Diagnostic Code 6260 pertains to recurrent tinnitus and provides for only one rating: 10 percent. 38 C.F.R. § 4.87, Diagnostic Code 6260. The Veteran’s tinnitus has been assigned that rating throughout the period on appeal. Because the Veteran’s tinnitus has been assigned the maximum schedular rating throughout the period on appeal, the Board finds there is no legal basis upon which to award a higher schedular evaluation for tinnitus. As such, entitlement to a rating for tinnitus in excess of 10 percent is not warranted on a schedular basis. See Sabonis v. Brown, 6 Vet. App. 426 (1994). 12. Diabetes Mellitus – Increased Rating The Veteran contends that his diabetes warrants higher ratings than those currently assigned. It is currently rated under 38 C.F.R. § 4.119, Diagnostic Code 7913, with a 10 percent rating from October 29, 2010 to June 22, 2015 and a 20 percent rating on and after June 23, 2015. For diabetes manageable by a restricted diet only, a 10 percent rating is warranted. 38 C.F.R. § 4.119, Diagnostic Code 7913. For diabetes requiring insulin and restricted diet, or requiring an oral hypoglycemic agent and a restricted diet, a 20 percent rating is warranted. Id. For diabetes requiring insulin, a restricted diet, and regulation of activities, a 40 percent rating is warranted. Id. Any rating higher than 40 percent requires other factors in addition to those three. Id. Regulation of activities is described as “avoidance of strenuous occupational and recreational activities.” Id. Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). The Veteran was afforded a VA examination in February 2012. The examiner found that the Veteran’s diabetes was managed by a restricted diet only and did not require regulation of activities. The examiner also found that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times per month, that he had not been hospitalized for episodes of either in the past year, and that he did not have progressive unintentional weight loss and loss of strength attributable to his diabetes. The examiner found that the Veteran’s diabetes mellitus would have no impact on his ability to work. The Veteran has provided a March 2012 statement by his private treating physician, who reported that he was a “diet controlled type II diabetic.” The Veteran has also provided a September 2012 examination by the same private treating physician. The examiner found that the Veteran’s diabetes was managed by a restricted diet only and did not require regulation of activities. The examiner also found that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times per month, that he had not been hospitalized for episodes of either in the past year, and that he did not have progressive unintentional weight loss and loss of strength attributable to his diabetes. The examiner found that the Veteran’s diabetes mellitus would only have an impact on his ability to work if considering associated neuropathy, which is now separately service-connected. A June 2015 private treatment record indicates that the Veteran began to take Metformin on June 23, 2015. Metformin is an oral antihyperglycemic agent, i.e., a hypoglycemic agent. Dorland’s Illustrated Medical Dictionary, 1146 (32nd Ed. 2012). The Veteran was afforded an additional VA examination in August 2015. The examiner found that the Veteran’s diabetes required oral hypoglycemic agents but did not require regulation of activities. The examiner noted that the Veteran had been taking Metformin for the past six months. The examiner also found that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times per month, that he had not been hospitalized for episodes of either in the past year, and that he did not have progressive unintentional weight loss and loss of strength attributable to his diabetes. The examiner found that the Veteran’s diabetes mellitus would have no impact on his ability to work. The preponderance of the evidence shows that the Veteran does not meet the schedular criteria for a rating in excess of 10 percent for diabetes mellitus from October 29, 2010 to June 22, 2015. During this period, the preponderance of the evidence does not show that the Veteran’s diabetes required the use of an oral hypoglycemic agent. Examiners and treatment providers during this period all reported that the Veteran’s diabetes was managed by restricted diet only. The Board notes the August 2015 examiner’s finding that the Veteran had been taking Metformin for six months but finds that the probative value of this finding is outweighed by the private treatment record listing the specific date on which the Veteran began taking Metformin as June 23, 2015. As the schedular criteria for every rating in excess of 10 percent require insulin or an oral hypoglycemic agent, a rating in excess of 10 percent is not warranted. The preponderance of the evidence shows that the schedular criteria for a rating in excess of 20 percent for diabetes mellitus on and after June 23, 2015 are not met. During this period, there is no medical evidence that the Veteran’s diabetes required regulation of activities. As the criteria for every rating in excess of 20 percent require regulation of activities, a rating in excess of 20 percent is not warranted. The Board has also taken the Veteran’s lay statements into account. The Veteran is competent to report his own observations with regard to the symptomatology of his diabetes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). His statements are also credible. However, as stated above, nothing in the Veteran’s lay statements indicates that there is medical evidence that his diabetes requires regulation of physical activity. 13. Peripheral Neuropathy –Upper Extremities – Increased Rating The Veteran contends that his peripheral neuropathy of the upper extremities warrants a higher rating than that currently assigned. His left upper extremity is currently rated under 38 C.F.R. § 4.124a, Diagnostic Code 8513, for paralysis of all radicular groups, with a 20 percent rating on and after October 29, 2010. The Veteran is right-handed. 38 C.F.R. § 4.124a, Diagnostic Code 8513 pertains to paralysis of all radicular groups. Regarding the left upper extremity, under Diagnostic Code 8513, paralysis of all radicular groups in the minor extremity is rated as follows: complete paralysis (80 percent); severe incomplete paralysis (60 percent); moderate incomplete paralysis (30 percent); and mild incomplete paralysis (20 percent). When the involvement is wholly sensory, the rating should be for the mild or, at most, the moderate degree. See Note at “Diseases of the Peripheral Nerves” in 38 C.F.R. § 4.124(a). Regarding the right upper extremity, under Diagnostic Code 8513, paralysis of all radicular groups in the major extremity is rated as follows: complete paralysis (90 percent); severe incomplete paralysis (70 percent); moderate incomplete paralysis (40 percent); and mild incomplete paralysis (20 percent). When the involvement is wholly sensory, the rating should be for the mild or, at most, the moderate degree. Id. During a November 2010 private treatment appointment, the Veteran reported numbness and tingling in his hands for a few years that had plateaued in the past few months. On examination, he had normal strength, bulk, and tone, there was dullness to light touch throughout the hands, and reflexes were brisk but symmetrical. The Veteran has provided a September 2012 examination by his private treating physician. The examiner found that the Veteran’s neuropathy would have an impact on his ability to work but did not provide further details regarding the nature of this impact. The Veteran was afforded a VA examination in February 2013. The Veteran reported no constant pain, intermittent pain, or numbness, but reported moderate paresthesias and/or dysesthesias in both upper extremities. On examination, strength and reflexes were normal bilaterally. Light touch/monofilament testing found decreased sensation in the hands and fingers bilaterally. There was no muscle atrophy and there were no trophic changes attributable to diabetic peripheral neuropathy. The Veteran was afforded an additional VA examination in August 2015. The Veteran reported tingling and numbness in his fingertips and having some difficulty with dexterity using his fingers. The Veteran reported no constant pain, moderate intermittent pain, severe paresthesias and/or dysesthesias, and severe numbness in both upper extremities bilaterally. On examination, strength and reflexes were normal bilaterally. Light touch/monofilament testing, position sense, and vibration sensation were normal bilaterally. There was no muscle atrophy and there were no trophic changes attributable to diabetic peripheral neuropathy. The examiner found mild incomplete paralysis of the left radial (musculospiral) nerve, median nerve, and ulnar nerve. The examiner found that the Veteran’s peripheral neuropathy would have a functional impact in the form of difficulty with dexterity using the fingers and difficulty driving due to numbness in his hands. With regard to the left upper extremity, the Board finds that his disability picture is more accurately described as moderate, warranting a 30 percent rating for the minor arm. With regard to the right upper extremity, the Board finds that his disability picture is more accurately described as moderate, warranting a 40 percent rating is warranted for the major arm. Both of these increased ratings are is based on the August 2015 VA examination, which documented the most severe symptoms that were equal in both upper extremities. Although the August 2015 VA examiner described the overall severity as mild, severe paresthesias and/or dysesthesias and severe numbness were noted, as was moderate intermittent pain. The only absent symptom was constant pain. The findings of moderate and severe symptoms are more consistent with moderate incomplete paralysis under Diagnostic Code 8513. A 30 percent rating is granted for left upper extremity peripheral neuropathy. However, at his August 2015 VA examination, as noted above, reflexes, sensation to light touch/monofilament, position sense, and vibration were all normal in the left upper extremity. This does not support a finding that severe incomplete paralysis is present in either upper extremity. The Board has considered the Veteran’s lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his peripheral neuropathy of the upper extremities. See Jandreau, 492 F.3d at 1376-77. However, nothing in those statements is incompatible with the assigned rating. The Board has considered the other Diagnostic Codes that apply to impairment of nerves of the upper extremities, but none of these provide for a rating greater than 30 percent for mild incomplete paralysis of the left (minor) upper extremity and 40 percent for the right (major) upper extremity. 38 C.F.R. § 4.124a, Diagnostic Codes 8510-8519. 14. Peripheral Neuropathy –Lower Extremities – Increased Rating The Veteran contends that his peripheral neuropathy of the lower extremities warrants a higher rating than that currently assigned. Each lower extremity is separately currently rated under 38 C.F.R. § 4.124a, Diagnostic Code 8520, for paralysis of the sciatic nerve, with a 10 percent rating on and after October 29, 2010. 38 C.F.R. § 4.124a, Diagnostic Code 8520 pertains to paralysis of the sciatic nerve. Under Diagnostic Code 8520, paralysis of the sciatic nerve is rated as follows: complete paralysis (80 percent); severe incomplete paralysis with marked muscular atrophy (60 percent); moderately severe incomplete paralysis (40 percent); moderate incomplete paralysis (20 percent); and mild incomplete paralysis (10 percent). When the involvement is wholly sensory, the rating should be for the mild or, at most, the moderate degree. See note at “Diseases of the Peripheral Nerves” in 38 C.F.R. § 4.124(a). During a November 2010 private treatment appointment, the Veteran had normal strength, bulk, and tone and reflexes were brisk but symmetrical. The Veteran was afforded a VA examination in February 2012 in which the examiner noted peripheral neuropathy on the bottoms of the Veteran’s feet. The Veteran has provided a September 2012 examination by his private treating physician. The examiner found that the Veteran’s neuropathy would have an impact on his ability to work but did not provide further details regarding the nature of this impact. The Veteran was afforded an additional VA examination in February 2013. The Veteran reported no constant pain, intermittent pain, or numbness, but reported moderate paresthesias and/or dysesthesias in both lower extremities. On examination, strength and reflexes were normal. Light touch/monofilament testing found decreased sensation in the feet and toes. There was no muscle atrophy and there were no trophic changes attributable to diabetic peripheral neuropathy. The Veteran was afforded an additional VA examination in August 2015. The Veteran reported numbness in his feet. The Veteran reported no constant pain, paresthesias and/or dysesthesias, or numbness, but moderate intermittent pain. On examination, strength and reflexes were normal, with the exception of absent ankle reflexes. Light touch/monofilament testing was normal, with the exception of decreased sensation in the feet and toes. Position sense was normal. Vibration sensation was decreased. There was no muscle atrophy and there were no trophic changes attributable to diabetic peripheral neuropathy. The examiner found mild incomplete paralysis of the left sciatic nerve and no paralysis of the femoral (anterior crural) nerve. The examiner found that the Veteran’s peripheral neuropathy would have a functional impact but only described an impact from his upper extremity neuropathy. The preponderance of the evidence shows that the Veteran’s peripheral neuropathy of lower extremities does not warrant a rating in excess of 10 percent for either extremity prior to August 20, 2015. No VA or private examiner found more than mild incomplete paralysis of the right sciatic nerve during the period on appeal. Significantly, in February 2013, he had essentially no symptoms other than moderate paresthesias/dysesthesias and decreased sensation in his feet/toes. He did not provide lay statements describing his symptoms. The August 20, 2015 examination showed the worst results, noting that intermittent pain, paresthesias/dysesthesias, and numbness were moderate bilaterally, his ankle reflex was absent bilaterally, his feet/toes had decreased sensation, and his lower extremities had decreased vibration sensation. No symptoms were described as severe. There was no constant pain. Strength and knee reflexes were normal. Sensory examination was normal for the knees/thighs and ankles/lower legs. The symptoms described at the examination are more consistent with moderate incomplete paralysis. A 20 percent rating is granted for each lower extremity, effective August 20, 2015, which is the first date that the record showed the presence of these symptoms. However, severe incomplete paralysis is not present in either lower extremity. The August 2015 VA examiner did not describe any of the Veteran’s symptoms as severe, and with the exception of the abnormalities described above, testing was normal. The Veteran did not provide lay statements describing his symptoms on or after August 20, 2015. The Board has considered the other Diagnostic Codes that apply to impairment of nerves of the lower extremities, but none of these provide for higher ratings. 38 C.F.R. § 4.124a, Diagnostic Codes 8520-8530. 15. PTSD – Increased Rating The Veteran contends that his PTSD warrants a higher rating than that currently assigned. It is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, for PTSD, with a 50 percent rating on and after April 18, 2012. VA received the Veteran’s claim for an increased rating on March 9, 2015. Under 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 provides that 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; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent evaluation 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 situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is 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; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, occupation, or own name. Id. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. See Vazquez–Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). When evaluating the level of disability from a mental disorder, VA 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). The Veteran was afforded a VA examination in May 2015. The Veteran reported that he continued to live with his spouse but that her depression had had a negative effect on the Veteran and their relationship. He reported that he kept in regular touch with his children and had good friends. He also reported that he stopped doing side jobs in 2012 due to a combination of neuropathy and difficulty with concentration and focus. He also reported nightmares about twice a week as well as flashbacks. He reported that he worked hard to be in a good mood but was not always successful and his motivation had decreased. He was capable of completing personal hygiene tasks. The examiner listed the Veteran’s symptoms for rating purposes as depressed mood, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He was neatly groomed, with appropriate thought content, linear and goal directed thought processes, good insight, fair judgment, anxious mood, constricted affect, and intact memory, attention, and concentration. He denied any suicidal or homicidal ideation, delusions, or hallucinations. The examiner also noted that the Veteran was more socially withdrawn and struggled to engage appropriately with others. The examiner characterized the Veteran’s overall level of functional impairment as occupational and social impairment with reduced reliability and productivity, which is consistent with a 50 percent rating, and described his overall symptoms as increased since 2012 but moderate. The Veteran has also submitted a February 2017 examination by a private psychologist. The Veteran reported that he had been married for 50 years and had one adult child. He reported that he kept his struggles to himself because he did not want to be a burden to others. He also reported being socially isolated and withdrawn. The examiner listed the Veteran’s symptoms for rating purposes as depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships. The Veteran detailed what the examiner characterized as “great ongoing difficulty with his symptom pattern” and reported that he could no longer enjoy the simplest of activities. His attention was normal and his concentration appeared variable. He reported increased trouble with short and long term memory and struggled to remember basic information. His speech flow was normal but brief with information offered. His thought content was appropriate for the circumstances and organization of thought was goal directed. There was no report of overt hallucinations. He reported feeling anxious and depressed and his affect was restricted. The examiner noted that the Veteran was “vague with response, suspicious and seems rather vigilant” during the examination. The examiner characterized the Veteran’s overall level of functional impairment as occupational and social impairment with deficiencies in most areas, which is consistent with a 70 percent rating. The examiner further opined that the Veteran would frequently miss work, need to leave early, or be unable to stay focused to complete simple, repetitive tasks due to his psychiatric symptoms and would respond in an angry manner without actually becoming violent when subjected to normal workplace stressors more than once a month. The examiner also opined that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD, that his sleep impairment and anxiety presented safety issues, and that his poor interpersonal skills and workplace trust issues would cause him to struggle with appropriate work interaction. Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, his psychiatric symptoms and overall disability picture warrant an evaluation of 70 percent for PTSD throughout the period on appeal. During that period, the record contains evidence of near-continuous panic or depression, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. For this reason, the Board finds that Veteran’s symptoms most nearly approximate those that warrant a 70 percent rating throughout the period on appeal. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board does not, however, find the criteria for a 100 percent evaluation are more nearly approximated by the Veteran’s symptoms at any point during the period on appeal. The record does not contain evidence of any of the symptoms listed in the criteria for a 100 percent rating or symptoms similar to those listed in the 100 percent rating criteria, and even the constant presence of some symptoms listed in the criteria for a 100 percent rating would be insufficient because the overall guiding criterion for a 100 percent rating is that both total occupational and total social impairment be present. 38 C.F.R. § 4.130; see, e.g., Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). In this case, the Veteran’s symptoms have not been shown to be so severe that he has both total occupational and total social impairment. The Board acknowledges that, in this decision, it has found the Veteran to be unemployable due to his service-connected disabilities, but the Veteran has been able to maintain some personal relationships, specifically with his spouse, children, and friends. The Board acknowledges that these relationships are sometimes strained or distant, but that is reflected in the current 70 percent rating for “deficiencies in most areas,” including inability to establish and maintain effective relationships. Because the Veteran is not totally socially impaired, a 100 percent rating is not warranted. The Board also notes that many of the Veteran’s reported symptoms throughout the period on appeal are included among those specifically listed in the General Rating Formula for Mental Disorders, pursuant to which a 70 percent disability rating has been assigned. See 38 C.F.R. § 4.130. Importantly, the Board notes that symptoms noted in the rating schedule 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran’s extent of occupational and social impairment. Accordingly, in this case, the Board finds that the existence and severity of the Veteran’s psychiatric symptoms are adequately contemplated by the 70 percent rating criteria. As noted above, many of the symptoms are specifically listed in the General Rating Formula for Mental Disorders, and the others are common psychiatric symptoms that-while not specifically listed-are comparable indicators of the type of occupational and social impairment contemplated in the Rating Formula. The Board has also considered the Veteran’s assertions regarding his psychiatric symptoms, which he is competent to provide. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The lay evidence is also credible. The symptoms described in those lay statements comport with the 70 percent rating that has now been assigned. However, these lay statements do not provide any basis upon which to assign a higher rating because they do not reflect total social impairment. In sum, the Board finds that, resolving reasonable doubt in the Veteran’s favor, his impairment due to PTSD has been most consistent with a 70 percent disability rating throughout the period on appeal. 16. TDIU VA will grant a total disability rating when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from securing and following substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the purposes meeting the requirement of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16 (a). The Veteran’s current combined disability rating, after the increased rating for PTSD granted above, is 90 percent: his PTSD is rated 70 percent disabling, his peripheral neuropathy of the left upper extremity is rated 20 percent disabling, his peripheral neuropathy of the right upper extremity is rated 20 percent disabling, his diabetes mellitus is rated 20 percent disabling, his peripheral neuropathy of the left lower extremity is rated 10 percent disabling, his peripheral neuropathy of the right lower extremity is rated 10 percent disabling, his tinnitus is rated 10 percent disabling, and his erectile dysfunction and bilateral hearing loss have noncompensable ratings. See 38 C.F.R. § 4.25 (2017). The Veteran’s heart disability, for which service connection is granted above, has not yet been rated. The criteria for consideration of a schedular TDIU are therefore met. The Board has discussed the evidence regarding occupational impairment caused by the Veteran’s PTSD in the context of the increased rating claim above. In addition, the Veteran has provided a January 2017 opinion by a private examiner who found that, as a result of the Veteran’s service-connected disabilities, he could only consistently stand, walk or sit for less than two hours, could only consistently lift or carry less than ten pounds, would need at least one additional break per day, and would not be able to remain focused for an entire workday at least three times a month. For these reasons, the examiner found that the Veteran would not be able to maintain substantially gainful employment as a result of his service-connected disabilities. The Veteran has also provided a February 2017 medical opinion by a private physician who also found that the Veteran’s service-connected disabilities combined to render him unable to maintain substantially gainful employment as a result of his mobility, pain, and physical limitations. The Veteran has also provided a March 2017 opinion by a private vocational consultant, who opined that the Veteran was totally and permanently precluded from substantially gainful employment due to the severity of his service-connected disabilities. The consultant cited studies regarding the frequency of absences and concentration difficulties employers are likely to be willing to tolerate and found that the Veteran’s service-connected disabilities would cause impairment beyond those levels. The Board therefore finds that the evidence is at least evenly balanced as to whether the Veteran’s service-connected disabilities have rendered him unemployable under the applicable regulations. As reasonable doubt must be resolved in favor of the Veteran, entitlement to a TDIU is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In reaching the conclusions above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claims except to the extent granted above, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Service connection for a skin disability is remanded. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was most recently afforded a VA examination of his skin in September 2013. The Veteran reported a rash that had waxed and waned over the past 45 years. The examiner found that the Veteran’s current skin disability was unrelated to his active duty service because of the length of time that had elapsed without evidence of continuity. The examiner checked the box for a positive nexus opinion while giving a rationale for a negative nexus opinion. In an addendum opinion later in September 2013, the examiner clarified that he intended a negative nexus opinion and characterized the Veteran’s in-service dermatitis as an “apparently isolated occurrence.” The examiner did not reconcile this with the Veteran’s reports of continuity of symptoms and did not discuss a March 2005 VA treatment record diagnosing dermatitis or the September 2012 private examiner’s opinion that the Veteran’s skin disability was caused by his service-connected diabetes mellitus. An additional examination is warranted to obtain an adequate nexus opinion. The matter is REMANDED for the following action: 1. Arrange for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s skin disability. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current skin disability had its origin in service or is related to the Veteran’s active service, including as a result of presumed exposure to herbicides. b. Whether it is as least as likely as not that any current skin disability was caused by the Veteran’s service-connected diabetes mellitus. c. Whether it is as least as likely as not that any current skin disability was aggravated beyond its natural progression by the Veteran’s service-connected diabetes mellitus. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: a. The Veteran’s April 1968 service treatment records showing hospitalization for “bullous dermatitis, cause undetermined.” b. The March 2005 VA treatment record diagnosing dermatitis. c. The Veteran’s lay statements in March 2006 and March 2011 regarding continuity of symptoms. d. The March 2011 lay statements from fellow service members regarding the onset of the Veteran’s skin condition in Vietnam. e. The September 2012 private examiner’s opinion that the Veteran’s skin disability was due to his diabetes mellitus. The examiner is advised that service connection can be established due to herbicide exposure by direct proof of causation, and that it is insufficient to conclude that there is no direct causation simply because the Veteran’s skin disability is not on the list of diseases and conditions that are presumptively associated with exposure to herbicide agents. The rationale for any opinion expressed should be provided. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 2. Readjudicate the claim. If the decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Ryan Frank, Counsel