Citation Nr: 1808866 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 16-43 745 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus, type 2 with hypertension, atherosclerotic vascular disease of the carotid arteries and erectile dysfunction. 2. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the right upper extremity. 3. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity. 4. Entitlement to an initial disability rating in excess of 20 percent prior to July 8, 2016 and 10 percent beginning on July 8, 2016 for peripheral neuropathy of the left lower extremity, sciatic nerve. 5. Entitlement to an initial disability rating in excess of 20 percent prior to July 8, 2016 and 10 percent beginning on July 8, 2016 for peripheral neuropathy of the right lower extremity, sciatic nerve. 6. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, femoral nerve. 7. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, femoral nerve. 8. Entitlement to an initial disability rating in excess of 60 percent for peripheral vascular disease of the right lower extremity. 9. Entitlement to an initial disability rating in excess of 60 percent for peripheral vascular disease of the left lower extremity. ATTORNEY FOR THE BOARD K. Churchwell, Associate Counsel INTRODUCTION The Veteran had active duty service from February 1967 to February 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The jurisdiction has since been transferred to the Chicago, Illinois RO. The September 2013 rating decision granted service connection for right and left upper extremity, peripheral neuropathy and assigned a 10 percent disability rating effective January 11, 2012. Additionally, evaluation of diabetes mellitus with hypertension, atherosclerotic vascular disease of the carotid arteries and erectile dysfunction was continued. Lastly, evaluation of diabetic polyneuropathy of the left and right lower extremities which was rated at 20 percent disabling was continued. Thereafter, the August 2016 rating decision granted service connection for peripheral vascular disease of the right and left lower extremity and assigned a 60 percent disability evaluation effective July 8, 2016. Moreover, service connection was granted for peripheral neuropathy of the right and left upper extremities and assigned a 20 percent disability rating effective January 11, 2012. Service connection was also granted for peripheral neuropathy of the femoral nerve in the right and left lower extremity and assigned a 10 percent disability rating effective July 8, 2016. Lastly, peripheral neuropathy of the sciatic nerve in the right and left lower extremities, which was evaluated as 20 percent disabling, was decreased to 10 percent effective July 8, 2016. The peripheral vascular disease is deemed a component of the lower extremity disability on appeal and thus the claim is expanded to include consideration of this disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran submitted an application for Increased Compensation based on Unemployability in June 2016. The August 2016 rating decision denied entitlement to individual unemployability and a Notice of Disagreement was not filed. Based on the previous denial of the issue and the lack of evidence in the record presently to support inferring the issue, the Board finds a claim for entitlement to individual unemployability is not presently before the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's type II diabetes mellitus required insulin and a restricted diet, but not restriction of activities. 2. Throughout the period on appeal, right upper extremity peripheral neuropathy did not result in moderately severe or severe paralysis of the sciatic nerve. 3. Throughout the period on appeal, left upper extremity peripheral neuropathy did not result in moderately severe or severe incomplete paralysis of the sciatic nerve. 4. Prior to July 8, 2016, left lower extremity peripheral neuropathy did not result in moderately severe or severe incomplete paralysis of the sciatic nerve. Beginning on July 8, 2016, the Veteran's service-connected left lower extremity peripheral neuropathy resulted in no more than mild paralysis of the sciatic nerve. 5. Prior to July 8, 2016, right lower extremity peripheral neuropathy did not result in moderately severe or severe paralysis of the sciatic nerve. Beginning on July 8, 2016, the Veteran's service-connected right lower extremity peripheral neuropathy resulted in no more than mild incomplete paralysis of the sciatic nerve. 6. Throughout the period on appeal, peripheral neuropathy of the left lower extremity did not result in moderate or severe paralysis of the femoral nerve. 7. Throughout the period on appeal, peripheral neuropathy of the right lower extremity did not result in moderate or severe paralysis of the femoral nerve. 8. Throughout the period on appeal, peripheral vascular disease of the right lower extremity has not resulted in ischemic limb pain at rest and there is no showing of either deep ischemic ulcers or ABI of 0.4 or less. 9. Throughout the period on appeal, peripheral vascular disease of the left lower extremity has not resulted in ischemic limb pain at rest and there is no showing of either deep ischemic ulcers or ankle-brachial index (ABI) of 0.4 or less. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for service-connected type II diabetes mellitus, including erectile dysfunction and hypertension, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.103, 3.105, 3.159, 3.321, 3.340, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.15, 4.16, 4.25, 4.79, Diagnostic Code (DC) 4.119, DC 7101, 7913, 4.115b, DC 7522 (2017). 2. The criteria for the assignment of a rating in excess of 20 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8520 (2017). 3. The criteria for the assignment of a rating in excess of 20 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8520 (2017). 4. The criteria for the assignment of a rating in excess of 20 percent prior to July 8, 2016 and 10 percent beginning on July 8, 2016 for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8520 (2017). 5. The criteria for the assignment of a rating in excess of 20 percent prior to July 8, 2016 and 10 percent beginning on July 8, 2016 for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8520 (2017). 6. The criteria for the assignment of a rating in excess of 10 percent for left lower extremity peripheral neuropathy of the femoral nerve have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8526 (2017). 7. The criteria for the assignment of a rating in excess of 10 percent for right lower extremity peripheral neuropathy of the femoral nerve have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8526 (2017). 8. The criteria for an initial disability rating in excess of 60 percent for service-connected peripheral vascular disease of the right lower extremity have not been met. 38 U.S.C. § 1155 (2012) 38 C.F.R. § 4.104, Diagnostic Code 7114 (2017). 9. The criteria for an initial disability rating in excess of 60 percent for service-connected peripheral vascular disease of the left lower extremity have not been met. 38 U.S.C. § 1155 (2012) 38 C.F.R. § 4.104, Diagnostic Code 7114 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). The duty to notify has been met. See March 2013 VCAA correspondence. Neither the Veteran, nor his representative, has alleged prejudice with regard to notice. The Federal Court of Appeals has held that "absent extraordinary circumstances...it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...." See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In light of the foregoing, nothing more is required. VA also has a duty to assist a claimant in the development of a claim. That duty includes assisting the claimant in the procurement of service and other relevant records and providing an examination when necessary. 38 U.S.C § 5103A (2012); 38 C.F.R. § 3.159 (2017). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has associated the Veteran's service treatment records and VA treatment records with the claims file. The Veteran was also afforded adequate examinations. An examination for erectile dysfunction was performed in June 2010, and examinations for diabetes mellitus were conducted in August 2013 and July 2016. The examiners considered the relevant history, provided a detailed description of the condition, and provided an extensive analysis to support the conclusions reached. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Legal Criteria for Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2017). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2017). 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 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. At 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. At 509. III. Diabetes Mellitus The Veteran's diabetes mellitus is rated as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913, effective December 7, 2007, which contemplates diabetes that requires insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is warranted when diabetes requires insulin, restricted diet, and regulation of activities. Regulation of activities is defined by DC 7913 as the avoidance of strenuous occupational and recreational activities. Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet.App. 360 (2007) (citing 61 Fed. Reg. 20,440 (May 7, 1996)). Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process. A VA examination was performed in August 2013. At that time, the Veteran was diagnosed with diabetes mellitus. The examiner noted the Veteran's diabetes mellitus was treated by managed restricted diet, prescribed insulin injection daily and prescribed oral hypoglycemic agent. The examiner also noted the Veteran did require regulation of activities as a part of medical management. As an example, the examiner stated that occasionally the Veteran had low sugar attacks due to too long between meals and is over active doing chores. The Veteran required less than two visits a month to a doctor for episodes of ketoacidosis or hypoglycemic reactions. Further, he required no hospitalizations for episodes of ketoacidosis or hypoglycemic reactions in the past year. He also had no loss of weight attributable to diabetes mellitus but did have progressive loss of strength attributable to diabetes mellitus. Erectile dysfunction was also noted as a condition associated with his diabetes mellitus. A July 2016 VA examination diagnosed diabetes mellitus. The treatment for his diabetes mellitus included management by restricted diet, prescribed oral hypoglycemia agent as well as insulin daily. The Veteran did not require regulation of activities as a part of medical management of his diabetes mellitus. Further, he required less than two visits per month to a doctor for episodes of ketoacidosis and hypoglycemia. Moreover, the Veteran had not been hospitalized for episodes of either ketoacidosis or hypoglycemia reactions in the past year. The Veteran also had no progressive unintentional weight loss and loss of strength attributable to diabetes mellitus. Again, the examiner diagnosed the Veteran with erectile dysfunction and peripheral vascular disease and found both were associated with his diabetes mellitus. The clinical records have also been reviewed. These show treatment for diabetes but fail to notate any regulation of activities or hospitalizations for ketoacidosis or hypoglycemia reactions. Given the above, the Board finds that an evaluation in excess of 20 percent is not warranted at any time during the period on appeal. Although the August 2013 VA examination noted a restriction in his activities, the remainder of the evidence of record contradicts that finding. In the July 2016 VA examination, the examiner reviewed the Veteran's medical history and noted that the Veteran has consistently been on a diet and medication (either insulin or another drug) to control his diabetes and that restriction of activities was not warranted or noted. The Board finds the preponderance of the evidence weighs against a finding that the treatment for diabetes mellitus requires regulation of activities. If such treatment was directed, it would be reflected in the medical treatment records, which it is not. As a rating in excess of 20 percent requires regulation of activities, an increased rating is not warranted at any time during the appeal period. The Board also finds that separate ratings for erectile dysfunction and hypertension are not warranted. A noncompensable rating is assigned to a disability when the criteria for a compensable rating are not met. 38 C.F.R. § 4.31. There is no DC for erectile dysfunction alone. An analogous DC therefore must be utilized to determine if it is compensable. 38 C.F.R.§ 4.20. 38 C.F.R. § 4.115b addresses disabilities of the genitourinary system. DC 7522 thereunder, which is for penis deformity with loss of erectile power, is most analogous to erectile dysfunction, and calls for a 20 percent rating. While the Veteran's loss of erectile power is undisputed, the June 2010, August 2013 and July 2016 VA examinations did not report any penile deformity or abnormality. Therefore, the Veteran's erectile dysfunction is noncompensable and is part of the diabetic process. The Veteran's service-connected hypertension is evaluated under Diagnostic Code 7101. Hypertension warrants a 10 percent evaluation with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent evaluation is warranted when diastolic pressure is predominantly 120 or more. A 60 percent evaluation is warranted when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The August 2013 examination diagnosed the Veteran with hypertension and found his treatment plan including taking continuous medication. He did not have a history of a diastolic blood pressure elevation to predominantly 100 or more and his current blood pressure reading was 97/51, 104/46 and 96/37. As such, a rating of 10 percent is not warranted. Again, because the Veteran's hypertension does not rise to a compensable level, it is considered a part of the diabetic process. In so finding, the Board acknowledges the October 2013 letter from R.L., the Veteran's wife. In her letter, the wife describes the serious health issues involved with the Veteran's diabetes, the side effects along with how the issues are negatively affecting him and their daily life. R.L. indicated that once the Veteran was diagnosed with diabetes, he began to control it with diet changes and oral medications. As the diabetes worsened, he was instructed by the VA to begin a daily regimen of insulin. At the time of the letter, the Veteran was taking insulin and oral medications to help control his diabetes. She also reported he has neuropathy in his arms and legs as a result of the diabetes. The diabetes and resulting neuropathies have impacted the Veteran and his family's life in the restrictions it places on activities with children, grandchildren, family and friends. His major issue is the inability to work any distance without pain. Because of his pain, they can no longer attend street fairs, festivals or go shopping together. He is also unable to go to any function or sports event concerning his grandchildren. The pain has mostly left him housebound, feeling like a prisoner in his own home. These issues have caused the Veteran to have a negative outlook on life and mood swings which also impacts the Veteran's marriage. In sum, the quality of his life had changed. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran's wife is competent to report observable symptoms of the Veteran's diabetes mellitus and neuropathies. See Layno v. Brown. However, while the Board is sympathetic to the impact of the Veteran's diabetes and neuropathy, the Board finds these disabilities and their side effects have been adequately considered and compensated under the Diagnostic Criteria above. IV. Peripheral Neuropathy of Sciatic and Femoral Nerves The Veteran contends that he should be entitled to initial ratings in excess of 10 percent for his service-connected sciatic peripheral neuropathy of the right and left lower extremities, as well as for his service-connected femoral peripheral neuropathy of the right and left lower extremities. The record reflects that 20 percent ratings effective January 11, 2012 were awarded in the August 2016 rating decision for peripheral neuropathy of the upper extremities, and 10 percent ratings effective July 8, 2016 were awarded in the August 2016 rating decision for sciatic peripheral neuropathy of the right and left lower extremities, under 38 C.F.R. § 4.124a , DC 8520. An initial rating of 10 percent was awarded in the August 2016 rating decision for peripheral neuropathy of the lower extremities under 38 C.F.R. § 4.124a, DC 8526, for femoral peripheral neuropathy of the right and left lower extremities. Finally, 20 percent evaluations for peripheral neuropathy, sciatic nerve, for each lower extremity are in effect for the period prior to July 8, 2016. Under Diagnostic Code 8520, which sets forth the rating criteria for sciatic nerve disorders, a Veteran will receive ratings of 10, 20, 40 or 60 percent for mild, moderate, moderately severe, or severe (with marked muscular atrophy) incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8520. A maximum 80 percent evaluation will be awarded for complete paralysis of the sciatic nerve manifested by the foot dangling and dropping, no active movement possible of muscles below the knees, and flexion of the knee weakened or lost. Id. Under Diagnostic Code 8526 for paralysis of the femoral nerve, mild incomplete paralysis warrants a 10 percent evaluation, moderate incomplete paralysis warrants a 20 percent evaluation, and severe incomplete paralysis warrants a 30 percent evaluation. The term incomplete paralysis with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement, and when there is bilateral involvement, the VA adjudicator should combine the ratings for the peripheral nerves, with application of the bilateral factor. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating, which may be assigned for neuritis not characterized by organic changes, will be that for moderate incomplete paralysis. 38 C.F.R. § 4.123. Peripheral neuralgia, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The use of terminology such as "mild," "moderate," and "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. The August 2013 VA examination diagnosed the Veteran with bilateral upper and lower extremity diabetes neuropathy. Numbness and burning pain in bilateral hands had been reported for the past 1 to 2 years and was progressively worsening. Additionally, he tried medication, which helped, but he suffered adverse reactions. His symptoms included mild constant pain in the upper extremities and moderate pain in the lower extremities, moderate intermittent pain in the upper extremities and severe intermittent pain in the lower extremities, mild paresthesias or dysesthesias in the upper extremities and severe paresthesias or dysesthesias in the lower extremities, as well as mild numbness in the upper extremities and severe numbness in the lower extremities. Muscle strength and deep tendon reflexes were slightly diminished. Additionally, the Veteran had decreased light touch/monofilament testing results in the hands, ankle and foot. No muscle atrophy was found but the Veteran did have loss of hair below the bilateral knees with shiny, scaly skin noted. The severity of the Veteran's upper extremity diabetic peripheral neuropathy was found to be mild incomplete paralysis on both sides, as well as normal median and ulnar nerves. Additionally, moderate incomplete paralysis was found in the right and left lower sciatic nerves. Mild incomplete paralysis was found in the right and left lower formal nerves. The July 2016 VA examination diagnosed diabetic peripheral neuropathy. At the examination, the Veteran described constant symptoms of buzzing and tingling that is painful. His condition has been progressive since its onset. He also reported current symptoms of paresthesia and pain but was not currently on medication for the condition. On examination, the Veteran did not have constant pain in any of his extremities but experienced mild intermittent pain in the lower extremities, mild paresthesias or dysesthesia in the upper extremities, moderate paresthesias or dysesthesias in the right lower extremity and severe in the left lower extremities as well as mild numbness in the upper and lower extremities. His strength was found to be all normal with some deep tendon reflex limitations as well as some decreased monofilament testing results. His position sense was normal but he experienced decreased vibration sensation in the right lower extremity and absent sensation in the left lower extremity as well as decreased cold sensation in the left upper extremity and absent sensations in the lower extremities. No muscle atrophy was present. He also had no hair from his knees down as a result of his diabetic peripheral neuropathy. The examiner found that the Veteran had mild incomplete paralysis in the right and left upper extremities, as well as mild incomplete paralysis of the median nerve and ulnar nerve. Further, the examiner found the Veteran had mild incomplete paralysis in the right and left lower extremities, as well as mild incomplete paralysis in the right and left lower femoral nerve. His upper and lower extremity sensory neuropathy was found to be mild. The Board finds that throughout the period of appeal the Veteran's peripheral neuropathy of the upper extremities have been manifested by mild incomplete paralysis of the sciatic nerve and therefore most the disability picture closely approximates a rating of 20 percent disabling. A rating in excess of 20 percent is not warranted, as at no point throughout the period of the appeal was the Veteran's peripheral neuropathy of the upper extremities extremity shown to have caused moderately severe or severe paralysis. See Diagnostic Code 8520. Further, the Board finds that prior to July 8, 2016, the Veteran's peripheral neuropathy of the left and right lower extremities were manifested by moderate incomplete paralysis of the sciatic nerve but beginning on July 8, 2016, the Veteran's peripheral neuropathy of the left and right lower extremities were manifested by mild incomplete paralysis of the sciatic nerve; and therefore most closely approximates a rating of 10 percent disabling. A rating in excess of 20 percent prior to July 8, 2016 or in excess of 10 percent beginning on July 8, 2016 is not warranted. See Diagnostic Code 8520. Lastly, the Board finds that throughout the period of appeal the Veteran's peripheral neuropathy of the left and right lower extremities were manifested by mild incomplete paralysis of the femoral nerve and therefore most closely approximates a rating of 10 percent disabling. A rating in excess of 10 percent is not warranted, as at no point throughout the period of appeal was the Veteran's peripheral neuropathy of the left lower extremities shown to have caused moderate, moderately severe, or severe paralysis of the femoral nerve. See Diagnostic Code 8526. V. Peripheral Vascular Disease The August 2016 rating decision granted a separate disability rating for service-connected peripheral vascular disease of the right and left lower extremities and assigned a disability evaluation of 60 percent effective July 8, 2016. Peripheral vascular disease is evaluated pursuant to Diagnostic Code 7114. This code provision provides a 20 percent disability rating if evidence shows claudication on walking more than 100 yards, and diminished peripheral pulses or an ankle/brachial index (ABI) of 0.9 or less. The next higher rating of 40 percent disability rating is assigned if there is claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ABI of 0.7 or less. A 60 percent disability rating requires claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; either persistent coldness of the extremity or ABI of 0.5 or less. A 100 percent disability rating is warranted for ischemic limb pain at rest, and; either deep ischemic ulcers or ABI of 0.4 or less. Note 1 to Diagnostic Code 7114 provides that the ABI is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure. The normal index is 1.0 or greater. 38 C.F.R. § 4.104, DC 7114 (2017). The criteria listed in DC 7114 are conjunctive, as evidenced by the use of the word "and." See Melson v. Derwinski, 1 Vet. App. 334, 337 (1991); Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (finding that the use of the conjunctive "and" in the criteria for a 40 percent rating for diabetes - "insulin, restricted diet, and regulation of activities" - meant that entitlement to that rating required all three criteria to be met). That is, in order to satisfy the criteria for a higher 20 percent rating, the Veteran must demonstrate claudication on walking more than 100 yards and either 1) diminished peripheral pulses, or (2) an ankle/brachial index of 0.9 or less. On examination in July 2016, the Veteran was diagnosed with peripheral vascular disease with residual claudication. The severity of the current signs and symptoms of his peripheral vascular disease included claudication on walking less than 25 yards on a level grade at 2 miles per hour bilaterally. The Veteran had not had an amputation of an extremity due to a vascular condition but did use a walker and a cane for claudication and neuropathy. Ankle/brachial index testing was performed and showed ABI of .77 in the right ankle and ABI of .82 in the left ankle. The objective evidence and subjective complaints outlined above simply do not support a rating of 100 percent. Rather, the Veteran's bilateral peripheral vascular disease has been manifested by claudication on walking less than 25 yards on a level grade at 2 miles per hour and an AMI of .77 in the right ankle and .82 in the left ankle. There is no evidence of ischemic limb pain at rest, and; either deep ischemic ulcers or ABI of 0.4 or less. ORDER Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus, type 2 with hypertension and erectile dysfunction is denied. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to an initial disability rating in excess of 20 percent prior to July 8, 2016 and in excess of 10 percent from July 8, 2016 for peripheral neuropathy of the left lower extremity, sciatic nerve, is denied. Entitlement to an initial disability rating in excess of 20 percent prior to July 8, 2016 and 10 percent from July 8, 2016 for peripheral neuropathy of the right lower extremity, sciatic nerve, is denied. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, femoral nerve, is denied. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, femoral nerve, is denied. Entitlement to an initial disability rating in excess of 60 percent for peripheral vascular disease of the right lower extremity is denied. Entitlement to an initial disability rating in excess of 60 percent for peripheral vascular disease of the left lower extremity is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs