Citation Nr: 1822684 Decision Date: 04/18/18 Archive Date: 04/25/18 DOCKET NO. 13-12 527 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to herbicide exposure, or secondary to service connected disease or injury. 2. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to herbicide exposure, or secondary to service connected disease or injury. 3. Entitlement to an initial rating for diabetes mellitus, type II, in excess of 10 percent prior to March 27, 2015. 4. Entitlement to an initial rating for diabetes mellitus, type II, in excess of 20 percent effective March 27, 2015. 5. Entitlement to a compensable rating for tinea pedis. 6. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for lower back pain. 7. Entitlement to an initial rating in excess of 70 percent for post-traumatic stress disorder (PTSD) with alcohol abuse. 8. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1967 to February 1970. This matter is before the Board of Veterans Appeals (Board) on appeal from an August 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, and July 2010, May 2012, and May 2014 rating decisions by the RO in Columbia, South Carolina. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam and is presumed to have been exposed to an herbicide agent. 2. Peripheral neuropathy of the left lower extremity was not manifest in service or within one year of separation, and is not caused or aggravated by a service-connected disease or injury. Peripheral neuropathy of the left lower extremity did not manifest to a compensable degree within one year after the last date of the Veteran's exposure to herbicide agent. 3. Peripheral neuropathy of the right lower extremity was not manifest in service or within one year of separation, and is not caused or aggravated by a service-connected disease or injury. Peripheral neuropathy of the right lower extremity did not manifest to a compensable degree within one year after the last date of the Veteran's exposure to herbicide agent. 4. Prior to March 27, 2015, diabetes mellitus type II was manifested by restricted diet. 5. From March 27, 2015, diabetes mellitus type II was manifested by the use of insulin, restricted diet, and regulation of activities. 6. Tinea pedis is manifested by at least 5 percent, but no more than 20 percent of the entire body affected. 7. An August 2008 rating decision denied service connection for low back pain (now claimed as spinal collapse). 8. The Veteran's Notice of Disagreement was not received until July 24, 2011. The Veteran did not file a notice of disagreement or submit new and material evidence within one year. 9. Evidence submitted since the August 2008 denial is cumulative of evidence previously of record at the time of the prior final denial. 10. PTSD is manifested by no more than depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbance of motivation and mood, difficulty in adapting to stressful situations, and suicidal ideation. 11. The Veteran last worked over a decade ago as a machinist. 12. The Veteran's service connected disabilities, PTSD, right and left upper extremity diabetic peripheral neuropathy, diabetes mellitus type II, and tinea pedis, preclude him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. Peripheral neuropathy of the left lower extremity was not incurred in or aggravated by service, and organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. Peripheral neuropathy of the left lower extremity is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 C.F.R. § 3.310 (2017). 3. Peripheral neuropathy of the right lower extremity was not incurred in or aggravated by service, and organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. Peripheral neuropathy of the right lower extremity is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 C.F.R. § 3.310 (2017). 5. Prior to March 27, 2015, the criteria for an initial rating in excess of 10 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2017). 6. Effective March 27, 2015, the criteria for a rating of 40 percent for diabetes mellitus have been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2017). 7. The criteria for a rating of 10 percent for tinea pedis have been met. 38 U.S.C. § 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.118, 4.2, 4.3, 4.7; Diagnostic Codes (DC) 7806, 7813 (2017). 8. The August 2008 rating decision denying service connection for low back pain (now claimed as spinal collapse) is final. The evidence received since the August 2008 rating decision is not new and material, and the claim is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 9. The criteria for an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 3.400, 4.1, 4.126, 4.130, 4.2, 4.3, 4.7; Diagnostic Code (DC) 9411 (2017). 10. Effective March 7, 2011, the criteria for a total disability rating based on individual unemployability are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). The Veteran has not 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 duty to assist argument). II. Peripheral Neuropathy of the Lower Extremities A. Service Connection To establish service connection a Veteran must generally show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). A disease specified in paragraph (2) of this subsection becoming manifest as specified in that paragraph in a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975; and (B) each additional disease (if any) that (i) the Secretary determines in regulations prescribed under this section warrants a presumption of service-connection by reason of having positive association with exposure to an herbicide agent, and (ii) becomes manifest within the period (if any) prescribed in such regulations in a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, and while so serving was exposed to that herbicide agent, shall be considered to have been incurred in or aggravated by such service, notwithstanding that there is no record of evidence of such disease during the period of such service. 38 U.S.C. §§ 1116 (a)(1). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. §§ 3.307 (a)(6)(iii). For the purposes of this section, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307 (a)(6)(i). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of §3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of §3.307(d) are also satisfied. AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309 (e). The diseases listed at § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and early-onset peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307 (a)(6)(ii). VA has determined there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 68 Fed. Reg. 27630-27641 (2003). The evidence from his DD-214 confirms the Veteran's presence in the Republic of Vietnam. It shows that he was a Bridge Specialist. His awards included the Vietnam Service Medal with Two Bronze Stars, and the Vietnam Campaign Medal. It also shows a notation of Vietnam Service from September 4, 1967 to August 31, 1968. Exposure to Agent Orange is presumed. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). B. History In the Veteran's February 1967 Report of Medical History, the Veteran denied neuritis. His February 1967 enlistment examination is clinically normal for the feet, lower extremities, and the neurologic system. A November 1968 Statement of Medical Condition shows that the Veteran indicated "There has been no change in my medical condition." His October 1969 exit examination is clinically normal for the feet, lower extremities, and the neurologic system. In the Veteran's October 1969 Report of Medical History, the Veteran denied neuritis. A May 2001 neurological evaluation shows that the Veteran sustained a back injury and had burning leg pain for one year. He injured his back lifting a box weighing an estimated 200 pounds at work in May of 2000. A later treatment record from May 2001 shows that the Veteran continued to have cramping spasms of the lower extremities. A July 13, 2001 private treatment record from Greenville Hospital System shows that spastic paraparesis started in May 2000 with the Veteran injuring his back. A February 2002 private medical opinion from Dr. B. R. M. shows that the Veteran was receiving treatment for progressive spastic paraparesis of the lower extremities. A related February 2002 Statement of Attending Physician shows impressions of spastic paraparesis. It also shows that symptoms first appeared in May 2000. A June 2002 private treatment record from Dr. J. R. shows, "Since the last visit the patient reports persistent pain in the mid back radiating into the legs." The Veteran was afforded an August 2008 VA examination. The VA examiner noted there were no symptoms of peripheral neuropathy related to diabetes. The VA examiner also noted there were no symptoms of diabetic neuropathy. The VA examiner found that the Veteran limps, but this is not related to diabetes. A VA treatment record from April 2010 shows the Veteran had a history of neuropathy. He walked with a cane. He denied a history of trauma or injury. A July 2010 neurology consult shows that the Veteran underwent C5-6 and C6-7 Anterior cervical discectomy and fusion (ACDF) in September 2003. The consult shows that he has remained with a spastic quadriparesis ever since. The Veteran had stiffness in arms and legs. The Veteran did not understand the cause of this. The treatment records show that an unspecified idiopathic peripheral neuropathy was identified, with an onset date of April 2010. The Veteran was afforded a May 2011 diabetes mellitus examination. The VA examiner noted that the Veteran had complaints and decreased sensation on examination consistent with previous impressions of idiopathic peripheral neuropathy. The VA examination shows that the Veteran had no known nephropathy. He had no known peripheral vascular disease. He just carried a diagnosis of idiopathic neuropathy which the VA examiner opined seemed to be involving the lower extremities. The VA examiner noted that a neurology consult done in July of 2010 presumed that potential B12 deficiency could be contributing to this as well. The VA examiner noted that this seems to precede any diagnosis of diabetes mellitus. A November 2012 diabetes mellitus VA examination showed that the Veteran had no diabetic peripheral neuropathy as a complication of his diabetes. A May 2015 VA Occupational Therapy Evaluation and Discharge Note shows impressions of idiopathic peripheral neuropathy with an onset date of April 2015. A November 2015 VA examination shows moderate constant pain, mild intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. The VA examiner indicated that the Veteran had lower extremity diabetic peripheral neuropathy, with incomplete paralysis of the sciatic nerve on the left and right sides. The VA examiner noted that EMG studies from 2010 show that the lower extremities were clinically normal. The VA examiner opined that the Veteran's peripheral neuropathy is at least as likely as not as due to the complications of diabetes mellitus, for the past several years. The VA examiner opined that the Veteran's EMG was normal from 2010, but the Veteran clearly has developed symptoms since then. A November 24, 2015 Disability Benefits Questionnaire (DBQ) from Dr. N. M. I. shows that the Veteran had diabetes with neuropathy, and he has known quadriperesis. It also shows a note that diabetes is making the symptoms worse. The Veteran was afforded a December 2015 VA peripheral nerves examination. It shows constant pain of a moderate level in the bilateral lower extremities, mild intermittent pain in the bilateral lower extremities, moderate paresthesisas and/or dysesthesias in the bilateral lower extremities, and moderate numbness in the bilateral lower extremities. The VA examiner opined that the Veteran does have peripheral neuropathy symptoms. The physician noted that the Veteran's peripheral neuropathy does cause a severe functional impact, and this is at least as likely as not related to his diabetes mellitus. The Veteran was afforded a December 2017 VA examination. He reported an onset of symptoms in 1969. He reported hauling Agent Orange while deployed. He reported numbness in his feet. The VA examiner found moderate constant pain in the lower extremities, no intermittent pain in the lower extremities, moderate paresthesias and/or dysesthesias, and moderate numbness. There were impressions of trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to diabetic peripheral neuropathy. A December 2017 medical opinion regarding the peripheral nerves shows that the claimed condition is at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran's service connected condition. The rationale provided is that the Veteran transported Agent Orange. The doctor noted unexplained peripheral neuropathy plus loss of teeth. Additional VA and private treatment records are substantially the same. C. Direct, Presumptive, and Herbicide Exposure Analysis The Veteran is competent to report feeling pain, tingling, burning, and weakness in the lower extremities. However, the Veteran has been an inconsistent historian regarding the onset of such symptoms. In the April 2013 VA Form 9, the Veteran contended that his "spine injury started in Vietnam." At the December 2017 VA examination, the Veteran reported a date of onset date of symptoms in 1969. In contrast, the STRs are all clinically normal for any neurologic pathology, and subsequent VA and private treatment records contain substantially the same onset date and impressions of pathology from 2000 and later. The Board finds the credibility of the Veteran's lay statements is diminished by such inconsistency regarding the onset of the neuropathy of the lower extremities. The STRs are clinically normal for the lower extremities, as well as the neurologic system, including the Veteran's own report of medical history from October 1969. Neuropathy of the lower extremities was not was not noted, manifest or diagnosed during service, within one year of the Veteran's last exposure to herbicide agent, or within one year from separation. He also did not have characteristic manifestations sufficient to identify the disease process during that time frame. The weight of the evidence, including the private treatment records, shows that the Veteran's reported symptoms in the lower extremities first manifest around May 2000. The weight of the competent and probative evidence does not link the Veteran's disability to service. The most probative evidence is the VA treatment records and the findings of the May 2011 VA examiner. Private treatment records show that the Veteran had a back injury in May of 2000, which resulted in spasms of the lower extremities. May 2001 private treatment records show that the Veteran continued to have cramping spasms of the lower extremities following the accident. A related February 2002 Statement of Attending Physician shows impressions of spastic paraparesis. It also shows that symptoms first appeared in May 2000. A June 2002 private treatment record from Dr. J. R. shows, "Since the last visit the patient reports persistent pain in the mid back radiating into the legs." A VA treatment record from April 2010 shows the Veteran had a history of neuropathy. At the time, he denied a history of trauma or injury. The Board notes that such inconsistent statements diminish the Veteran's credibility as to the onset of his symptomatology and his contention that his symptoms were productive of peripheral neuropathy of the lower extremities. The July 2010 neurology consult only repeated the April 2010 report of a history of unspecified idiopathic peripheral neuropathy. The Board has considered multiple theories of entitlement, to include, direct service connection, presumptive service connection, and a connection based upon Agent Orange exposure. In addition, the Board notes that subsequent manifestations of an already service connected disease process are service connected. 38 C.F.R. § 3.303. Regardless of the theory, the weight of the evidence shows that neuropathy of the lower extremities was not manifest in service or for decades after discharge, and did not manifest to a compensable degree within one year after the last date of the Veteran's exposure to herbicide agent. Consequently, service connection on any of these bases is not warranted. D. Secondary Analysis It appears that an argument is also that neuropathy is a consequence of diabetes mellitus, a service connected disease. Service connection may be granted for disability that is proximately due to, or the result of, or aggravated by service connected disease or injury. 38 C.F.R. § 3.310. In addition, subsequent manifestations of the same disease process are service connected unless due to intercurrent cause. 38 C.F.R. § 3.303. Here, the weight of the evidence shows that neuropathy of the lower extremities is not proximately due to, or the result of, or aggravated by service connected disease or injury. Therefore, the neuropathy is not a subsequent manifestation of diabetes. Moreover, the most credible and probative medical evidence shows that he does not have diabetic neuropathy of the lower extremities. The Veteran essentially asserts that the claimed neuropathy of the lower extremities is a consequence of service-connected diabetes mellitus. While the Veteran is competent to report what he has been told by a physician, the Board assigns greater probative weight to the negative medical evidence of record. This evidence does not show that the Veteran had diabetic neuropathy of the lower extremities. Prior to a back injury, there was no proof of lower extremity neuropathy. Later, the peripheral neuropathy of the lower extremities was identified in April 2010 as idiopathic. Even assuming that the Veteran later contracted peripheral neuropathy of the lower extremities of an unknown etiology, the evidence shows that peripheral neuropathy of the lower extremities is not due to diabetes. In other words, he did not have diabetic peripheral neuropathy of the lower extremities. The August 2008 VA examiner found that the Veteran limps, but this is not related to diabetes. The VA examiner noted that there were no symptoms of diabetic neuropathy. The July 2010 neurology consult is also consistent, showing a surgery in September 2003, and that the Veteran remained with a spastic quadriparesis ever since. The Board finds this to be highly probative. Later, at the July 2010 neurology consult, VA treatment records showed that the Veteran had remained with a spastic quadriparesis. The consult also noted an impression of unspecified idiopathic peripheral neuropathy. The May 2011 VA examiner found that the Veteran had complaints and decreased sensation on examination consistent with previous impressions of idiopathic peripheral neuropathy. The VA examination showed that the Veteran had no known nephropathy. He just carried a diagnosis of idiopathic neuropathy, which the VA examiner opined seemed to be involving the lower extremities. The VA examiner noted that a neurology consult done in July of 2010 presumed that potential B12 deficiency could be contributing to this as well. The VA examiner noted that this seems to precede any diagnosis of diabetes mellitus. The November 2012 diabetes mellitus VA examination showed that the Veteran had no diabetic peripheral neuropathy as a complication of his diabetes. Such findings are consistent with the contemporaneous treatment records, and the Board assigns them significant probative weight. Here, the most probative evidence is the contemporaneous medical records (including STRs) and May 2011 VA examination and medical opinion. These collectively establish that despite his complaints, the reported pain and other symptoms of the lower extremities are not proximately due to, or the result of, or aggravated by a service connected disease or injury. In addition, the most probative evidence shows that any complaints of pain, tingling, burning, and weakness in the lower extremities are not attributable to a subsequent manifestation of a service connected disease. The November 2012 diabetes mellitus VA examination showed that the Veteran had no peripheral neuropathy as a complication of his diabetes. The Board also has considered the November 24, 2015 DBQ by Dr. N. M. I. It shows that diabetes was making the symptoms worse. Similarly, the Board has considered that the November 2015 VA examiner indicated that the Veteran had lower extremity peripheral neuropathy. In regards to the November 2015, December 2015, and December 2017 VA examinations, there is a conflict in the record. The positive evidence includes the Veteran's lay statements and the VA medical opinions of Dr. R. B. (November 2015), Dr. M. P. (December 2015), and Dr. M. P. D. (December 2017), finding that the Veteran has diabetic neuropathy. However, we find that the VA examiners who input impressions of diabetic neuropathy did not justify their findings of diabetic neuropathy versus other forms of neuropathy. Here, the most probative evidence consists of the VA outpatient treatment records that establish idiopathic neuropathy. We also note that these recent VA medical opinions are inconsistent with the opinions rendered at the time of the earliest manifestations. Although there is positive and negative evidence, we find that the preponderance of the evidence is against the claim, and there is no doubt to resolve. Consequently, service connection is not warranted. C. Comments The Board has considered multiple theories of entitlement, to include, direct service connection, presumptive service connection, secondary service connection, and a connection based upon Agent Orange exposure. The Veteran does not have diabetic neuropathy of the lower extremities. The original identification of peripheral neuropathy of the lower extremities appears to be idiopathic. The Board has considered the Veteran's lay statements regarding the onset of symptoms, including his lay history of what he has been told by his treating physicians. The Veteran is competent to report his symptoms and what he has been told by an examiner. However, his lay reports regarding the onset and etiology of his pain are outweighed by the more credible and probative medical evidence. The weight of the evidence, including the private treatment records, shows that the Veteran's symptoms first manifest around May 2000. Furthermore, the weight of the evidence shows that the Veteran did not develop diabetic neuropathy of the lower extremities. The neuropathy is unrelated (causation or aggravation) to service connected disease. Regardless of the theory, the most probative evidence shows that peripheral neuropathy of the lower extremities was not manifest in service or during the many decades after discharge, did not manifest to a compensable degree within one year after the last date of the Veteran's exposure to herbicide agent, and is not proximately due to, or the result of, or aggravated by service connected disease or injury. Consequently, service connection for peripheral neuropathy of the lower extremities is not warranted. III. Rating of Diabetes Mellitus and Tinea Pedis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. A. Diabetes Mellitus Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability has changed and a staged evaluation is warranted. Diabetes has been rated as 10 percent disabling prior to March 27, 2015, and 20 percent from March 27, 2015 under DC 7913 of 38 C.F.R. § 4.119. This DC authorizes compensable ratings of 10, 20, 40, 60, and 100 percent. Under DC 7913, a 10 percent rating is warranted where diabetes is manageable by restricted diet only, a 20 percent rating is warranted where treatment requires insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, a 40 percent rating is warranted where treatment requires insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted where treatment requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. Note (1) to DC 7913 provides that VA must evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under diagnostic code 7913. For a 40 percent rating, "regulation of activities" means "avoiding strenuous occupational and recreational activities." Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). In Camacho, the Court of Appeals for Veterans Claims (Court) held that in order for a claimant to be entitled to a 40 percent disability rating, the evidence must show that it was medically necessary for a claimant to avoid strenuous occupational and recreational activities. Medical evidence is required to establish that occupational and recreational activities have been restricted under Diagnostic Code 7913. The Court further held, "In light of the conjunctive 'and' as used in the criteria for a 40 percent disability rating under 38 C.F.R. § 4.119, DC 7913, all criteria must be met to establish entitlement to a 40 percent rating." Id. The Court further reasoned that, if taking insulin and having a restricted diet were sufficient to support a 40 percent disability rating without restriction of activities, then there would be no reason for insulin and restricted diet to be one of the two ways to qualify for a 20 percent disability rating. This would render part of Diagnostic Code 7913 meaningless. See Splane v. West, 216 F.3d 1058, 1068-69 (Fed. Cir. 2000) ("Canons of construction... require us to give effect to the clear language of a [regulation] and avoid rendering any portions meaningless or superfluous"). Diabetes mellitus, type II is currently rated as 10 percent disabling prior to March 27, 2015, and 20 percent disabling from March 27, 2015. The Veteran contends that he is entitled to an increased rating for both stages. i. Prior to March 27, 2015 Prior to March 27, 2015, diabetes is assigned a 10 percent rating. The 10 percent evaluation contemplates a restricted diet. In order to warrant a higher evaluation, there must be treatment requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. Private medical records from Dr. M. G. from Ft. Myers, Florida show impressions of diabetes mellitus type II in February 2008. The Veteran was afforded an August 2008 examination. The VA examination shows that the Veteran was being treated by his private physician. He was using diet to control his glucose level. Diet had been modified to keep off of diabetic medication. A VA treatment record from August 2010 shows that the Veteran's diabetes was diet controlled. A VA treatment record from June 2011 shows that the Veteran was on diet control. It lists his A1C as "good." It shows that the same treatment was continued. A November 2012 VA examination shows that the Veteran's diabetes is managed by restricted diet. He does not require regulation of activities. There was no indication that he used insulin. A VA treatment record from April 2014 shows that the Veteran declined to start medication. He was on diet control and advised to lose weight. VA treatment records are substantially the same. They show impressions of and treatment for diabetes mellitus type II in the form of diet. The Veteran contends that he is entitled to a rating in excess of 10 percent for diabetes mellitus type II prior to March 27, 2015. Here, the most probative evidence is the VA examinations and contemporary medical treatment records consistently showing that the Veteran's diabetes mellitus was managed by diet and that he did not take medication. They show that the Veteran's condition has been relatively stable. In particular, the August 2008 and November 2012 VA examinations showed that the Veteran was active. The Veteran's implementation of a restricted diet is already contemplated by the current 10 percent rating. The most probative evidence does not show that the Veteran's condition required insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, which would warrant a higher evaluation of 20 percent. The 10 percent rating most closely approximates the Veteran's level of disability for this period. Consequently, a rating in excess of 10 percent for diabetes mellitus type II prior to March 27, 2015 is not warranted. ii. March 27, 2015 From March 27, 2015, diabetes is assigned a 20 percent rating. The 20 percent evaluation contemplates a requirement for an oral hypoglycemic agent and restricted diet. In order to warrant a higher evaluation, there must insulin, restricted diet, and regulation of activities. A March 2015 VA treatment record shows that the Veteran was taking metformin orally twice per day. He was not doing good diet control. A November 24, 2015 Disability Benefits Questionnaire (DBQ) from Dr. N. M. I. shows that the Veteran was being prescribed insulin with a dosage of more than one injection per day. Under the heading for regulation of activities for management of diabetes, the physician indicated in the affirmative. The physician wrote, "Needs to avoid strenuous activities to avoid hypoglycemia." A December 2015 VA examination shows that the Veteran was being prescribed insulin with a dosage of more than one injection per day. It also shows that his doctor prescribed that he not engage in strenuous activity. A February 2016 VA treatment record shows that the Veteran was in the nutrition clinic for assistance diabetes management. A VA treatment record from April 2016 shows that the Veteran was not taking Metformin. He was taking insulin 70/30, with 20 units in the AM and 12 units in the PM. A VA treatment record from October 2017 shows that the Veteran was taking insulin 70/30, with 20 units in the AM and 12 units in the PM. He was continuing with diet control and to lose weight. Additional VA treatment records are substantially the same. They show impressions of and treatment for diabetes mellitus type II, most recently in the form of insulin injections. A July 2017 VA treatment record shows that the Veteran was on an exercise program. Other VA treatment records are substantially the same, showing that the Veteran was on a medically recommended exercise program. A VA treatment record from November 2017 shows that the Veteran reports still being active around the house and yard, and still rides a stationary bike for exercise. He last rode about 15 to 20 minutes last week without difficulty. He was also able to push a power mower. The Veteran contends that he is entitled to a rating in excess of 20 percent for diabetes mellitus type II. The VA examinations and contemporary medical treatment records consistently show that the Veteran's diabetes mellitus is managed by diet and oral medication later changing to insulin injections, along with restricted activities. They reveal that the Veteran's condition has been relatively stable during this staged time period. The November 24, 2015 DBQ from Dr. N. M. I. shows that the Veteran was being prescribed insulin with a dosage of more than one injection per day. The physician indicated that the Veteran required regulation of activities as part of medical management of diabetes. The December 2015 VA examination also shows that the Veteran was being prescribed insulin with a dosage of more than one injection per day. It also shows that his doctor prescribed that the Veteran not engage in strenuous activity. The Board notes that the July 2015 VA examination showed that the Veteran was active. Although the Veteran was able to push a mower and ride on a stationary bike, the Veteran has also been advised by his doctor to avoid strenuous activities. Here, the most probative evidence shows that the Veteran's present condition is managed by diet, insulin, and regulation of activities, which is most closely approximated by a 40 percent evaluation. He has a history of diet and insulin use, and has more recently had to regulate his activities per medical advice. See Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). In order to warrant an even higher evaluation, there must regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. The Veteran has not had ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Consequently, a rating of 40 percent, but no higher, for diabetes mellitus type II is warranted. B. Tinea Pedis Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). As discussed below, a uniform evaluation is warranted. Tinea pedis is currently rated at a noncompensable rating. Diagnostic Code 7813 provides that dermatophytoses are rated as disfigurement of the head, face, or neck, scars, or dermatitis, depending on the predominant disability. Here this has been rated under DC 7806 for dermatitis. A noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is warranted for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. The Veteran was afforded an August 2008 VA examination. The Veteran reported that he has a skin problem around three to four times per year, and it may last for as long as two months. He reported receiving a prescription from a private physician for a skin cream for his rash in November 2007. He used this fourteen times per day. The Veteran reported that the rash involved both feet, left inner groin, top of left shoulder, left side of back, and left buttock. He had used it less than one week in the past month. It was neither a corticosteroid nor an immunosuppressive. The left lateral thoracic area had numerous tiny macules in three separate areas covering about 25 percent of this part of back left shoulder. There were a few tiny macules on the anterior aspect of the left shoulder. The left inner thigh had a few tiny macules on the medial left thigh. The feet had no rash. The physician opined that the Veteran had a recurrent rash involving multiple body areas. The Veteran was afforded a May 2010 VA examination. A clinical examination revealed the presence of heavy scaling of the soles of both feet but the dorsum of both feet appeared normal. The Veteran had marked cutaneous hypersensitivity in the affected areas. The fraction of the legs affected by tinea pedis was approximately 4 percent, giving 1.5 percent of the entire body. A January 2013 addendum shows that tinea pedis affects his feet bilaterally and that the total area affected is less than 5 percent. A December 14, 2015 VA examination showed symptoms that were "not bad" but during bad flares his feet will crack and bleed. His symptoms were currently mild. The VA examiner found that the Veteran has constant or near constant treatment with oral or topical medications in the past 12 months for any skin condition. The VA examiner found that infection of the total body area was 5 to less than 20 percent, and none of the exposed area. The VA examiner opined that currently he could not see any evidence of functional disability from this, but from his and the Veteran's wife's report, it is disabling when he has bad flares. The VA examiner opined that this represents a progression of his service connected condition. A May 2017 VA treatment record shows that the Veteran reported that he had the rash since he returned home from Vietnam in 1968. He stated that it re-appeared about a week ago. A July 2017 VA treatment record shows that the Veteran had recently previously stated that his rash was completely gone and this was the best his skin had looked in 40 years. The VA treatment records show that the rash had been back for past two weeks covering whole back and skin. He had erythematous, a ring shaped rash all over the skin, with itching. He denied taking any new medications, denied using any cosmetics, lotion or cream, and had no known exposure to allergens. Antifungal Fluconazole helped in past. A VA treatment record from February 2018 shows that the Veteran's feet were very sweaty and he had a fungal skin infection that was treated with cream and salt soaks. They will occasionally flare up, crack, and bleed. This was most noticeable on his right shoulder area. The previous May, he was given Fluconazole that cleared it up. His wife stated that the feet have gotten much better since he was able to wear sandals or go barefoot. Additional VA treatment records are substantially the same. Here, the most probative evidence is the December 2015 VA examination and subsequent VA treatment records showing a worsening of the Veteran's condition. The Veteran's current noncompensable rating contemplates less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. In order to warrant a higher evaluation, there must be at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The evidence shows that the severity of his tinea pedis has worsened since it was assigned a noncompensable rating. Despite varying levels during flare ups, the Board finds that the severity of tinea pedis most closely approximates a 10 percent rating. The December 2015 VA examination and subsequent VA treatment records show that at least 5 percent, but less than 20 percent, of the entire body is affected. Although some VA treatment records show improvement, they also showed that a flare up occurred not long thereafter. The December 14, 2015 VA examination clearly indicated that this represented a progression in the severity of the Veteran's tinea pedis. An even higher rating is not warranted, as this would require 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. The Board notes that the Veteran has treated this with topical creams and shampoo. A ten percent evaluation most closely approximates the severity of his disability. Consequently, a rating of ten percent, but no higher, is warranted. IV. Lower Back Pain A. Finality Law and Regulations If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. 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 can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The United States Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156 (a) as creating a low threshold. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." See id. In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). B. History Service connection for low back pain was denied in an October 1974 rating decision. In 1974, ultimately, there was no current disability due to disease or injury. Also, it follows that there was no nexus. The STRs show that there was no present back disability due to disease or injury upon separation. The October 1969 exit examination was clinically normal for the spine, and other musculoskeletal system. In his October 1969 Report of Medical History, the Veteran denied arthritis or rheumatism, as well as recurrent back pain. The October 1974 rating decision noted that the Veteran was treated during service for lumbar muscle spasm, but the August 1974 VA examination found normal, painless range of motion of his back. The Veteran did not file a notice of disagreement or submit new evidence within one year. This decision became final. The Veteran filed an Application for Compensation and/or Pension received in September 2007. This was construed as an application to reopen his previous claim. In part, he listed his disability as "spine collapsed." August 2008 was the last final rating decision. The August 2008 rating decision confirmed and continued the previous denial of service connection for low back pain, now claimed as spinal collapse. The Veteran was informed of the decision and of the right to appeal. He did not appeal or submit new and material evidence within one year of notification. The August 2008 rating decision denying service connection for low back pain (now claimed as spinal collapse) became final. At the time of the August 2008 rating decision, the reason for the denial changed because the Veteran had evidence of back pathology. The explicit denial was for low back pain, now claimed as spinal collapse. The implicit denial was for findings of degenerative disc disease, arthritis, and nerve root impingement, which were shown in the record. The evidence established post service pathology, but there was no relationship to service. By way of background, at the time of the August 2008 last final rating decision, private treatment records impressions of herniated discs with complaints of lower back pain. A June 2000 private treatment record from Dr. J. B. E. shows an assessment of "Sciatica with low back pain and LS strain muscle spasm." A contemporaneous June 2000 imaging report from North Hill Medical Center revealed degenerative spurs seen especially at L4-L5. Otherwise the lumbar spine was unremarkable. A July 2000 Progress Note for Workers' Compensation shows an impression of a herniated lumbar disc. A subsequent August 2000 CAT scan revealed a broad-based disc bulge with spinal canal narrowing at L2-3 L3-4 and L4-L5 posterior disc protrusion with central and left paracentral disc herniation involving the left L5 nerve roots and maybe the nerve root on the right as well. It also showed a right-sided osteophytic ridging and spondylitic disc bulge laterally at L5-S1 which abutted the right L5 nerve root. There was an impression of multiple disc bulges involving the right L5 and S1 nerve root distributions. A January 2000 private treatment record found that there was previously degenerative disc disease (DDD) identified with some nerve root impingement. A February 6, 2001 private treatment record from Piedmont Neurosurgical Group, P.A. shows that he had no problem with back prior to this injury. Myelography and a CT scan of the lumbar spine showed a slight disc bulge at L5-S1 not causing any significant neurological compression. An impression was entered of "a lower extremity spasticity of uncertain etiology status post work related accident." Related imaging from Health South revealed small midline herniation at the L5-S1 level, not causing any significant canal compromise. Private treatment records from Neurology Associates of Greenville, PA from 2001 continued to show back pathology. In particular, a treatment record from May 8, 2001 shows that the Veteran injured his back in May 2000 while lifting a box that weighed 200 pounds. His back had become increasingly stiff since the accident. It notes no past medical or surgical history. A CT scan of the lumbar and thoracic spine showed a diffuse annular disc bulge at L4-5 without impingement or cord impression. A July 13, 2001 private treatment record from Greenville Hospital System shows that the Veteran's spastic paraparesis started in May 2000 with the Veteran injuring his back. A June 2002 private treatment record from Dr. J. R. shows, "It remains possible that spasm of the paraspinal muscle is periodically compromising several of the nerve root/nerve projections." The Veteran also submitted private treatment records from Lee Memorial Health System. A private treatment record from September 8, 2003 shows "He is disabled for the past 1.5 years due to a workers comp low back injury 3 years ago in S.C. for which he had a CT scan and was felt to be nonsurgical." C. Analysis At the time of the August 2008 last prior denial, there was evidence of a current disability. The denial implicitly encompassed all identified back disabilities. At the minimum, the evidence showed degenerative disc disease and residuals of a lower back injury. More specifically, at the time of the prior denial, the evidence included impressions of slight disc bulge at L5-S1 not causing any significant neurological compression, diffuse, annular disc bulge at L4-5 without impingement or cord impression, nerve root/nerve projections, a broad-based disc bulge with spinal canal narrowing at L2-3 L3-4 and L4-L5 posterior disc protrusion with central and left paracentral disc herniation involving the left L5 nerve roots, and a right-sided osteophytic ridging and spondylitic disc bulge laterally at L5-S1 which abutted the right L5 nerve root and reports of lower back pain. To the extent that there is evidence of post service back pathology, this was already previously established in the prior denial. Such additional evidence is cumulative. There were impressions of degenerative disc disease and imaging studies showed pathology in the L2, L3, L4, L5, and S1. There were also reports of a back injury in 2000. In essence, there was evidence of back pathology. The implicit denial encompassed all of this. There was still no evidence of a nexus to service. Since the last prior final decision of August 2008, the Veteran submitted additional lay evidence and argument. VA treatment records were also associated with the claims file. VA treatment records show that the Veteran was unable to get MRIs because of shrapnel in his eyes. An August 2008 VA treatment record shows that the Veteran had complaints of pain in lower back and extremities. An April 26, 2010 VA treatment record shows low back pain/leg pain. A June 2011 VA treatment record shows impressions of back pain/leg pain. A January 2013 VA examination showed impressions of low back strain. The VA examiner opined that it is less likely than not that his low back pain is due to his military service. The VA examiner noted that it has been more than 40 years since his back spasms in the military. Additional evidence also includes a May 2014 Compensation and Pension Report indicating that only his condition of the thoracolumbar spine would be felt to affect employment of a physical nature. A VA treatment record from February 23, 2018 shows "C/O Chronic lower back pain." Subsequent VA treatment records are substantially the same, and show that the Veteran reported ongoing "low back pain/leg pain." Evidence submitted since the last final denial of August 2008 is cumulative of the evidence of record at the time of the prior denial. At the time of the final prior denial, there was post service evidence of pathology, and evidence of in-service complaints, but no accepted evidence of a nexus. The record also contained the STRs and his claim that his back disorder was due to service. None of the added evidence is new and material. In the August 2008 denial, the Veteran lacked a nexus. The added evidence, in pertinent part, consists of lay argument, VA treatment records, and VA examinations. However, at the time of the August 2008 last prior denial, there was evidence of post service pathology and the Veteran's claim of a link to service. Evidence that confirms previously established facts or repeats prior claims is cumulative. The Veteran's lay statements repeat evidence already of record at the time of the August 2008 decision. At the time of this prior decision, there was evidence of in-service complaints and remote post service pathology, but no accepted evidence of a nexus. The added evidence is cumulative. New and material evidence has not been submitted and the claim is not reopened. V. PTSD with Alcohol Abuse A. Rating of PTSD Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, a staged rating is not warranted. PTSD is currently rated at 70 percent pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. DC 9411 and other DC's addressing psychiatric disabilities are addressed under the General Rating Formula for Mental Disorders. Ratings are assigned according to the manifestation of particular symptoms. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A rating of 100 percent is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) the Federal Circuit stated that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. It was further noted that § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. The such symptoms as language means for example, and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran and his representative assert that the 70 percent rating for PTSD does not accurately depict the severity of the disability. B. History The Veteran was afforded an April 2011 VA examination. The Veteran reported difficulty handling stressors since service. PTSD with alcohol abuse was identified. The Veteran reported problems with social interactions and irritability. He reported chronic insomnia and nightmares. He had symptoms of hypervigilance and a hyper startle response to loud noises. He attended to his activities of daily living, except where he needed physical help due to his nerve disability. An October 26, 2011 VA treatment record shows that there were impressions of PTSD and adjustment disorder with depression. The Veteran presented as dressed casually and appropriately with good grooming and hygiene. He was polite and cooperative. He described his mood as "the same." His affect was stable. He denied suicidal ideation. His insight was good. The Veteran was afforded a July 2012 VA examination. The VA examiner opined that the Veteran's symptoms were best summarized by occupational and social impairment with reduced reliability and productivity. Current symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impatient, mild memory loss, flattened affect, disturbance of motivation and mood, difficulty in adapting to stressful situations, and suicidal ideation. A January 2014 VA treatment record shows that the Veteran was taking an increased dose of medication which helped with his anxiety. He reported that he was getting along well with his wife, and with family and friends. He stated that his symptoms from PTSD were better with medication. He had less irritability and less depressed mood. He stated that he was not able to be active in the community due to his pain. He reported that his appetite was good, but his energy was not good. His concentration was "ok," and his memory was better. His mood was described as "ok." He denied suicidal or homicidal ideation, as well as hallucinations. His symptoms were due to medical problems, chronic pain, and PTSD symptoms. He startled easily. He reported not being able to cope with things in general. An April 2014 VA addendum medical opinion shows that PTSD was productive of occupational and social impairment with reduced reliability, with disturbances of motivation and mood relationships, and difficulty in adapting to stressful circumstances including work or a worklike setting. The VA examiner noted that as of January 2, 2014, the Veteran had not reported active suicidal ideation. The Veteran's September 2015 VA Form 9 shows that he was not able to learn and comprehend. He did not work well with others. He did not socialize. His memory was not good. He couldn't sit, stand, or walk for long periods of time. He did not like to be around people. A VA treatment record from February 2015 shows that the Veteran's treatment benefited greatly by medication. He continued to have nightmares regularly. He reported that he had never been preoccupied with suicidal thoughts. He reported no homicidal ideation or hallucination. He reported hypervigilance and flash backs of war events ever since he got back from Vietnam. A December 2015 VA treatment record shows that the Veteran presented as "depressed 'cause I can't do anything." He had anxiety, manifested by flashbacks and hypervigilance. He denied suicidal and homicidal ideation. A January 2016 VA treatment record shows that the Veteran reported that he preferred to return to a previous medication. He stated that his PTSD symptoms were worsening. A March 2016 VA treatment record shows that the Veteran reported that he was doing fairly well. He stated that his mood was depressed secondary to not being able to do anything. He had some flashbacks, hypervigilance, crowd avoidant, irritability. He denied suicidal and homicidal ideation. An October 2017 VA treatment record showing a mental health PTSD screening shows that the Veteran denied any suicidal or homicidal ideation. He was not feeling hopeless about the present or future. January 2018 VA treatment record shows that the Veteran was not suicidal or homicidal. He was oriented to time and place. A February 27, 2018 VA Social Work Note shows that the Veteran was adequately groomed and dressed appropriately. He presented with content mood and flat affect. There were no observable cognitive impairments, no suicidal or homicidal ideation, and the Veteran was cooperative during the visit. The Veteran had recently acquired a dog that helped with his PTSD symptoms. A February 27, 2018 VA Mental Health Note shows that the Veteran stated that new medication made him feel less ornery. He stated that his mood was depressed secondary to not being able to do anything. He had some flashbacks, hypervigilance, crowd avoidance, and irritability. The psychiatric entered an impression of "PTSD, chronic." Additional VA treatment records are substantially the same. C. Analysis The Veteran is competent to report his feelings, including depressed mood, anxiety, chronic sleep impairment, difficulty in adapting to stressful situations, and suicidal ideation. He is competent to report that he has been diagnosed with PTSD. The Board finds these reports credible. The Board assigns significant probative weight to the Veteran's lay reports of his symptoms, including those exhibited at the time of the July 2012 VA examination. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has been assigned a 70 percent rating for PTSD under Diagnostic Code (DC) 9411, 38 C.F.R. §§ 4.130. The evaluation contemplates occupational and social impairment with reduced reliability and productivity, disturbances of motivation and mood, flattened affect, anxiety, chronic sleep impairment, depressed mood, mild memory loss, suspiciousness, and suicidal ideation. In order to have a higher evaluation, there must be total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The weight of competent lay and medical evidence indicates that a higher evaluation is not warranted. The July 2012 VA examination showed the most severe symptoms, best summarized by occupational and social impairment with reduced reliability and productivity. The Veteran had suicidal ideation. Later VA treatment records show that the Veteran's condition stabilized and improved to a slight extent through medication and therapy. By the April 2014 VA addendum opinion, the Veteran had begun to deny suicidal ideation. This continued through the 2018 VA treatment records. While he still had depressed mood, anxiety, chronic sleep impairment, and flashbacks, he was able to socialize with his wife and was oriented to place and time. The February 27, 2018 VA Social Work Note shows that he acquired a dog, and that had helped. Although the Veteran consistently did not have suicidal ideation for several recent years (or homicidal ideation and hallucinations), the Board will not disturb the Veteran's current 70 percent rating. The Board finds the 2018 VA treatment records and July 2012 VA examination, taken together, describe a consistent picture of symptomatology associated with PTSD. These symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss flattened affect, disturbance of motivation and mood difficulty in adapting to stressful situations, and suicidal ideation are most closely approximated by the current 70 percent rating. Here, the contemporaneous VA treatment records and July 2012 VA examination have reflected that the Veteran's PTSD results in occupational and social impairment, with deficiencies in most areas, such as work, family relations, thinking, and mood. The Veteran does not have total occupational and social impairment. He does not have symptoms such as persistent delusions or hallucinations; grossly inappropriate behavior, or persistent danger of hurting self or others. As such, the symptoms are not of the severity and frequency to cause the level of occupational and social impairment associated with a higher disability rating. See Bankhead v. Shulkin, No. 15-2404, slip op. at 10 (U.S. Vet. App. Mar. 27, 2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Consequently, a rating in excess of 70 percent for PTSD is not warranted. VI. Individual Unemployability A. TDIU Law and Regulations Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2006); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: Provided That, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). It is the established policy of the Department of Veterans Affairs that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) of this section. The rating board will include a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16 (b). The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. The issue is whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The ultimate issue of whether TDIU should be awarded is not a medical issue, but is a determination for the adjudicator. In the present case, PTSD has been rated at 70 percent from March 7, 2011. Right upper extremity diabetic peripheral neuropathy, musculospiral, median, and ulnar nerves (previously rated as diabetic peripheral neuropathy, right upper extremity) associated with diabetes mellitus type II is rated 20 percent from August 6, 2015 and 40 percent from July 31, 2017. Left upper extremity, peripheral neuropathy musculospiral, ulnar, and median nerves (previously rated as diabetic peripheral neuropathy, left upper extremity) associated with diabetes mellitus type II is rated 20 percent from August 6, 2015 and 30 percent from July 31, 2017. Diabetes mellitus type II is rated 10 percent prior to March 27, 2015 and 40 percent from March 27, 2015 (pursuant to this decision). Tinea pedis is rated at 10 percent pursuant to this decision. B. Analysis From March 7, 2011, the Veteran has met the schedular requirement under 38 C.F.R. § 4.16 (a). The Board finds that the Veteran's service connected disabilities preclude him from securing and following substantially gainful employment. In regard to the period prior to March 7, 2011, the Veteran did not meet the schedule criteria, and there was no credible evidence that he was unable to engage in and retain substantially gainful employment due to his service connected disabilities during that time (tinea pedis and diabetes). The Veteran's termination of employment in 2000 was due to other factors. The March 2014 VA medical opinion shows only the Veteran's condition of the thoracolumbar spine was felt to affect employment of a physical nature due to decreased range of motion, pain, and limited tolerance for standing activity and walking. The VA examiner opined that this condition would not be affected by a sedentary occupation. Nevertheless, the evidence also shows that the Veteran's service connected disabilities later precluded him from securing and following substantially gainful employment. In the September 2015 VA Form 9, the Veteran contended that he was not able to learn and comprehend, and does not work well with others. In December 2016, the Veteran reported, "Because of what turned out to be PTSD disorder I was always kept working by myself, not around people." The Board finds this to be credible, and assigns significant probative weight to these VA 21-8940 Applications. The VA 21-8940 forms generally cite to his collapsed spine and his PTSD symptoms as the reasons for unemployability. The Veteran is rated at 70 percent for PTSD from March 7, 2011. The Board incorporates the Veteran's history of PTSD by reference. The March 2018 VA 21-8940 Form shows that the Veteran can't concentrate, has trouble around people, can't recall things, and can't follow directions. He cannot walk far, stand, or sit for long. He has panic and nervous anxiety. The Board has considered the other VA treatment records. They collectively show that the Veteran had total occupational or social impairment as a result of his service connected disabilities. 38 C.F.R. § 4.16 (a). VA medical opinions have been obtained regarding the severity of his service connected disabilities. The Veteran's own lay reporting of his occupational, social, and medication history has also been considered. The Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities from March 7, 2011. To the extent that he has other non-service connected disabilities, the Board has considered these other factors. Consequently, a TDIU is warranted effective March 7, 2011. ORDER Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to herbicide exposure, as secondary to service connected disease or injury is denied. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to herbicide exposure, as secondary to service connected disease or injury is denied. Entitlement to an initial rating for diabetes mellitus, type II, in excess of 10 percent prior to March 27, 2015 is denied. Entitlement to an initial rating for diabetes mellitus, type II, of 40 percent, but no higher, from March 27, 2015 is granted. Entitlement to rating of 10 percent, but no higher, for tinea pedis is granted. The application to reopen the claim for lower back pain is denied. Entitlement to an initial rating in excess of 70 percent for post-traumatic stress disorder (PTSD) with alcohol abuse is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) from March 7, 2011 is granted. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs