Citation Nr: 18148026 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-43 119 DATE: November 6, 2018 ORDER Entitlement to service connection for gout is denied. Entitlement to service connection for malaria is denied. New and material evidence having been submitted, the claim of entitlement to service connection for an acquired psychiatric disorder is reopened. New and material evidence having not been submitted, the claim of entitlement to service connection for hepatitis is denied. New and material evidence having not been submitted, the claim of entitlement to service connection for hypothyroid disease, to include as due to Agent Orange exposure is denied. New and material evidence having not been submitted, the claim of entitlement to service connection for periodontitis is denied. Entitlement to a rating in excess of 20 percent for diabetes mellitus is denied. Entitlement to a compensable rating for impotence with penile implantation is denied. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. Entitlement to a compensable rating for residuals of prostate cancer is denied. REMANDED The reopened claim of entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has gout due to a disease or injury in service, to include a specific in-service event, injury, or disease. 2. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of malaria. 3. The RO denied the Veteran’s claim of entitlement to service connection for hypothyroid disease in a May 2007 rating decision. The Veteran was notified of the decision but he did not file an appeal, and the claim is final. 4. The RO denied the Veteran’s claims of entitlement to service connection for hepatitis, an acquired psychiatric disorder, and periodontitis in a July 2010 rating decision. The Veteran was notified of the decision but he did not file an appeal, and the claims are final. 5. Evidence added to the record since the final May 2007 and July 2010 rating decisions is either cumulative or redundant of evidence previously considered, or does not relate to an unestablished fact necessary to substantiate the claims for service connection for hypothyroid disease, hepatitis, and periodontitis. 6. However, evidence obtained since the July 2010 rating decision concerning the claim of entitlement to service connection for an acquired psychiatric disorder is new and raises a reasonable possibility of substantiating this claim. 7. The Veteran’s diabetes mellitus has not been manifested by the requirement of insulin. 8. The preponderance of the evidence is against a finding of moderate incomplete paralysis for the left upper extremity peripheral neuropathy. 9. The preponderance of the evidence is against a finding of moderate incomplete paralysis for the right or the left lower extremity peripheral neuropathy. 10. The Veteran’s prostate cancer residuals were not manifested by daytime voiding intervals of less than one hour, or awakening to void five or more times per night. 11. The Veteran’s erectile dysfunction does not result in penile deformity. CONCLUSIONS OF LAW 1. The criteria for service connection for gout are not met. 38 U.S.C. §§ 1110, 1131, 1154, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 2. The criteria for service connection for malaria are not met. 38 U.S.C. §§ 1110, 1131, 1154, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 3. The May 2007 rating decision which denied entitlement to service connection for hypothyroid disease is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 4. New and material evidence has not been received in order to reopen the claim of entitlement to service connection for hypothyroid disease. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 5. The July 2010 rating decision which denied entitlement to service connection for hepatitis, a psychiatric disorder, and periodontitis is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 6. New and material evidence has been received in order to reopen the claim of entitlement to service connection for an acquired psychiatric disorder. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 7. New and material evidence has not been received in order to reopen the claim of entitlement to service connection for hepatitis. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 8. New and material evidence has not been received in order to reopen the claim of entitlement to service connection for periodontitis. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 9. The criteria for a disability rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.119, Diagnostic Code 7913 (2017). 10. The criteria for an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, Diagnostic Code 8516 (2017). 11. The criteria for an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2017). 12. The criteria for an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2017). 13. The criteria for rating in excess of 20 percent for residuals of prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7528 (2017). 14. The criteria for a compensable rating for impotence with penile implantation have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.104, 4.115a, 4.115b, Diagnostic Code 7528-7522 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1963 to March 1968. Additional evidence was added to the claims file by the Agency of Original Jurisdiction (AOJ) in September 2018. As such evidence is cumulative or duplicative of evidence considered in the January 2016 statement of the case, or is not relevant, a waiver for review of this evidence is not necessary. 38 C.F.R. §§ 19.37, 20.1304 (2017). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 1. Entitlement to service connection for gout The Veteran contends that he suffers from gout as a result of his military service and, as such, he is entitled to service connection for this disorder. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Here, the medical evidence is in conflict as to whether he has a current diagnosis. An October 2004 treatment record shows a diagnosis of gout, while a September 2018 VA treatment record notes a prior history of gout but also notes that he has not experienced a flare in many years. Nevertheless, the Board concludes that, while the Veteran arguably has a current diagnosis of gout, (see September 2018 VA treatment record), the preponderance of the evidence weighs against finding that the Veteran’s gout began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). Additionally, while the claims folder does show he has a prior history of gout noted during the appeals period, the claims file does not contain any medical records or etiological opinions linking the Veteran’s disorder to his active service. In sum, there is no evidence, medical or otherwise, to support the Veteran’s assertions. While the Veteran believes his gout is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the lack of medical evidence of record attributing the Veteran’s gout to his military service. Accordingly, service connection for gout is not warranted because the Veteran has not satisfied the nexus requirement of attributing the current disorder to his active service. See 38 C.F.R. § 3.303 (2017). In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine does not apply. 38 U.S.C. § 5107(b) (2012). The claim of entitlement to service connection for gout is denied. 2. Entitlement to service connection for malaria The Veteran is seeking entitlement to service connection for malaria that he claims is due to his military service. The question for the Board is whether the Veteran has a current diagnosis of malaria that began during service or is at least as likely as not related to an in-service injury, event, or disease. For the reasons discussed below, the Board concludes that the Veteran does not have a current diagnosis of malaria and has not had a diagnosis at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, 557 F.3d 1363, 1366; Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s available service treatment records fail to show complaints of or treatment for malaria. Further, despite the existence of numerous treatment records dating through 2018, neither the VA nor private treatment records show that the Veteran ever received treatment, complained of, or was diagnosed with malaria during the pendency of this appeal. While the Veteran believes he currently suffers from this disorder, he is not competent to provide a diagnosis in this case. The issue is medically complex and requires specialized medical education and the ability to interpret complicated diagnostic medical testing in order to render a diagnosis. Jandreau, 492 F.3d 1372 1377 n.4. Consequently, the Board gives more probative weight to the lack of competent medical evidence rendering a diagnosis. In sum, the Veteran’s claim fails to meet the first prong of service connection, which is the requirement of a current disability. As the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for malaria, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b). As such, the claim must be denied. New and Material Evidence The Veteran’s claim of entitlement to service connection for hypothyroid disease was previously denied in a May 2007 rating decision. Additionally, the claims of entitlement to service connection for a psychiatric disorder, hepatitis, and periodontitis were all previously denied in a July 2010 rating decision. The Veteran did not appeal either of these rating decisions. As such, the May 2007 and July 2010 decisions are final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that 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. 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 Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Veteran filed a petition to reopen these claims in July 2013. The April 2014 rating decision currently on appeal continued the denial of these claims. 3. Acquired Psychiatric Disorder At the time of the prior July 2010 determination, the evidence included the Veteran’s service treatment records failing to show in-service complaints, treatment, or a diagnosis of a psychiatric disorder; post-service VA and private treatment records dated through 2010; a June 2010 VA examination noting a diagnosis of depression; and, statements in support of his claim. While these records noted a diagnosis of depression they failed to show that his currently diagnosed depression was either due directly to the Veteran’s military service or was due to or aggravated by his service-connected diabetes mellitus. Since the July 2010 denial, the Veteran has provided additional VA and private treatment records, a February 2015 Disability Benefits Questionnaire (DBQ) completed by the Veteran’s private psychologist, and a February 2015 statement from the private psychologist. Notably, the February 2015 statement from the Veteran’s private psychologist determined the Veteran’s depression is aggravated by his service connected disabilities. However, no rationale was provided. Nevertheless, this finding that the Veteran’s depression is aggravated by his service connected disabilities is material. As such, the Board finds that the evidence submitted since the July 2010 prior denial relates to a previously unestablished fact necessary to substantiate the Veteran’s claim. Reopening of the claim for service connection for an acquired psychiatric disorder is accordingly warranted, and the Veteran’s appeal is granted to that extent. 4. Hepatitis In previously denying the Veteran’s claim for service connection for hepatitis in the most recent July 2010 rating decision, the evidence of record included the Veteran’s service treatment records that failed to show any complaints, treatment, or diagnoses for hepatitis; VA and private treatment records dated through 2010 that failed to show a diagnosis; and, the Veteran’s statements in support of this claim stating the he contracted hepatitis as a result of his service in Vietnam. The RO denied the claim on the basis there was no evidence showing the Veteran has a current diagnosis of hepatitis C. The evidence received since the last prior final denial of the claim in July 2010 relevant to this claim includes additional VA treatment records and additional statements by the Veteran in support of his claim that he contracted hepatitis in Vietnam. The VA treatment records do not contain any references to a diagnosis of or treatment for hepatitis. Moreover, there is no evidence in the claims file indicating the Veteran has a current diagnosis of hepatitis. In fact, a March 2013 VA treatment record specifically notes the Veteran does not have hepatitis. Consequently, there is no evidence of record indicating the Veteran has a current diagnosis of hepatitis aside from the arguments previously considered in the July 2010 rating decision. As there are no new contentions or evidence to support this claim, the evidence added to the record is either cumulative, or unrelated to the claim. As new and material evidence has not been submitted, the claim is not reopened, and the appeal as to this issue is denied. 5. Hypothyroid Disease In previously denying the Veteran’s claim for service connection for hypothyroid disease in the May 2007 decision, the RO considered the service treatment records that failed to show in-service treatment or a diagnosis of hypothyroid disease during service; VA and private treatment records dated through 2007 that show a diagnosis of hypothyroid disease in September 2006; and, the Veteran’s lay statements in support of his claim. The RO denied this claim as there was no in-service injury or treatment for this disorder, or evidence to support a finding that this disorder is due to his military service, to include as due to exposure to Agent Orange during his military service. The evidence received since the last prior final denial of the claim in May 2007 relevant to this claim includes additional VA and private treatment records and, additional statements by the Veteran in support of his claim. However, there is no evidence of record attributing the Veteran’s hypothyroid disease to the Veteran’s military service aside from the arguments previously considered in the May 2007 rating decision. As there are no new contentions or evidence to support this claim, the evidence added to the record is either cumulative, or unrelated to the claim. As new and material evidence has not been submitted, the claim is not reopened, and the appeal as to this issue is denied. 6. Periodontitis In previously denying the Veteran’s claim for service connection for periodontitis in the July 2010 decision, the RO considered the service treatment records that failed to show in-service treatment or a diagnosis of periodontitis during service; VA and private treatment records dated through 2010, including a March 2010 dental consultation; a December 2009 statement from the Veteran’s dentist stating that he has been treated for periodontitis since 1990 and it is due to the Veteran’s diabetes mellitus; and, the Veteran’s lay statements in support of his claim. The RO denied this claim as there was no in-service injury or treatment for this disorder, or evidence to support a finding that this disorder is due to his military service, to include as secondary to his diabetes because it was not diagnosed until after the periodontitis diagnosis. The evidence received since the last prior final denial of the claim in July 2010 relevant to this claim includes additional VA and private treatment records and, additional statements by the Veteran in support of his claim. However, these records do not contain any additional dental treatment or evidence attributing any dental disorder to the Veteran’s military service aside from the arguments previously considered in the July 2010 rating decision. As there are no new contentions or evidence to support this claim, the evidence added to the record is either cumulative, or unrelated to the claim. As new and material evidence has not been submitted, the claim is not reopened, and the appeal as to this issue is denied. Increased Rating Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran’s symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Disability evaluations are determined by assessing the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2 (2017). If there is a question as to which evaluation should be applied to the veteran’s disability, 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). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2017). The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran’s disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 7. Entitlement to a rating in excess of 20 percent diabetes mellitus By way of background, the RO granted entitlement to service connection for this disability in a May 2007 rating decision. Most recently, he filed a claim for an increased rating for this disability on July 16, 2013, which means the relevant appeals period is from July 16, 2012, one year prior to receipt of the claim. 38 C.F.R. § 3.400. The April 2014 rating decision currently on appeal assigned the 20 percent rating. The Veteran is seeking a disability rating in excess of 20 percent for his service connected diabetes mellitus. The Veteran’s service connected diabetes mellitus is rated at 20 percent by the RO under the provisions of Diagnostic Code 7913. Under this regulatory provision: Diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational 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 warrants a 100 percent disability rating; Diabetes mellitus requiring 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 warrants a 60 percent disability rating; Diabetes mellitus requiring insulin, restricted diet, and regulation of activities warrants a 40 percent disability rating; Diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, warrants a 20 percent disability rating. 38 C.F.R. § 4.120, Diagnostic Code 7913. Compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). The Veteran was afforded a VA examination in April 2014. At that time, the Veteran’s diabetes was managed by a restricted diet and prescribed an oral hypoglycemic agent. The Veteran reported he suffers from episodes of ketoacidosis and hypoglycemia less than 2 times a month and has never been hospitalized. Further, the examiner specifically noted no evidence of cardiac complications, retinopathy, nephropathy, or right upper extremity neuropathy. Bilateral lower extremity peripheral neuropathy and erectile dysfunction have been found to be attributable to the Veteran’s diabetes; however, as service connection has already been established for those disabilities, they are discussed in separate sections below. Also of record are the Veteran’s VA and private treatment records. These extensive records show his diabetes is well documented and that the Veteran has been continuously treated for this disease, but there is no indication of additional medications aside from the oral hypoglycemic. VA treatment records show the Veteran’s diabetes to be uncontrolled at various times during the appeals period due to nonadherence to diet, medications, and exercise. See January 2017 VA treatment record. Based on the objective medical evidence of record, a disability rating in excess of 20 percent for diabetes mellitus is not warranted. What distinguishes the schedular criteria for the current 20 percent rating for diabetes from those for the next higher 40 percent rating is the requirement of insulin, restricted diet, and regulation of activities. The Board further notes that the criteria for the progressively increasing ratings for diabetes are stated in the conjunctive rather than the disjunctive, i.e., each level of increase in the rating requires additional criteria which must be met to warrant the increase in the rating. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). In this case, the evidence does not show that at any time during the appeal period manifestations of the Veteran’s diabetes mellitus satisfied, or approximated, the criteria for the next higher, 40 percent rating. The Board has considered the applicability of a staged rating, but finds it is not applicable. As a rating in excess of 20 percent for the service connected diabetes is not warranted, benefit of the doubt is not for application. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). The appeal is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 8. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity By way of background, service connection for peripheral neuropathy of the left upper extremity was granted in the April 2014 rating decision currently on appeal as secondary to his already service-connected diabetes mellitus. The RO granted an initial rating of 10 percent, effective from July 16, 2013, pursuant to Diagnostic Code 8516. 38 C.F.R. § 4.124a, Diagnostic Code 8516 (2017). The Veteran is seeking a higher initial rating. Under Diagnostic Code 8516, incomplete paralysis, a 10 percent rating is assigned for a “mild” disability of either extremity. A 30 percent rating is assigned for a “moderate” disability afflicting the major extremity, and 20 percent for the minor extremity. A 40 percent rating is assigned for a “severe” disability afflicting the major extremity, and a 30 percent rating for the minor extremity. Complete paralysis of the ulnar nerve includes the “griffin claw” deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened is rated at 60 percent for the major extremity and 50 percent for the minor extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8516 (2017). Under 38 C.F.R. § 4.124a, the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, at most, the moderate degree. The ratings for peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. The April 2014 VA examination determined the Veteran is right hand dominant. Physical examination showed mild paresthesias/ dysesthesias of the left upper extremity, the non-dominant extremity. Muscle strength and deep tendon reflexes were normal in the upper extremity. Position sense, vibration sensation, and cold sensation were normal and there was no evidence of muscle atrophy. The examiner ultimately provided a diagnosis of diabetic peripheral neuropathy manifested by mild incomplete paralysis of the ulnar nerve. VA and private treatment records associated with the claims file do not provide any additional objective medical evidence that shows the Veteran’s diabetic peripheral neuropathy of the left upper extremity has ever been manifested by moderate incomplete paralysis of the ulnar nerve. Therefore, and in consideration of the entirety of the evidence, the Board finds that the preponderance of the evidence is against a finding of moderate incomplete paralysis of the ulnar nerve, warranting the next higher 20 percent rating for the non-dominant extremity. The Board has considered the applicability of a staged rating, but finds it is not applicable. As a rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is not warranted, benefit of the doubt is not for application. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70. The appeal is denied. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 54-56. 9. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left and right lower extremities Service connection for peripheral neuropathy of the right and left lower extremities was granted in the April 2014 rating decision currently on appeal as secondary to his already service-connected diabetes mellitus. The RO granted an initial rating of 10 percent for each lower extremity, effective from July 16, 2013, pursuant to Diagnostic Code 8520. 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). The Veteran is seeking a higher initial rating for each lower extremity. Under Diagnostic Code 8520, incomplete paralysis of the sciatic nerve warrants a 10 percent evaluation when mild, 20 percent evaluation when moderate, 40 percent rating when moderately severe, and 60 percent when severe, with marked muscular atrophy. An 80 percent evaluation is warranted for complete paralysis where the foot dangles and drops, with no active movement possible of muscles below the knee, with flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. 38 C.F.R. § 4.124a. Under 38 C.F.R. § 4.124a, the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, at most, the moderate degree. The ratings for peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. The April 2014 VA examination showed mild paresthesias/ dysesthesias and numbness of the left and right lower extremities. Muscle strength was normal in the left and right lower extremity, and deep tendon reflexes were increased without clonus in the knees and decreased in the ankles, bilaterally. In the bilateral lower extremities, position sense was decreased, vibration sensation was absent, and cold sensation was absent. There was no evidence of muscle atrophy. Additionally, the examiner noted trophic changes, starting mid tibia and continuing distally. The examiner ultimately provided a diagnosis of diabetic peripheral neuropathy of the right and left lower extremities manifested by mild incomplete paralysis of the sciatic and femoral nerves. VA and private treatment records associated with the claims file do not provide any additional objective medical evidence that shows the Veteran’s diabetic peripheral neuropathy of either the right and left lower extremity has ever been manifested by moderate incomplete paralysis. The Board has also considered whether the Veteran would receive a higher rating for symptomatology based on the femoral nerve. However, given that symptoms of the femoral nerve for the left and right lower extremities are described as mild and would not provide a higher rating for the Veteran’s disability, an increased rating under Diagnostic Code 8526 is not warranted. The Board also considered whether a separate rating is warranted. However, as the sciatic and femoral nerve overlap, a separate rating would not be appropriate due to the law against pyramiding. See 38 C.F.R. § 4.14. Therefore, and in consideration of the entirety of the evidence, the Board finds that the preponderance of the evidence is against a finding of moderate incomplete paralysis for either the left or right lower extremity. The Board has considered the applicability of a staged rating, but finds it is not applicable. As ratings in excess of 10 percent for peripheral neuropathy of the left and right lower extremities are not warranted, benefit of the doubt is not for application. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70. The appeal is denied. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 54-56 (1990). 10. Entitlement to a compensable rating for residuals of prostate cancer In May 2007, the RO granted service connection for prostate cancer, and assigned an initial noncompensable rating under 38 C.F.R. § 4.115b, Diagnostic Code 7528 effective October 30, 2006. The Veteran filed a claim for an increased rating for this disability on July 16, 2013, which means the relevant appeal period is from July 16, 2012, one year prior to receipt of the claim. 38 C.F.R. § 3.400. The April 2014 rating decision currently on appeal increased the Veteran’s disability rating to 20 percent. He contends that he is entitled to an even higher rating for residuals of his prostate cancer. Prostate cancer is rated under Diagnostic Code 7258, which assigns a rating of 100 percent for malignant neoplasms of the genitourinary system. 38 C.F.R. 4.115b. A Note after Diagnostic Code 7528 provides that, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. 3.105(e). If, as here, there has been no local reoccurrence or metastasis, the disability is to be rated on residuals, such as voiding dysfunction or renal dysfunction, whichever is predominant. See 38 C.F.R. 4.115b, Diagnostic Code 7528, Note. In this instance, there is no evidence of any renal dysfunction in the Veteran’s medical records or in the Veteran’s statements. As such, the issue of renal dysfunction will not be discussed further. Under Diagnostic Code 7528, the criteria for voiding dysfunction assigns a maximum 60 percent rating if there is continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence which requires the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. Id. A 40 percent disability rating is assigned for incontinence requiring the wearing of absorbent materials which must be changed 2 to 4 times per day. A 20 percent disability rating is assigned where the incontinence requires wearing of absorbent materials which must be changed less than 2 times per day. Id. The Board will also consider whether an increased rating might be assigned under the criteria for urinary frequency in this case. A 20 percent disability rating is assigned where there is daytime voiding at intervals between one and two hours or awakening to void three to four times per night. A 40 percent disability rating is assigned where there is daytime voiding at intervals of less than one hour or awakening to void five or more times per night. 38 C.F.R. § 4.115a. The April 2014 VA examination noted that the Veteran’s prostate cancer is in remission. The Veteran reported an increase in his urinary incontinence symptoms. The examiner noting the Veteran suffers from voiding dysfunction that results in urine leakage. However, the Veteran’s voiding dysfunction does not require the use of absorbent materials or the use of an appliance. The day time voiding interval was found to be between one to two hours, and awakening to void at night three to four times. Obstructed voiding was not found. No other objective findings were noted. The Board finds that the Veteran’s disability picture for residuals of prostate cancer does not warrant a rating in excess of 20 percent. The evidence of record does not show a need for absorbent material due to voiding dysfunction to be changed two to four times a day, nor does it show urinary frequency resulting in daytime voiding intervals of less than one hour or nighttime voiding of five times or more per night. Therefore, the competent probative evidence weighs against finding entitlement to a rating in excess of 20 percent. The Board has considered the applicability of a staged rating, but finds it is not applicable. As a rating in excess of 20 percent for residuals of prostate cancer is not warranted, benefit of the doubt is not for application. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70. The appeal is denied. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 54-56. 11. Entitlement to a compensable rating for impotence with penile implantation By way of background, service connection for impotence with penile implantation was granted in a May 2007 rating decision as a residual of his service-connected prostate cancer. Most recently, he filed a claim for an increased rating for this disability on July 16, 2013, which means the relevant appeal period is from July 16, 2012, one year prior to receipt of the claim. 38 C.F.R. § 3.400. The April 2014 rating decision currently on appeal continued the noncompensable rating. The Veteran is seeking a compensable rating for this disability. The Veteran’s impotence with penile implantation is currently rated at 0 percent pursuant to Diagnostic Code 7528-7522. See 38 C.F.R. § 4.115b, Diagnostic Codes 7528-7522 (2017). Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Residuals of prostate cancer are rated under Diagnostic Code 7528 (malignant neoplasms of the genitourinary system). Diagnostic Code 7528 provides, in pertinent part, that if there has been no local reoccurrence or metastasis, then the disability will be rated on residuals of voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Here, the primary residual associated with the Veteran’s prostate cancer is voiding dysfunction, as previously discussed above, but also erectile dysfunction. Erectile dysfunction is properly evaluated under Diagnostic Code 7522. Diagnostic Code 7522 provides a 20 percent rating for a deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. “Deformity” under Diagnostic Code 7522 means “a distortion of the penis, either internal or external,” based on the ordinary meaning of the term as gleaned from Dorland’s Illustrated Medical Dictionary. Internal deformity may include abnormalities such as nerve damage caused by a radical prostatectomy. Williams v. Wilkie, No. 16-3252, 2018 U.S. App. Vet. Claims LEXIS 1037 (Vet. App. Aug. 7, 2018). A footnote to this diagnostic code indicates that claims for penis deformities should be reviewed for entitlement to special monthly compensation (SMC). See 38 U.S.C. §§ 1114(k) (2012); 38 C.F.R. § 3.350(k) (2017). SMC is payable for anatomical loss or loss of use of a creative organ. Id. Here, a compensable rating for erectile dysfunction is not warranted. Although the Veteran has loss of erectile power, the medical evidence does not reflect a penile deformity. The April 2014 VA examination report did not include any indication of deformity of the penis. The available VA and private treatment records do not include any objective evidence of a penile deformity. The evidence indicates that the Veteran does have loss of erectile power (see April 2014 VA examination); however, the evidence of record does not reveal any deformity of the Veteran’s penis. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive “and” in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive “or” requirement must be met in order for an increased rating to be assigned). That is, the requirement under Diagnostic Code 7522 of deformity of the penis “with” loss of erectile power clearly means that both factors are required. In this regard, the Veteran has not reported, and the evidence does not document, any penile deformity. As noted above, the April 2014 VA examiner noted a normal penis on examination. Furthermore, the evidence does not show any potential internal deformity, such as nerve damage. While the Veteran did undergo a radical prostatectomy as noted in the April 2014 VA examination, nerve damage associated with such has not been shown. Accordingly, the lay and medical evidence does not warrant a compensable evaluation for erectile dysfunction. Moreover, other diagnostic codes for the penis or testes that provide for a rating greater than zero percent are not more appropriate, as the facts of the case do not support their application. See 38 C.F.R. § 4.115b, Diagnostic Code 7520 (removal of half or more of the penis); Diagnostic Code 7521 (removal of the penis glans); Diagnostic Code 7523 (atrophy of the testes); or Diagnostic Code 7524 (removal of the testes). Indeed, Diagnostic Code 7522 specifically governs ratings for erectile dysfunction, and the Veteran has not been shown to have removal of the penis glans, atrophy of the testes, or removal of the testes. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). The Board also notes that the Veteran has already been granted special monthly compensation pursuant to 38 U.S.C. § 1114(k) based on the loss of use of a creative organ for his erectile dysfunction. Thus, the Veteran is compensated for his erectile dysfunction and any associated symptoms and impairment. The Board has considered the applicability of a staged rating, but finds it is not applicable. As a compensable rating for impotence with penile implantation is not warranted, benefit of the doubt is not for application. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70. The appeal is denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. at 54-56. REASONS FOR REMAND The reopened claim of entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran is seeking entitlement to service connection for an acquired psychiatric disorder that he alleges is due to his military service or, alternatively, is due to or aggravated by his service connected disabilities and, specifically, diabetes mellitus. The Board notes that there are no in-service complaints, treatment, or diagnoses of a psychiatric disorder during the Veteran’s military service or within one year of his separation. However, the Veteran does have a current diagnosis of depression. See June 2010 VA examination and February 2015 DBQ. The June 2010 VA examiner determined the Veteran’s depression is not due to his service-connected disabilities because the Veteran reported symptoms beginning in 1968, which is before the date of onset for his service-connected disabilities. However, the examiner did not provide an opinion as to whether these disabilities aggravated the Veteran’s depression. In support of his claim, the Veteran submitted a statement from his private psychologist in February 2015, included with the February 2015 DBQ. Dr. H.G. provided a conclusory statement that the Veteran’s depression is aggravated by his service-connected disabilities. No rationale was provided. The Board cannot make a fully-informed decision regarding this claim because a sufficient rationale has not been provided to determine whether the Veteran’s depression is attributable to his military service, either on a direct incurrence basis or secondary to his service-connected disabilities. As such, a remand is warranted for a VA examination to obtain this necessary opinion. The matter is REMANDED for the following action: 1. Obtain and associated with the electronic claims file any outstanding private or VA treatment records dated since September 2018. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the diagnosed depression. The examiner should specifically state whether it is at least as likely as not (50 percent or greater probability) related to the Veteran’s military service. 3. Alternatively, the examiner must state whether it is at least as likely due to or aggravated by his service connected disabilities. 4. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. L. BARSTOW Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Berry, Counsel