Citation Nr: 1813259 Decision Date: 03/08/18 Archive Date: 03/14/18 DOCKET NO. 11-16 672 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for migraine headaches. 2. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus. 3. Entitlement to an initial evaluation in excess of 10 percent for lumbar spine disability. 4. Entitlement to an initial compensable evaluation for peroneal nerve impairment of the right lower extremity (RLE). 5. Entitlement to an initial compensable evaluation for peroneal nerve impairment of the left lower extremity (LLE). 6. Entitlement to an initial evaluation in excess of 10 percent prior to December 30, 2014, and in excess of 30 percent therefrom for peripheral neuropathy of the left (minor) upper extremity (LUE). 7. Entitlement to an initial evaluation in excess of 30 percent prior to November 23, 2015, an in excess of 50 percent therefrom for adjustment disorder with mixed anxiety and depressed mood. 8. Entitlement to an effective date earlier than February 12, 2008, for the grant of service connection for diabetes mellitus. 9. Entitlement to an effective date earlier than February 12, 2008, for the grant of service connection for lumbar spine disability. 10. Entitlement to an effective date earlier than February 12, 2008, for the grant of service connection for bilateral peroneal nerve impairment. REPRESENTATION Veteran represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The Veteran served on active duty from April 1986 to January 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Offices (RO) in Atlanta, Georgia, and Cleveland, Ohio. Jurisdiction currently resides with the Atlanta RO. The issues of entitlement to service connection for migraine headaches, an initial evaluation in excess of 10 percent for lumbar spine disability, and an initial evaluation in excess of 50 percent from November 23, 2015, for adjustment disorder with mixed anxiety and depressed mood are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. During the appeal period, diabetes has not required regulation of activities. 2. During the appeal period, moderate incomplete paralysis of the RLE peroneal nerve is not more nearly shown. 3. During the appeal period, moderate incomplete paralysis of the LLE peroneal nerve is not more nearly shown. 4. Prior to December 30, 2014, peripheral neuropathy of the LUE is not more nearly manifested by moderate or worse incomplete paralysis; and from December 30, 2014, it is not more nearly manifested by severe incomplete paralysis or complete paralysis. 5. During the appeal period prior to November 23, 2015, service-connected adjustment disorder with mixed anxiety and depressed mood is not more nearly manifested by occupational and social impairment with reduced reliability and productivity. 6. Prior to February 12, 2008, there was no informal or formal claim, or written intent to file a claim, of service connection for diabetes mellitus, lumbar spine disability, or peroneal nerve impairment. CONCLUSIONS OF LAW 1. The criteria for an initial disability evaluation in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.119, Diagnostic Code 7913 (2017). 2. The criteria for an initial compensable disability evaluation for RLE peroneal nerve impairment are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.124a, Diagnostic Code 8523 (2017). 3. The criteria for an initial compensable disability evaluation for LLE peroneal nerve impairment are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.124a, Diagnostic Code 8523 (2017). 4. The criteria for an initial evaluation in excess of 10 percent prior to December 30, 2014, and in excess of 30 percent therefrom for LUE (minor) peripheral neuropathy are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.124a, Diagnostic Codes 8515, 8612 (2017). 5. The criteria for an evaluation in excess of 30 percent for adjustment disorder with mixed anxiety and depressed mood prior to November 23, 2015, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9440 (2015). 6. The criteria for an effective date earlier than February 12, 2008 for the grant of service connection for diabetes mellitus are not met. 38 U.S.C. §§ 5101, 5107, 5110, 5111 (2012); 38 C.F.R. § 3.400 (2017). 7. The criteria for an effective date earlier than February 12, 2008 for the grant of service connection for lumbar spine disability are not met. 38 U.S.C. §§ 5101, 5107, 5110, 5111 (2012); 38 C.F.R. § 3.400 (2017). 8. The criteria for an effective date earlier than February 12, 2008 for the grant of service connection for bilateral peroneal nerve impairment are not met. 38 U.S.C. §§ 5101, 5107, 5110, 5111 (2012); 38 C.F.R. § 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Neither the Veteran, nor her attorney, has alleged prejudice or any issues with the duty to notify or the duty to assist. The Federal Court of Appeals has held that "absent extraordinary circumstances... it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...." See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Evaluations Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. A. Diabetes Mellitus In a June 2009 rating decision, the RO granted service connection for diabetes at the 20 percent disability level under Diagnostic Code 7913, effective from February 12, 2008. See Rating Decision (June 2009). This appeal arises from the Veteran's disagreement with the assigned initial evaluation. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet; a 40 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities; a 60 percent rating is warranted when diabetes 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; and a 100 percent rating when the diabetes requires 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. 38 C.F.R. § 4.119, Diagnostic Code 7913. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial evaluation in excess of 20 percent for diabetes mellitus. The evidence does not more nearly reflect the criteria for the next higher evaluation. 38 C.F.R. § 4.7. During this appeal, the management of diabetes mellitus has not required regulation of activities. The criteria for a rating excess of 20 percent are conjunctive not disjunctive-i.e., there must be insulin dependence and restricted diet and regulation of activities. See Melson v. Derwinski, 1 Vet. App. 334 (1991). "Regulation of activities" is defined by Diagnostic Code 7913 as the "avoidance of strenuous occupational and recreational activities." Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007) (citing 61 Fed. Reg. 20,440 (May 7, 1996)). Report of VA examination dated in June 2009 reflects no indication of any restrictions on either occupational or recreational activities. In fact, the examiner specifically stated that diabetes had no effect on the Veteran's occupational functioning or her daily activities. Similarly, a November 2015 VA examination report reflects that regulation of activities is not required for her diabetes. Neither the VA treatment records nor examination reports reflect that the Veteran has required regulation of activities during this appeal due to diabetes; or loss of strength or weight; or hospitalizations for ketoacidosis or hypoglycemic reactions. Also, other than separately evaluated peripheral neuropathy, there are no complications of diabetes during this appeal. The Board acknowledges the Veteran's belief that her use of insulin to control diabetes warrants a higher evaluation. See VA Form 21-4138 (July 2009). However, this theory is not supported by the schedular criteria as explained above, which is conjunctive in design. 38 C.F.R. § 38 C.F.R. § 4.119, Diagnostic Code 7913. The Board further acknowledges the May 2010 statement of her doctor that "Her diabetes interferes with her daily activities due to dietary changes for weight management and the use of insulin" and that the Veteran needs management/counselling of nutrition/weight. See Third Party Correspondence (May 2010) and Notification Letter (April 2012). The Board accepts the reported interference as described here; however, this is not the same as regulation of activities, which refers to the avoidance of strenuous physical activities and not annoyances from an altered diet and use of insulin. See Camacho, supra. Therefore, this evidence has little probative value. The Board accepts that the Veteran is competent to report on her observable symptomatology. However, whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board. In this case, the medical evidence is more probative of whether the schedular criteria are met and the medical findings do not comport with the assignment of a higher evaluation, as explained and discussed above. Additionally, the Board finds that there is no basis for a higher or separate schedular evaluation under any other potentially available provision. Accordingly, an evaluation in excess of 20 percent for diabetes is denied. As the evidence is not in equipoise, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The disability has not met the criteria for a higher evaluation at any time during the appeal period and, as such, there is no basis for a staged rating. See Fenderson v. West, 12 Vet. App. 119, 126 (2001); Hart v. Mansfield, 21 Vet. App. 505 (2007). B. Peroneal Nerve Impairment of Lower Extremities In a June 2009 rating decision, the RO granted service connection for peroneal nerve impairment of the lower extremities at the 10 percent disability level for each extremity under Diagnostic Code 8523, effective from February 12, 2008. See Rating Decision (June 2009). This appeal arises from the Veteran's disagreement with the assigned initial evaluation. Diagnostic Code 8523 provides a noncompensable rating for mild incomplete paralysis of the nerve; a 10 percent rating for moderate incomplete paralysis; a 20 percent rating for severe incomplete paralysis; and a 30 percent rating for complete paralysis with dorsal flexion of the foot lost. 38 C.F.R. § 4.124a, Diagnostic Code 8523. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture 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 is for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. See 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial compensable evaluation for peroneal impairment involving either the RLE or LLE. The evidence does not more nearly reflect the criteria for a compensable evaluation for either extremity. 38 C.F.R. § 4.7. Report of VA examination dated in March 2009 reflects neurological deficits thought "most likely" to involve the deep peroneal nerve. A June 2009 VA examination report shows that, on neurological evaluation, sensory and motor functions of the lower extremities were within normal limits although ankle jerks were absent. The examiner stated that peripheral nerve involvement was not evident during the examination. An April 2011 VA examination report reflects no abnormal neurological findings for either lower extremity. The examiner stated that there was no deficiency in "either a motor or sensory component of the deep peroneal nerves or any evidence of peripheral neuropathy in the lower extremities." A November 2015 VA examination report also shows normal peroneal nerves. The Board has considered the April 2012 letter from the Veteran's doctor noting that she had "nerve compression leading to her leg pain." However, this evidence is inadequate to support a compensable evaluation since it does not identify the nerve involved or the severity. Therefore, the statement has no probative value. The Veteran is competent to report her symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, she is not competent to opine on the etiology of her symptoms, to include the nerve involved, as she lacks the requisite medical expertise and this is not susceptible to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board assigns greater probative value to the reports of VA examination showing that the Veteran does not have a moderate or worse incomplete paralysis of the peroneal nerve of either lower extremity. This is more probative than the Veteran's belief that her condition warrants a compensable evaluation because it is based on examination of the Veteran with consideration of her complaints and medical expertise, which the Veteran lacks. In this case, the medical findings do not comport with the assignment of a higher evaluation in the absence of findings for moderate incomplete paralysis or analogous symptoms causing impairment of either lower extremity. Accordingly, compensable evaluations for peroneal impairment of the lower extremities are denied. As the evidence is not in equipoise, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert, supra. Neither disability met the criteria for compensable evaluations at any time during the appeal period; as such, there is no basis for staged ratings. See Fenderson, supra. To the extent that the Veteran developed peripheral neuropathy of the lower extremities, these disabilities are separately rated based on sciatic nerve impairment and they are not on appeal at this time. C. LUE Peripheral Neuropathy VA received a claim for peripheral neuropathy in March 2012. See VA Form 21-4138 (March 2012). A June 2012 rating decision granted service connection for LUE peripheral neuropathy, assigning a 10 percent evaluation effective from March 16, 2012, under Diagnostic Code 8515 (median nerve). In September 2012, VA received the Veteran's notice of disagreement with the assigned evaluation. In a January 2016 rating decision, the RO granted a 30 percent evaluation for LUE peripheral neuropathy, effective from December 30, 2014, under Diagnostic Code 8612 (lower radicular group), which the RO determined more accurately reflects the disability picture. The Veteran is right hand dominant. As such, the applicable schedular provisions for the LUE involve the monodominant hand (minor). Under Diagnostic Codes 8515 and 8612, moderate incomplete paralysis of the nerve in the minor extremity is rated at 20 and 30 percent, respectively. Severe incomplete paralysis of the nerve warrants a 40 percent rating under both provisions. Complete paralysis warrants a 60 percent rating under provisions. 38 C.F.R. § 4.124a, Diagnostic Codes 8512 and 8515. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial evaluation in excess of 10 percent prior to December 30, 2014, and in excess of 30 percent therefrom LUE peripheral neuropathy. The evidence does not more nearly reflect the criteria for a higher evaluation. 38 C.F.R. § 4.7. Neither the lay nor the medical evidence reflects that peripheral neuropathy of the LUE is more nearly manifested by moderate or worse incomplete paralysis prior to December 30, 2014; or that peripheral neuropathy of the LUE is more nearly manifested by severe incomplete paralysis or complete paralysis from December 30, 2014. Report of VA examination dated in July 2012 reflects peripheral neuropathy of LUE. The Veteran reported "mild" symptoms of paresthesias and/or dysesthesias, and numbness. She denied constant or intermittent pain on this examination. LUE strength and reflexes were normal. There was decreased (but not absent) sensation to light touch/monofilament in the hand/fingers. Position and vibration senses were normal. There was no LUE atrophy. The LUE radial, median, and ulnar nerves were identified as involved and the severity was characterized as "mild incomplete paralysis." It was noted that no diagnostic EMG study had been performed and the condition did not impact the Veteran's ability to work. Report of VA examination dated in November 2015 reflects peripheral neuropathy of LUE. In the LUE, she reported "moderate" symptoms constant pain and paresthesias and/or dysesthesias. She denied numbness. LUE strength was normal (5/5) except on grip (4/5). There was no muscle atrophy and reflexes were normal throughout the LUE. There was decreased (not absent) sensation at shoulder area to light touch. The LUE radial, median, ulnar, and radicular nerves (middle and lower) were identified and the severity was characterized as "mild incomplete paralysis." A December 30, 2014, EMG test of the LUE showed mild carpal tunnel syndrome with primary focal demyelination associated with cervical spine problems. The LUE disability does not impact the Veteran's ability to work. During the appeal period, VA examinations show that there is not functional impairment of the LUE such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the complaints coupled with the medical evidence. Here, although the Veteran believes that she meets the criteria for higher disability ratings, her symptoms and the medical findings do not satisfy the schedular requirements for higher ratings than assigned in the absence of findings for moderate or worse incomplete paralysis prior to December 30, 2014; or severe incomplete paralysis or complete paralysis from December 30, 2014. The evidence shows essentially little to no LUE impairment of strength or reflexes and no muscle atrophy. Accordingly, the claim is denied. As the evidence is not in equipoise, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert, supra. Additional staging of the disability rating is not warranted. See Fenderson, supra. D. Psychiatric Disorder In a November 2013 rating decision, the RO granted service connection for adjustment disorder with mixed anxiety and depressed mood at the 30 percent disability level under Diagnostic Code 9440, effective from November 6, 2012. See Rating Decision (November 2013). In a January 2016 rating decision, the RO assigned a 50 percent evaluation, effective from November 23, 2015. See Rating Decision (January 2016). This appeal arises from the Veteran's disagreement with the assigned initial evaluations. The issue of entitlement to a higher evaluation from November 23, 2015, is addressed in the remand below. All mental disorders, Diagnostic Codes 9201 through 9440, are evaluated pursuant to the rating schedule set out at 38 C.F.R. § 4.130. See 38 C.F.R. § 4.130, Diagnostic Codes 9201-9440 (omitted here). When evaluating a mental disorder, the rating agency considers the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency assigns an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-V). See 38 C.F.R. § 4.130. Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial evaluation in excess of 30 percent prior to November 23, 2015, for adjustment disorder with mixed anxiety and depressed mood. The evidence does not more nearly reflect the criteria for a higher evaluation prior to November 23, 2015. 38 C.F.R. § 4.7. Prior to November 23, 2015, neither the lay nor the medical evidence more nearly reflects occupational and social impairment with reduced reliability and productivity due to service-connected mental disorder. VA treatment records dated November 6, 2012, to November 23, 2015, reflect no complaints or findings for panic attacks or difficulty in establishing and maintaining effective work and social relationship due to service-connected mental disorder. The Veteran maintained full time employment and, at the same time, cared for her disabled husband and 2 children, and attended to her non-psychiatric medical problems including chronic pain. Report of VA examination dated in November 2013 reflects symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss (i.e. forgetting names, directions or recent events), disturbances of motivation and mood, and difficulty adapting to stressful circumstances, including work and work-like setting. However, the symptoms are not of the severity, frequency, or duration to support the assignment of a higher rating. The Veteran has anxiety, but no panic attacks. She has depression, but only a past history of suicidal ideation without intent or plan-she denied any suicidal thoughts in a few months. Her symptoms of depression were characterized during a VA treatment visit in July 2013 as mild. She has mild memory impairment and reported forgetting how to do familiar tasks at work, but there is no indication that she has been unable to adequately perform at work or to maintain her household which falls largely on her shoulders. She has chronic sleep impairment, but this appears due to her other medical problems and her husband's psychiatric problems. She stated that "she cannot sleep because her husband is 'homicidal and suicidal.'" Although the Veteran feels fatigued 3 days a week, she denied feeling worthless or having no sense of purpose, and she has not reported lost time from work due to this or any other symptoms associated with her mental disorder. The Veteran reported anger problems; however, she denied any anger-driven behavioral actions or outbursts in past 5-6 years. Notwithstanding her symptoms, the Veteran reported attending church with friends, and keeping herself organized with the use of notebooks. The November 2013 VA examiner reported that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Board observes that this medical finding corresponds with the VA schedular criteria for a 10 percent rating, and not the currently assigned 30 percent rating. See 38 C.F.R. § 4.130, Diagnostic Code 9440. The Board has considered the Disability Benefits Questionnaire dated in August 2013 submitted by Veteran and completed by her primary care provider. See VA Examination (August 2013). This form reflects diagnoses for depressive and anxiety disorders, manifested by depressed mood, anger and worry. This doctor indicated that there was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Board observes that the Veteran-provided medical evidence comports with the schedular criteria for a 30 percent evaluation and not the higher 50 percent evaluation under Diagnostic Code 9440. See 38 C.F.R. § 4.130, Diagnostic Code 9440 (The VA Rating Schedule provides a 30 percent evaluation where there is "Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events)). The record shows that the Veteran has been able to maintain full-time employment as the sole provider in her household, as well as, care for 2 children and a disabled husband who cannot work. The Veteran has been able to establish and maintain effective relationships with her husband and children, and friends. Between November 2012 and November 2015, there is no documented mental health treatment. The weight of the evidence is against an initial evaluation in excess of 30 percent prior to November 23, 2015. The Board has not excluded any symptoms from consideration. As explained above, the lay and medical evidence do not more nearly approximate the severity, frequency, or duration of symptoms contemplated for the next higher disability rating. The Veteran is competent and credible to report the severity, frequency, and duration of her symptoms. Layno, supra. Furthermore, the Board generally accepts that the Veteran's report of symptoms is credible. However, the evidence of frequency, severity, and duration of psychiatric symptoms, to include the length of remissions, and capacity for adjustment during periods of remission does not approximate the criteria for an evaluation in excess of 30 percent. Whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the Veteran's complaints coupled with the medical evidence. Here, both the lay and VA medical evidence are highly probative. However, although the Veteran may believe that she meets the criteria for the next higher disability rating, her complaints along with the more probative medical findings do not meet the schedular requirements for a higher evaluation than assigned. It is noted that separate evaluations are not warranted for anxiety and depression because both disabilities are evaluated under the same schedular criteria set out in VA's general rating schedule for mental disorders, 38 C.F.R. § 4.130 , and separate evaluations under different diagnostic codes would violate the rule against pyramiding. See 38 C.F.R. § 4.14 (an evaluation of the same disability or the same manifestations under various diagnostic codes is prohibited). Therefore, a numeric evaluation for depression as separate from anxiety is not warranted. Accordingly, an initial evaluation in excess of 30 percent prior to November 23, 2015, is denied. Because the evidence is not in equipoise, there is no doubt to resolve. 38 U.S.C. § 5107(b); Gilbert, supra. Lastly, because the Veteran's disorder did not meet the criteria for a higher rating than assigned at any point during this appeal prior to November 23, 2015, staging the rating prior to this date is not warranted. Fenderson, supra. III. Effective Dates The Veteran seeks effective dates earlier than February 12, 2008, for the grants of service connection for diabetes mellitus, lumbar spine disability, and bilateral peroneal nerve impairment. Legal Criteria Except as otherwise provided, the effective date of an evaluation and award of pension, compensation or dependency, and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be on the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. §§ 3.400, 3.400(b)(2). If a claim is reviewed at the request of the claimant more than one year after the effective date of a liberalizing law, benefits may be authorized for a period of one year prior to the date of receipt of such request. 38 C.F.R. § 3.114 (a)(2). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 U.S.C. § 101(30); 38 C.F.R. § 3.1(p). The date of receipt shall be the date on which a claim, information or evidence was received by VA. 38 U.S.C. § 101(30); 38 C.F.R. § 3.1(r). Any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claims must identify the benefit sought. 38 C.F.R. § 3.155. Under 38 C.F.R. § 3.157, a report of examination or hospitalization will be accepted as an informal claim for benefits. However the provisions of 38 C.F.R. § 3.157(b)(1) state that such reports must relate to examination or treatment of a disability for which service-connection has previously been established or that the claim specifying the benefit sought is received within one year from the date of such examination, treatment, or hospital admission. 38 C.F.R. § 3.157(b)(1). Facts & Analysis Having carefully reviewed the evidence of record, the Board finds that effective dates earlier than February 12, 2008, for the grants of service connection for diabetes mellitus, lumbar spine disability, and bilateral peroneal nerve impairment are not warranted. VA received an original claim of entitlement to service connection for diabetes and lumbar spine disorders on February 12, 2008. See VA Form 21-526 (February 2008). The RO subsequently granted those claims effective from the date of the claims' receipt by VA-February 12, 2008. It is noted that peroneal nerve impairment was associated with lumbar spine disorder on VA examination dated in March 2009 and that the RO assigned an effective date for peroneal nerve impairment of February 12, 2008-also, date of original claim. Here, the Board finds no basis upon which to assign effective dates earlier than February 12, 2008, for the grants of service connection. VA did not receive a claim within 1 year after separation from service and there is no communication prior to February 12, 2008, that could be reasonably construed as a claim of entitlement to disability benefits. Although the Board accepts that the Veteran had disability prior to the date of receipt of her application for VA compensation in February 2008, the law dictates that the effective date of service connection is the date of the receipt of the claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110 (a); 38 C.F.R. §3.400. Therefore, the effective date for grants of service connection is appropriately February 12, 2008, for diabetes mellitus, lumbar spine disability, and bilateral peroneal nerve impairment-and no earlier. Accordingly, the earlier effective date claims are denied. There is no doubt to resolve. 38 U.S.C. § 5107(b); Gilbert, supra. ORDER An initial evaluation in excess of 20 percent for diabetes mellitus is denied. An initial compensable evaluation for RLE peroneal nerve impairment is denied. An initial compensable evaluation for LLE peroneal nerve impairment is denied. An initial evaluation in excess of 10 percent prior to December 30, 2014, and in excess of 30 percent therefrom for LUE peripheral neuropathy is denied. An initial evaluation in excess 30 percent prior to November 23, 2015, for adjustment disorder with mixed anxiety and depressed mood is denied. An effective date earlier than February 12, 2008, for the grant of service connection for diabetes mellitus is denied. An effective date earlier than February 12, 2008, for the grant of service connection for lumbar spine disability is denied. An effective date earlier than February 12, 2008, for the grant of service connection for bilateral peroneal nerve impairment is denied. REMAND Migraine Headaches The Veteran argues that she has migraine headaches secondary to service-connected diabetes mellitus. See VA Form 21-4138 (June 2010). Although a VA medical opinion was obtained in March 2011, the Board finds that the medical opinion is inadequate as it does not clearly reflect whether the Veteran's headaches are either proximately due to diabetes, including medication taken for treatment, or aggravated (permanently worsened) by diabetes as theorized by the Veteran. See Medical Treatment Record - Non-Government Facility (March 2011). Therefore, remand for a medical opinion with a complete rationale is necessary to decide the matter. It is noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. 38 C.F.R. § 3.159(c). See Stefl v. Nicholson, 21 Vet.App. 102, 124-25; Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 301 (2008) ("[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two."). Lumbar Spine Disability In May 2017 correspondence, the Veteran's attorney reported that the Veteran's lumbar spine disability had so significantly worsened that she now requires reasonable accommodations from her employer under the "Americans with Disabilities Act" and he submitted a copy of a letter from the Veteran's medical provider for her employer in this regard. See Correspondence (May 2017). Because this evidence suggests a material worsening of the Veteran's lumbar spine symptoms since his last VA examination in July 2014, reexamination is necessary. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Psychiatric Disorder from November 23, 2015 The Veteran seeks an evaluation in excess of 50 percent from November 23, 2015, for adjustment disorder with mixed anxiety and depressed mood. The Board finds that report of VA examination dated November 23, 2015 is inadequate for evaluation purposes as it does not describe the severity, frequency, or duration of the Veteran's symptoms associated with adjustment disorder with mixed anxiety and depressed mood. The examiner listed the associated symptoms, but provided no detailed findings from mental status examination. See C&P Exam (November 2015). Therefore, remand for a VA examination to ascertain the severity of the service-connected disability is necessary to decide the claim. 38 C.F.R. § 3.159(c). Accordingly, these matters are REMANDED for the following action: 1. The AOJ should obtain all pertinent updated treatment records and associate these with the claims file to the extent possible. 2. The Veteran should be scheduled for a VA examination by an appropriately skilled physician to address the etiology of her headache complaints to include the Veteran's theory that service-connected diabetes and/or medications for treatment cause or aggravate her headaches. A detailed medical history regarding onset and development chronic headache symptoms should be obtained. To this end, the following questions should be expressly answered to the extent possible: (a) Does the Veteran have a chronic headache disorder that is as likely as not (50 percent or greater probability) related to service? (b) Does the Veteran have a chronic headache disorder that is as likely as not (50 percent or greater probability) proximately due to service-connected diabetes mellitus and/or medications for treatment thereof? (c) Does the Veteran have a chronic headache disorder that is as likely as not (50 percent or greater probability) aggravated by service-connected diabetes mellitus and/or medications for treatment thereof? The examiner should consider the statements of Dr. Sturtz regarding the relationship of glycemic control and the Veteran's headaches. See Third Party Correspondence (May 2010). Aggravation is defined as a permanent worsening of the nonservice-connected disability beyond that due to the natural disease process as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. A complete rationale for the medical opinion is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusions. If an opinion cannot be expressed without resort to speculation, the examiner should so indicate and discuss why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. The Veteran should be scheduled for a VA examination of the lumbar spine to ascertain the severity of her service-connected disability using the most recent Disability Benefits Questionnaire. The claims file must be reviewed and the review noted in the report. All symptoms should be identified along with their frequency, duration, and severity. All clinical findings should be reported in detail to include the functional impact. To the extent possible, the examiner should indicate the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to provide the information, he or she should clearly explain why that is so. 4. The Veteran should be scheduled for a VA examination of her service-connected adjustment disorder with mixed anxiety and depressed mood to ascertain the severity of the disability using the most recent Disability Benefits Questionnaire. All symptoms to include the severity, frequency, and duration should be indicated. The examiner should indicate the overall level of occupational and social impairment, to include whether the Veteran's symptoms more nearly approximate occupational and social impairment with deficiencies in most areas. The examiner should expressly indicate whether the Veteran has an inability to establish and maintain effective relationships. 5. After ensuring any other necessary development has been completed, the AOJ should readjudicate the claims. If the benefits sought are not granted, the Veteran and her attorney should be furnished a Supplemental Statement of the Case and given the requisite opportunity to respond before the case is returned to the Board. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran and her representative have the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ G. A. WASIK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs