Citation Nr: 20006097 Decision Date: 01/24/20 Archive Date: 01/24/20 DOCKET NO. 14-22 795 DATE: January 24, 2020 ORDER Entitlement to service connection for sarcoidosis is granted. Entitlement to service connection for hypogonadism, secondary to sarcoidosis on a causation basis, is granted. Entitlement to an initial 20 percent rating, from October 6, 2011, for peripheral neuropathy of the right lower extremity is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 20 percent for peripheral neuropathy of the right lower extremity is denied. Entitlement to an initial 20 percent rating, from October 6, 2011, for peripheral neuropathy of the left lower extremity is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 20 percent for peripheral neuropathy of the left lower extremity is denied. Entitlement to a rating in excess of 40 percent, prior to November 4, 2017, and a rating in excess of 20 percent, since that date, for diabetes mellitus is denied. Entitlement to a rating in excess of 80 percent for renal insufficiency is denied. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s sarcoidosis began during active service. 2. The Veteran’s hypogonadism is caused by his sarcoidosis. 3. Since the October 6, 2011 effective date of service connection, the Veteran’s peripheral neuropathy of the right lower extremity has been manifested by no more than moderate neuralgia of the femoral and/or sciatic nerves. 4. Since the October 6, 2011 effective date of service connection, the Veteran’s peripheral neuropathy of the left lower extremity has been manifested by no more than moderate neuralgia of the femoral and/or sciatic nerves. 5. The Veteran’s diabetes mellitus has been treated with insulin and a restricted diet, but his activities have not been restricted. 6. The Veteran’s renal insufficiency is manifested by persistent proteinuria, persistent edema, and limitation of exertion; creatinine has been at most 2.6 and BUN has not been greater than 37; the Veteran has not required regular dialysis, his kidney disability has not precluded more than sedentary activity, and there has not been markedly decreased function of the kidneys or other organ systems. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for sarcoidosis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 2. The criteria for service connection for hypogonadism, as secondary to sarcoidosis on a causation basis, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for an initial 20 percent rating, but no higher, from October 6, 2011, for peripheral neuropathy of the right lower extremity, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, Diagnostic Codes (DC) 8520, 8526. 4. The criteria for an initial 20 percent rating, but no higher, from October 6, 2011, for peripheral neuropathy of the left lower extremity, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, Diagnostic Codes (DC) 8520, 8526. 5. The criteria for a rating in excess of 40 percent, prior to November 4, 2017, and a rating in excess of 20 percent, since that date, for diabetes mellitus, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.119, Diagnostic Code (DC) 7913. 6. The criteria for a rating in excess of 80 percent for renal insufficiency are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.115a, 4.115b. Diagnostic Code (DC) 7541. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1994 to February 2000. These matters initially came before the Board of Veterans’ Appeals (Board) from a September 2012 rating decision. In February 2015, the agency of original jurisdiction (AOJ) awarded a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, from June 14, 2014. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at an August 2017 hearing and a transcript of the hearing is associated with his claims file. In November 2017, the AOJ assigned 20 percent ratings for peripheral neuropathy of the right and left lower extremities, both from November 4, 2017. The AOJ also reduced the disability rating for diabetes mellitus from 40 percent to 20 percent, effective from November 4, 2017. In February 2018, the Board awarded a TDIU, prior to June 14, 2014, and remanded the matters currently on appeal for further development. In August 2018, the AOJ implemented the Board’s decision and awarded a TDIU, from October 6, 2011. As a final preliminary matter, in the February 2018 remand, the Board instructed the AOJ to, among other things, ask the Veteran to complete an updated authorization form so as to allow VA to obtain any outstanding pertinent private treatment records from Riverside Williamsburg Urgent Family Care and FirstMed of Williamsburg. In a November 2018 letter, the Veteran was asked to complete the appropriate authorization forms so as to allow VA to obtain any outstanding private treatment records (to include records from Riverside Williamsburg Urgent Family Care and FirstMed of Williamsburg). Copies of the authorization forms (VA Forms 21-4142 and 21-4142a) were included with the letter. The Veteran did not respond to the November 2018 letter and has not otherwise completed an updated authorization form so as to allow VA to obtain treatment records from Riverside Williamsburg Urgent Family Care and FirstMed of Williamsburg. In this regard, VA is only required to seek pertinent records that are adequately identified and for which necessary releases are furnished. 38 U.S.C. § 5103A (b); see Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (the duty to assist is not always a one-way street); 38 C.F.R. §§ 3.159 (c)(1)(i), (c)(2)(i) (requiring a claimant to cooperate fully with VA’s efforts to obtain federal and non-federal records). Thus, VA has no further duty to attempt to obtain any additional treatment records. I. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a) (e.g., sarcoidosis). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Although entitlement to service connection on any of the presumptive bases noted above may not be established, a veteran is not precluded from establishing service connection on a direct basis. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). Service connection is also warranted for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). 1. Entitlement to service connection for sarcoidosis The Veteran contends, among other things, that he has current sarcoidosis which is related to respiratory symptoms that he experienced in service. The Board finds, for the following reasons, that the Veteran has a current diagnosis of sarcoidosis and that the evidence is at least evenly balanced as to whether this disability began during active service. Medical records, including a September 2015 VA urology consultation note and the report of a September 2019 VA respiratory examination, show the Veteran has a current diagnosis of sarcoidosis. There is also evidence of respiratory symptoms in service and evidence of continuous symptoms in the years since service. In this regard, service treatment records indicate that the Veteran was treated for a cough in June 1994 and November 1998 and was diagnosed as having upper respiratory infections. Also, he reported that he experienced periodic dyspnea with wheezing on exertion and at rest on a July 1999 report of medical history form completed for purposes of a Medical Board examination. Moreover, the Veteran’s post-service medical records and lay statements indicate that his respiratory symptoms have continued in the years since service. For instance, he experienced shortness of breath during an exercise stress test that was conducted in May 2000, only 3 months following his separation from service. He reported during an October 2000 VA cardiac evaluation that he had been experiencing various symptoms, including shortness of breath, for the previous year. Also, his treatment records reflect that he was subsequently diagnosed as having sarcoidosis in 2004 when he sought treatment for lesions on his chest and associated shortness of breath. The lesions were biopsied and found to be sarcoid. The examiner who conducted the September 2019 VA respiratory examination opined that the Veteran’s sarcoidosis was not likely (“less likely as not”) caused by or a result of in-service environmental exposures. She reasoned that medical literature revealed that sarcoidosis is a condition of uncertain etiology with immunopathogenesis. The stimulus that initiates the disease process is unknown, but several possible etiologic agents have been investigated (including exposure to beryllium, zirconium, aluminum, and infectious agents). The actual cause of sarcoidosis could not be selected from multiple potential causes without resort to mere speculation. The September 2019 opinion is of limited probative value because it only addresses whether the Veteran’s sarcoidosis is related to environmental exposures in service. The examiner did not acknowledge or comment upon the Veteran’s respiratory symptoms in service or his treatment for respiratory symptoms within months of his discharge from service. In this regard, a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history, even if recorded in the course of the examination. Dalton v. Peake, 21 Vet. App. 23 (2007). In sum, the evidence reflects that the Veteran experienced respiratory symptoms in service, that he continued to experience respiratory symptoms in the months following his separation from service, that he was diagnosed as having sarcoidosis in 2004, and that he continues to experience current sarcoidosis. There is no adequate medical opinion contrary to a conclusion that the current sarcoidosis had its onset in service. Thus, the evidence is at least evenly balanced as to whether this disability had its onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for sarcoidosis is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. See also Buchanan, 451 F.3d at 1335 (“[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself”). 2. Entitlement to service connection for hypogonadism The Veteran contends that he has current hypogonadism and that this disability is associated with his sarcoidosis. The Board finds, for the following reasons, that the Veteran has a current diagnosis of hypogonadism and that this disability is caused by his now service-connected sarcoidosis. Medical records, including a November 2016 VA medicine endocrinology note, show the Veteran has a current diagnosis of hypogonadism. As for the etiology of this disability, the examiner who conducted a September 2019 VA male reproductive system conditions examination opined that the Veteran’s hypogonadism was likely (“at least as likely as not”) partially caused by or a result of his treatment for sarcoidosis. The examiner reasoned that medical literature revealed that chronic glucocorticoid use can lower testosterone levels by approximately one-third. The mechanism is not clear, but inhibition may occur at both the testis and pituitary. The Veteran was treated with prednisone in 2004, but it would be with resort to mere speculation to assign a percentage that this prednisone use contributed to his low testosterone. He has not been maintained on chronic glucocorticoid medication. The September 2019 opinion is based upon an examination of the Veteran, a review of his claims file and medical literature, and consideration of his reported history, and it is accompanied by a specific rationale that is consistent with the evidence of record. Therefore, this opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). In sum, the Board finds that the evidence supports the conclusion that the Veteran’s hypogonadism is caused, at least partially, by the treatment received for his now service-connected sarcoidosis. There is no medical opinion contrary to this conclusion. The Board points out that service connection for disability due to medications taken for a service-connected disease or injury is a valid theory of entitlement. See Wanner v. Principi, 17 Vet. App. 4, 8 (2003) (noting that “the Board awarded service connection for tinnitus as ‘the result of treatment for a service-connected disability’”), rev’d on other grounds, 370 F.3d 1124 (Fed. Cir. 2004); Velez v. West, 11 Vet. App. 148, 157 (1998) (discussing “an implicit secondary-service-connection claim that his gastrointestinal disorder was the result of, inter alia, pain medication taken for his service-connected right-shoulder condition”); Jones v. Brown, 7 Vet. App. 134, 137 (1994) (reviewing Board’s denial of service connection for glaucoma as secondary to treatment for blepharoconjunctivitis). For the foregoing reasons, service connection for hypogonadism, as secondary to now service-connected sarcoidosis on a causation basis, is warranted. II. Higher Initial Ratings/Increased Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be “staged.” Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). If two ratings are potentially applicable, 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. 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. In evaluating a disability, the Board considers the current examination reports considering the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to higher initial ratings for peripheral neuropathy of the right and left lower extremities, currently rated 10 percent disabling prior to November 4, 2017 and 20 percent disabling since that date The Veteran’s peripheral neuropathy of the right and left lower extremities are rated under 38 C.F.R. § 4.124a, DC 8520 as paralysis of the sciatic nerve. Under DC 8520, the following ratings apply: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and an 80 percent rating is warranted for complete paralysis resulting in the foot dangling and dropping, no possible active movement of muscles below the knee, and weakened or (very rarely) lost flexion of the knee. 38 C.F.R. § 4.124a, DC 8520. The rating schedule provides guidance for rating neurological disabilities. With regard to rating neurological disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested right and left lower extremity neurological symptoms of the type and extent, frequency, and/or severity, as appropriate to warrant 20 percent ratings, but no higher, since the October 6, 2011 effective date of service connection. The report of a February 2012 VA neurological examination, VA treatment records dated from November 2012 to November 2016, and the Veteran’s testimony during the August 2017 Board hearing indicate that he reported that he experienced mild numbness/tingling/paresthesias and/or dysesthesias in both lower extremities and occasional excruciating burning pain in the legs and feet. He used a cane to assist with ambulation (which was observed during the August 2017 hearing). Examinations revealed that the Veteran’s gait was normal and that his lower extremity muscle strength was normal bilaterally. There was occasional decreased sensation to pinprick up to the mid-calf bilaterally, deep tendon reflexes were occasionally impaired (1+) at the knees, there were occasionally no Achilles reflexes, and the Veteran’s lower legs were shiny and hairless with a waxy/glossy quality. Position sense, vibration sensation, and cold sensation were all normal in the lower extremities bilaterally and there was no muscle atrophy. Overall, there was mild incomplete paralysis of the femoral (anterior crural) nerve bilaterally. There was no scarring associated with the Veteran’s disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran was diagnosed as having bilateral peripheral neuropathy of the lower extremities. This disability did not impact his ability to work. A November 2017 VA neurological examination report reveals that the Veteran experienced moderate constant pain in the lower extremities bilaterally, severe intermittent pain in the lower extremities bilaterally, and moderate paresthesias/dysesthesias and numbness in the lower extremities bilaterally. Examination revealed that lower extremity muscle strength was normal (5/5) bilaterally and that lower extremity reflexes were normal (2+) bilaterally. Sensation at the knees/thighs was normal, but sensation was decreased at the ankles/lower legs and was absent at the feet/toes. Position sense was normal bilaterally, but vibration sensation and cold sensation were both absent in the lower extremities bilaterally. There was no muscle atrophy. There were trophic changes attributable to diabetic peripheral neuropathy, including dystrophic toenails and smooth shiny skin of the lower extremities. Overall, there was moderate incomplete paralysis of the sciatic nerve bilaterally. There was no scarring associated with the Veteran’s disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. A diagnosis of bilateral diabetic neuropathy of the lower extremities was provided. This disability impacted the Veteran’s ability to work because he had a difficult time feeling anything below the groin. The above evidence reflects that the Veteran’s right and left lower extremity peripheral neuropathy has been manifested by pain, occasionally absent to somewhat impaired (1+) lower extremity reflexes, and occasionally absent to decreased lower extremity sensation. He has required the use of a cane to assist with ambulation. In light of the Veteran’s reported lower extremity neurological symptoms and the clinical findings of impaired sensation and reflexes, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the symptoms of his service-connected peripheral neuropathy of the right and left lower extremities have more closely approximated the criteria for 20 percent ratings for paralysis of the sciatic nerve (i.e., moderate incomplete paralysis) under DC 8520 during the entire period since the October 6, 2011 effective date of service connection. The Board also finds, however, that ratings higher than 20 percent are not warranted at any time during the claim period. In particular, the Veteran’s lower extremity muscle strength has been normal, there has been no muscle atrophy, and the examiners who conducted the February 2012 and November 2017 VA examinations reported that there was at most mild to moderate incomplete paralysis of the lower extremities. Overall, the peripheral neuropathy of the right and left lower extremities has been manifested by at most moderate incomplete paralysis. The Board acknowledges that there is evidence of incomplete paralysis of both the femoral (anterior crural) and sciatic nerves. Nevertheless, moderate incomplete paralysis warrants a 20 percent rating under both DC 8520 and DC 8526 (the diagnostic code pertaining to paralysis of the anterior crural (femoral) nerve). The Board is already awarding 20 percent ratings for the entire claim period on the basis of the Veteran’s lower extremity neurological symptoms. Therefore, separate ratings under both DC 8520 and DC 8526 on the basis of the same lower extremity neurological symptoms would constitute prohibited pyramiding and separate ratings are not warranted. 38 C.F.R. § 4.14. In sum, initial 20 percent ratings, but no higher, are warranted for peripheral neuropathy of the right and left lower extremities, from October 6, 2011. See 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. § 4.7, 4.124a, DC 8520. 2. Entitlement to a rating in excess of 40 percent, prior to November 4, 2017, and a rating in excess of 20 percent, since that date, for diabetes mellitus The claim for an increased rating for diabetes mellitus was received on October 6, 2011. The Veteran’s diabetes mellitus is rated under 38 C.F.R. § 4.119, DC 7913. This diagnostic code provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). Specifically, under DC 7913, a 20 percent rating is warranted when diabetes requires the use of insulin or oral hypoglycemic agent, and a restricted diet. A 40 percent rating is warranted for diabetes that requires insulin, a restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes that 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 (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, DC 7913. “Regulation of activities” has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining “regulation of activities,” as used by VA in DC 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Since DC 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’ favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran’s diabetes mellitus has not met or approximated the criteria for a rating higher than 40 percent at any time during the claim period prior to November 4, 2017 or a rating higher than 20 percent at any time since that date. The report of a VA diabetes examination dated in February 2012, VA treatment records dated in November 2013, and the Veteran’s testimony during the August 2017 Board hearing indicate that his diabetes was treated with an insulin pump/daily insulin injections. He reported that he visited his diabetic care provider at least 2 times per month and had been hospitalized for episodes of ketoacidosis and/or hypoglycemic reactions, but regulation of activities was not required as part of the medical management of diabetes. He did not experience any progressive unintentional weight loss or progressive loss of strength attributable to diabetes. His complications of diabetes included diabetic peripheral neuropathy, erectile dysfunction, and renal disease. There were no scars associated with his disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran was diagnosed as having diabetes mellitus. This disability impacted his ability to work in that it caused fatigue with exertion. A November 2017 VA diabetes examination report reflects that the Veteran’s diabetes was managed by a restricted diet and that he required 4 insulin injections on a daily basis. Regulation of activities was not required as part of the medical management of his diabetes, the Veteran visited his diabetic care provider less than 2 times per month for episodes of ketoacidosis or hypoglycemia, and he did not require any hospitalization for ketoacidosis or hypoglycemia during the previous 12 months. He did not experience any progressive unintentional weight loss or loss of strength attributable to diabetes. Complications of diabetes included diabetic peripheral neuropathy, diabetic nephropathy or renal dysfunction, and hypertension. There were no scars associated with his disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran was diagnosed as having diabetes mellitus. This disability impacted his ability to work. The above evidence reflects that during the claim period, the Veteran’s diabetes mellitus has been treated with insulin and a modified diet. The February 2012 and November 2017 examination reports indicate that regulation of activities was not required and there is otherwise no evidence of any restriction of activities due to diabetes, as that term is defined (i.e., medical evidence of being prescribed or advised to avoid strenuous occupational and recreational activities), at any time during the claim period, and neither the Veteran nor his representative has alluded to the existence of any such evidence. Thus, the evidence does not support a finding that the Veteran’s diabetes has resulted in regulation of activities (as that term is defined above) at any time during the claim period. Hence, regardless of the fact that there is evidence of insulin use and a modified diet due to diabetes and regardless of any visits to a diabetic care provider or hospitalizations due to ketoacidosis or hypoglycemia, the symptoms of the Veteran’s diabetes have not met the criteria under DC 7913 for a rating higher than 40 percent, at any time during the claim period prior to November 4, 2017, or a rating higher than 20 percent at any time since that date. Therefore, higher ratings for diabetes mellitus are not warranted at any time during the claim period. See 38 U.S.C. §§ 1155, 5107(b); Camacho, 21 Vet. App. at 360; 38 C.F.R. §§ 4.7, 4.119, DC 7913. Regarding associated diabetic complications, service connection has already been awarded for renal insufficiency, erectile dysfunction, bilateral peripheral neuropathy of the lower extremities, and hypertension. The rating assigned for the Veteran’s renal insufficiency is addressed below. He has not expressed disagreement with any other rating(s) assigned for the complications of his diabetes. 3. Entitlement to a rating in excess of 80 percent for renal insufficiency The claim for an increased rating for renal insufficiency was received on October 6, 2011. The Veteran’s renal insufficiency is rated under 38 C.F.R. § 4.115b, DC 7541. Renal insufficiency under this diagnostic code is rated as renal dysfunction. Under the criteria for rating renal dysfunction, an 80 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a. Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran’s renal insufficiency has not met or approximated the criteria for a rating higher than 80 percent at any time during the claim period. The report of a February 2012 VA kidney examination indicates that the Veteran experienced renal dysfunction which resulted in recurring proteinuria and limitation of exertion. His treatment plan did not include taking continuous medication and he did not require regular dialysis. He did not experience any hypertension or heart disease due to renal dysfunction, kidney/ureteral/bladder calculi (urolithiasis), history of recurrent symptomatic urinary tract or kidney infections, kidney transplant or removal, or benign or malignant neoplasm or metastases related to his kidney disability. There was no scarring associated with his kidney disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. Laboratory testing revealed a BUN of 24 and a creatinine of 2.60. The Veteran was diagnosed as having renal insufficiency. This disability impacted his ability to work in that it resulted in fatigue with exertion. A November 2017 VA kidney examination report reflects that the Veteran experienced renal dysfunction which resulted in persistent proteinuria (albuminuria) and edema. His treatment plan did not include taking continuous medication and he did not require regular dialysis. He did not experience any hypertension or heart disease due to renal dysfunction, symptomatic renal tubular disorder, frequent attacks of colic with infection (pyonephrosis), kidney/ureteral/bladder calculi (urolithiasis), history of recurrent symptomatic urinary tract or kidney infections, kidney transplant or removal, or benign or malignant neoplasm or metastases related to his kidney disability. There was no scarring associated with his kidney disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. Laboratory testing revealed a BUN of 37 and a creatinine of 2.6. A diagnosis of diabetic nephropathy was provided. This disability impacted his ability to work in that it resulted in daily swelling. The above evidence reflects that the Veteran experiences renal dysfunction that is manifested by persistent proteinuria, persistent edema, limitation of exertion, and elevated BUN and creatinine levels. He has not required regular dialysis, he has not been limited to no more than sedentary activities due to his kidney disability, his BUN has been 37 at its highest, and his creatinine has been 2.6 at its highest. Moreover, the evidence does not reflect markedly decreased function of the kidneys or any other organ systems. Overall, the Board finds that the symptoms of the Veteran’s renal insufficiency have most closely approximated the criteria for an 80 percent rating under the criteria for rating renal dysfunction during the entire claim period. Therefore, a rating in excess of 80 percent for this disability is not warranted. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.7, 4.115a, 4.115b, DC 7541. 4. Additional Considerations As a final point, the Board notes that in conjunction with the higher rating issues decided herein, no other related issues have been raised by the Veteran or his representative, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Elwood, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.