Citation Nr: 20021671 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 13-34 469 DATE: March 26, 2020 ORDER Entitlement to an effective date of April 17, 2012, for an evaluation of 10 percent for peripheral neuropathy of the left lower extremity, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an effective date of April 17, 2012, for an evaluation of 10 percent for peripheral neuropathy of the right lower extremity, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an evaluation in excess of 30 percent, for the period prior to September 4, 2018, and in excess of 50 percent, for the period beginning September 4, 2018, to prior to March 28, 2019, for posttraumatic stress disorder (PTSD), is denied. Entitlement to an evaluation of 70 percent, and no higher, for the period beginning March 28, 2019, for PTSD, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a total disability rating based upon individual unemployability (TDIU), for the period beginning September 4, 2018, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to a compensable evaluation for the period prior to September 5, 2018, and in excess of 30 percent thereafter, for peripheral neuropathy of the right upper extremity, is remanded. Entitlement to a compensable evaluation for the period prior to September 5, 2018, in excess of 20 percent for the period from September 5, 2018, to prior to November 29, 2018, and in excess of 40 percent thereafter, for peripheral neuropathy of the left upper extremity, is remanded. Entitlement to an evaluation in excess of 10 percent for the period prior to September 5, 2018, and in excess of 20 percent thereafter, for peripheral neuropathy of the left lower extremity, is remanded. Entitlement to an evaluation in excess of 10 percent for the period prior to September 5, 2018, and in excess of 20 percent thereafter, for peripheral neuropathy of the right lower extremity, is remanded. Entitlement to a TDIU, for the period prior to September 4, 2018, is remanded. FINDINGS OF FACT 1. On October 12, 2012, the Agency of Original Jurisdiction (AOJ) received the Veteran’s claim for an increased rating for bilateral peripheral neuropathy of the lower extremities. It is factually ascertainable that an increase in disability occurred on April 17, 2012, within the one-year period prior to October 12, 2012. 1. During the period prior to September 4, 2018, the severity, frequency, and duration of the Veteran’s PTSD symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 2. During the period from September 4, 2018, to prior to March 28, 2019, the severity, frequency, and duration of the Veteran’s PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 3. During the period beginning March 28, 2019, the Veteran’s PTSD manifested symptoms more closely approximate occupational and social impairment with deficiencies in most areas. 4. During the period beginning March 28, 2019, the Veteran’s PTSD did not manifest total occupational and social impairment. 5. Beginning September 4, 2018, the Veteran’s service-connected disabilities meet the schedular criteria for award of a TDIU and preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an effective date of April 17, 2012, for the assignment of a 10 percent rating for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C. §§ 5107; 5110; 38 C.F.R. §§ 3.102, 3.400, 4.124a Diagnostic Code 8520. 2. The criteria for an effective date of April 17, 2012, for the assignment of a 10 percent rating for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C. §§ 5107; 5110; 38 C.F.R. §§ 3.102, 3.400, 4.124a Diagnostic Code 8520. 3. The criteria for a disability rating in excess of 30 percent, for the period prior to September 4, 2018, and in excess of 50 percent, for the period from September 4, 2018, to prior to March 28, 2019, for PTSD, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for a disability rating of 70 percent, and no higher, for the period beginning March 28, 2019, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 5. The criteria for an award of TDIU, beginning September 4, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1968 to October 1970. The case was previously before the Board in October 2017 when it was remanded for additional development. In a rating decisions dated in October 2018 and March 2019, the Agency of Original Jurisdiction (AOJ) increased and continued evaluations of the Veteran’s above listed disabilities. The Board has recharacterized the issues listed above. Additional evidence has been associated with the claims file subsequent to the most recent Supplemental Statements of the Case dated in October 2018. In a statement dated in October 2019 and resubmitted in February 2020,the Veteran’s representative noted that further adjudication of this matter can proceed at the higher level and that the Veteran awaited further adjudication of the matters identified above at the Board. The Board interprets these statements as waivers of AOJ consideration and will proceed with adjudication. Effective Date 1. Entitlement to an effective date prior to October 12, 2012, for the grant of an evaluation of 10 percent for peripheral neuropathy of the left lower extremity. 2. Entitlement to an effective date prior to October 12, 2012, for the grant of an evaluation of 10 percent for peripheral neuropathy of the right lower extremity. Except as otherwise provided, the effective date for the assignment of an increased evaluation shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application therefor. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The applicable statute specifically provides that the effective date of an award of increased compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if an application is received within one year from such date. 38 U.S.C. § 5110 (b)(2). However, if the increase became ascertainable more than one year prior to the date of receipt of the claim, then the proper effective date would be the date of the claim. In a case where the increase became ascertainable after the filing of the claim, then the effective date would be the date of increase. See generally Harper v. Brown, 10 Vet. App. 125 (1997). Effective March 24, 2015, VA amended its regulations regarding claims. The amendment requires claims to be filed on standard forms, eliminates constructive receipt of claims, and eliminates informal claims. This includes eliminating the provisions of 38 C.F.R. § 3.157 which allowed for VA reports of hospitalization or examination and other medical records which could be regarded as informal claims for increase. Here, the claim on appeal was filed before March 24, 2015 so the Board has included analysis as to informal claims, including via 38 C.F.R. § 3.157. The Veteran filed a claim for a higher evaluation for left and right lower extremity peripheral neuropathy in October 2012. In a statement dated in August 2017 the Veteran’s representative argued that review of the treatment records within one year prior to the October 2012 claim showed an April 17, 2012, VA treatment note regarding a diabetic foot examination and that sensation was noted to be absent. Review of the record shows that within one year prior to October 2012, on April 17, 2012, during a VA primary care visit, a diabetic foot examination was accomplished. Sensation testing showed absent sensation throughout. The absence of sensation is indicative of a peripheral neuropathy of mild severity. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. Within a year prior to April 2012, the record shows additional VA podiatry treatment records. However, these records show that the Veteran had intact sensation. See, e.g., VA Treatment June 2011. As such, it is factually ascertainable that an increase in disability occurred on April 17, 2012, within the one-year period prior to October 12, 2012. Therefore, entitlement to an effective date of April 17, 2012, and no earlier, for the grant of an evaluation of 10 percent for left and right lower extremity peripheral neuropathy is granted. Increased Rating Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Entitlement to an evaluation in excess of 30 percent, for the period prior to September 4, 2018, and in excess of 50 percent thereafter, for PTSD. The Veteran’s PTSD has been evaluated as 30 percent disabling, for the period prior to September 4, 2018, and 50 percent thereafter, under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A maximum 100 percent rating is assigned when there is total occupational or social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Based on a review of the record, the Board finds that the claims for ratings in excess of 30 percent, for the period prior to September 4, 2018; and in excess of 50 percent from that date to March 28, 2019, are denied. A 70 percent rating is warranted from March 28, 2019. The Veteran was afforded a VA examination in January 2011. The Veteran had no evidence of impairment of thought process or communication. There were no delusions or hallucinations. He made good eye contact and his behavior was appropriate throughout the examination. He denied any suicidal or homicidal ideations. He was able to maintain minimum personal hygiene and other basic activities of living. He was oriented and his memory was grossly intact. He denied any obsessive or ritualistic behaviors. Rate and flow of speech was normal. He reported long-term history of panic attacks, having a few on and off over the years. He was prescribed Vistaril to help control the panic attacks. He reported that his depression started in Vietnam and worsened over the years. His symptoms included social isolation, anhedonia, low mood and crying spells. He reported his depressive episodes lasted a few days to a week. He also reported episodic anxiety. His symptoms included gastrointestinal upset, nervousness, feeling jittery, and difficulty relaxing. He reported symptoms of both depression and anxiety that were worse since he retired. He reported 4 to 5 hours of sleep that was generally fragmented and he was tired much of the day. He reported symptoms of frequent nightmares, intrusive thoughts about rocket attacks and checking bunkers, hyper-startle response to loud noises, avoiding talking about Vietnam to anyone, avoiding war-related movies, television, and newspaper articles, hypervigilance in public places, feelings of detachment, poor concentration and sleep. The Veteran was diagnosed with PTSD and alcohol dependence in remission. In a March 2012 VA examination addendum the Veteran was noted to remain fairly isolated. The Veteran was afforded a VA examination in February 2015. The Veteran was diagnosed with PTSD and was noted to have 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. Since his prior examination in January 2011 he reported that he continued to be married to his wife for over 42 years. Two of his children lived close by and two lived more distant. He was his children often and got along well with them. He avoided crowded places but was able to go grocery shopping. He helped with chores at home and liked working his yard. He went for walks and visited one of his neighbors. He saw some friends about once a week and attended church regularly. He volunteered at church activities once a month. He was not working and noted that he took retirement. The Veteran indicated that he retired because he had enough time in and they were closing the department and laying people off. The selected PTSD diagnostic criteria included recurrent, involuntary, and intrusive distressing memories of the traumatic event, recurrent distressing dreams in which the dream was related to the traumatic event, avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event, avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic events, persistent negative emotional state, feelings of detachment or estrangement from others, irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects, hypervigilance, exaggerated startle response, and sleep disturbance. Symptoms were noted to be depressed mood, anxiety, and chronic sleep impairment. The Veteran appeared his stated age. He did not display agitation. Mood was sometimes depressed, sometimes anxious. Affect was congruent with stated mood (he appeared mildly anxious). Speech was clear, thoughts were goal directed, there was no evidence or report of suicidal ideation, homicidal ideation, psychosis. The Veteran was oriented times three, recall was 3/3 words after a few minutes. He made one error in spelling a 5 letter word backward. The examiner noted that the Veteran’s symptoms were mild in intensity and would likely improve when he resumed his medications. His PTSD did not significantly affect his ability to work but affected his social/family life to a mild degree. In January 2016, February 2016 and March 2016 the Veteran was noted to be alert and oriented times three with no impairment of recent or remote memory, normal attention span and ability to concentrate and able to name objects and repeat phrases. Entitlement to an evaluation in excess of 30 percent for the period prior to September 4, 2018, is not warranted. At no point during the period prior to September 4, 2018, did the Veteran’s PTSD manifest symptoms of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or result in difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges that in February 2015 a VA examiner indicated that the Veteran was noted to have the PTSD diagnostic criteria of irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects. However, at no point during the period prior to September 4, 2018, did the Veteran’s PTSD manifest suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Therefore, as the symptoms of PTSD prior to September 4, 2018, do not more nearly approximate the criteria for an evaluation in excess of 30 percent disabling, entitlement to an evaluation in excess of 30 percent for the period prior to September 4, 2018, is denied. Entitlement to an evaluation in excess of 50 percent for the period beginning September 4, 2018, is not warranted. On VA examination in September 2018, the Veteran was noted to have 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 Veteran reported that he had been prescribed psychiatric medication in the past but was not taking any medications at the time of the examination due to a change in provider. The selected PTSD diagnostic criteria included recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s); dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s); marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s); avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s); and avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s); persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame); markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; reckless or self-destructive behavior; hypervigilance; exaggerated startle response; problems with concentration; and sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Symptoms were noted to be depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, and disturbances of motivation and mood. The Veteran was alert and fully oriented. His remote memory was not precise, but he was nevertheless judged to be an accurate historian. His appearance, behavior, and speech were within normal limits. Veteran's thought processes and content were within normal limits. His judgment was intact. The examiner noted that for the VA established diagnosis of PTSD, the diagnosis was changed, and it was a progression of the previous diagnosis. The Veteran's nightmares and acting out while sleeping have gotten worse. He has slept separately from his wife for approximately the past 5 years. His depressive symptoms are notably more severe and more frequent. The Veteran stated he avoids crowds often and becomes irritable with his wife more than he would like to do so. He did not appear to pose any threat of danger or injury to self or others. Entitlement to an evaluation in excess of 50 percent for the period beginning September 4, 2018, to prior to March 28, 2019, is not warranted. At no point during the period beginning September 4, 2018, to prior to March 28, 2019, did the Veteran’s PTSD manifest suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. It is acknowledged that at the September 2018 examination the Veteran was noted to have the PTSD diagnostic criteria of irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. However, it was not noted that the Veteran had impaired impulse control. Therefore, as the symptoms of PTSD from September 4, 2018, to prior to March 28, 2019, do not more nearly approximate the criteria for an evaluation in excess of 50 percent disabling, entitlement to an evaluation in excess of 50 percent for the period from September 4, 2018, to March 28, 2019, is denied. Entitlement to an evaluation of 70 percent, and no higher, is warranted for the period beginning March 28, 2019. The Veteran was afforded a VA examination on March 28, 2019,. The Veteran reported depressed mood, anxiety, suspiciousness, chronic sleep problems, mild memory loss, anhedonia, difficulty in relationships, and impaired impulse control as a result of PTSD. The Veteran was noted to have occupational and social impairment with reduced reliability and productivity. The selected PTSD diagnostic criteria included recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s); dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s); marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s); avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s); avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s); persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; exaggerated startle response; problems with concentration; and sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Symptoms were noted to be depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran was alert and fully oriented. He was pleasant and cooperative. His affect was appropriate. The examiner noted that the Veteran’s depressive symptoms of PTSD including anhedonia and irritability, have worsened. His functional impairment appeared to be grossly the same compared to last exam, with somewhat more difficulty in relationships, including with his wife. Affording the Veteran the benefit of the doubt, during the period beginning March 28, 2019, the Veteran’s PTSD manifested symptoms that more nearly approximate an evaluation of 70 percent. The Board notes that during the period on appeal beginning March 28, 2019, the Veteran did not manifest suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. In addition, the examiner noted that the Veteran’s functional impairment appeared to be grossly the same as compared to the prior examination. However, in March 2019 the Veteran was noted to have impaired impulse control, such as unprovoked irritability with periods of violence. Furthermore, the Veteran was noted to have somewhat more difficulty in relationships, including with his wife. However, at no point during the period beginning March 28, 2019, did the Veteran’s PTSD manifest total social impairment. Therefore, entitlement to an evaluation of 70 percent, and no higher, is warranted for PTSD, effective March 28, 2019. 2. Entitlement to a TDIU, for the period beginning September 4, 2018. Effective September 4, 2018, the Veteran meets the schedular criteria for award of a TDIU. See 38 C.F.R. § 4.16 (a). At issue is whether he is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Affording the Veteran the benefit of the doubt, the Board finds his service-connected disabilities render him unable to secure and follow substantially gainful employment. 38 C.F.R. § 4.16 (a). In the Veteran’s Application for Increased Compensation Based on Unemployability dated in November 2018, he reported that he last worked in April 2006. He reported that his service-connected PTSD, type II diabetes mellitus, peripheral neuropathy, and hypertension prevented him from securing or following any substantially gainful occupation. The Veteran reported that he had one year of high school education and work history as a truck driver, lifting lifted heavy laundry. He. In other statements the Veteran reported that he worked up to 2009. In a VA examination report dated in September 2018 the Veteran was noted to have mild memory loss and disturbances in motivation and mood. In another VA examination report dated in September 2018, the Veteran’s peripheral neuropathy was noted to impact the Veteran’s ability to work. His lower leg pain, tingling, and numbness caused difficulty with prolonged walking. His upper arm tingling and numbness caused difficulty with repetitive motion. In another VA examination report dated in September 2008, the Veteran’s hypertension impacted the Veteran’s ability to work due to generalized fatigue with exertion. In a VA examination report dated in March 2019 the Veteran’s diabetic neuropathy was noted to restrict the Veteran to light work. In another examination report dated in March 2019 the Veteran’s peripheral neuropathy could intermittently impact his ability to operate truck hand and foot controls. In a VA examination report for the Veteran’s PTSD, dated in March 2019, the Veteran was noted to have disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. A VA examiner noted that the Veteran had difficulty maintaining concentration and focus on work over a period of time, tended to skip from one task to another without completing the prior task, was so depressed that s/he has difficulty sustaining energy and motivation to complete assignments at work, and had other mental health problems or symptoms that interfere significantly with the ability to work, identified as increased irritability and acting out of anger (throwing objects). Considering the Veteran’s high school education, and his labor intensive work history, VA examiners opinions that the Veteran’s service-connected disabilities would interfere with his ability to perform work, the Board finds that his Veteran’s service-connected disabilities render him unemployable beginning, at least, September 4, 2018. Entitlement to TDIU, beginning September 4, 2018, is granted. REASONS FOR REMAND 1. Entitlement to a compensable evaluation for the period prior to September 5, 2018, and in excess of 30 percent thereafter, for peripheral neuropathy of the right upper extremity, is remanded. 2. Entitlement to a compensable evaluation for the period prior to September 5, 2018, in excess of 20 percent for the period from September 5, 2018, to prior to November 29, 2018, and in excess of 40 percent thereafter, for peripheral neuropathy of the left upper extremity, is remanded. 3. Entitlement to an evaluation in excess of 10 percent for the period prior to September 5, 2018, and in excess of 20 percent thereafter, for peripheral neuropathy of the left lower extremity, is remanded. 4. Entitlement to an evaluation in excess of 10 percent for the period prior to September 5, 2018, and in excess of 20 percent thereafter, for peripheral neuropathy of the right lower extremity, is remanded. A March 2019 VA examination identified moderate incomplete paralysis of the radial (musculospiral nerve), median, and ulnar nerves of the right and left upper extremities due to diabetic peripheral neuropathy. In a March 2019 rating decision, the AOJ increased the ratings, taking into account the musculospiral, ulnar, and median nerves, rated as all radicular groups. The AOJ did not discuss why separately rating radial, median, and ulnar nerves would create pyramiding despite being distinct nerve groupings. There is similar confusion in connection with the diagnoses and evaluations assigned for the lower extremity neuropathies. The right and left lower extremity disabilities have been evaluated under DC 8520 for the sciatic nerve, but the September 2018 VA examination identified the femoral nerve as the nerve affected. The claims are remanded because each of the affected nerves are rated under distinct Diagnostic Codes. See 38 C.F.R. § 4.124a. The Veteran should be afforded a new VA examination to identify the specific nerves involved and attempt to provide an opinion as to the related severity for the entire appeal period. The AOJ must readjudicate the claims for the entire appeal period to determine whether separate ratings are warranted for each identified nerve for any period on appeal. If separate ratings are not assigned, the AOJ must include a specific discussion as to why that is. 5. Entitlement to a TDIU, for the period prior to September 4, 2018, is remanded. Finally, because a decision on the remanded issues could signficant impact a decision on the issue of entitlement to TDIU prior to September 4, 2018, the issues are inextricably intertwined. A remand of the claim for TDIU prior to September 4, 2018, is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination of the bilateral upper and lower peripheral neuropathies by an appropriate clinician to specifically identify the affected nerves and related severity of those nerves. Copies of all pertinent records must be made available to the examiner for review. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must answer the following: (a) Specifically identify all affected nerves in the bilateral upper and lower extremities from April 2012 to the present. (b) For each nerve identified, the examiner should provide an opinion on (i) the current severity and (ii) attempt to provide a retrospective opinion for each identified nerve for the period from April 2012. In answering this, the examiner must specifically discuss (i) the February 2013 VA examination that identified the sciatic nerve; (ii) the February 2018 VA examination that identified the femoral nerve, and; (iii) the March 2019 VA examination that identified involvement of the sciatic, radial, median and ulnar nerves. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner’s own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. 2. Confirm that the VA medical opinion complies with the remand questions, and undertake any other development deemed warranted. 3. After completion of the above, the AOJ must readjudicate the neurological ratings of the upper and lower extremities, with specific consideration of whether separate ratings are warranted for affected nerves identified during the rating period, and entitlement to TDIU for the period prior to September 4, 2018. M.E. LARKIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert J. Burriesci, 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.