Citation Nr: 20031334 Decision Date: 05/05/20 Archive Date: 05/05/20 DOCKET NO. 16-53 881 DATE: May 5, 2020 ORDER Restoration of a 40 percent disability rating for peripheral neuropathy of the right upper extremity is granted. Restoration of a 30 percent disability rating for peripheral neuropathy of the left upper extremity is granted. Restoration of a 20 percent disability rating for peripheral neuropathy of the right lower extremity is granted. Restoration of a 20 percent disability rating for peripheral neuropathy of the left lower extremity is granted. Entitlement to a disability rating in excess of 40 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to a disability rating in excess 30 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to a disability rating in excess of 20 percent, prior to September 11, 2019, for peripheral neuropathy of the right lower extremity is denied. Entitlement to a disability rating of 40 percent, effective September 11, 2019, for peripheral neuropathy of the right lower extremity is granted. Entitlement to a disability rating in excess of 20 percent, prior to September 11, 2019, for peripheral neuropathy of the left lower extremity is denied. Entitlement to a disability rating of 40 percent, effective September 11, 2019, for peripheral neuropathy of the left lower extremity is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. Entitlement to a special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s), beginning April 18, 2019, is granted. FINDINGS OF FACT 1. At the time of the reduction in rating of the peripheral neuropathy of the right upper extremity, the preponderance of the evidence of record did not reflect improvement in symptomology. 2. At the time of the reduction in rating of the peripheral neuropathy of the left upper extremity, the preponderance of the evidence of record did not reflect improvement in symptomology. 3. At the time of the reduction in rating of the peripheral neuropathy of the right lower extremity, the preponderance of the evidence of record did not reflect improvement in symptomology. 4. At the time of the reduction in rating of the peripheral neuropathy of the left lower extremity, the preponderance of the evidence of record did not reflect improvement in symptomology. 5. The preponderance of the evidence of record reflects that the Veteran is right-handed, and for the entire period on appeal, Veteran’s right upper extremity peripheral neuropathy was productive of, at most, mild to moderate symptomology. 6. The preponderance of the evidence of record reflects that for the entire period on appeal, the Veteran’s left upper extremity peripheral neuropathy was productive of, at most, mild to moderate symptomology. 7. Prior to September 11, 2019, the preponderance of the evidence of record reflects that the Veteran’s right lower extremity peripheral neuropathy was productive of moderate symptomology. 8. Beginning on September 11, 2019, the preponderance of the evidence of record reflects that the Veteran’s right lower extremity peripheral neuropathy was productive of moderately severe symptomology. 9. Prior to September 11, 2019, the preponderance of the evidence of record reflects that the Veteran’s right lower extremity peripheral neuropathy was productive of moderate symptomology. 10. Beginning on September 11, 2019, the preponderance of the evidence of record reflects that the Veteran’s left lower extremity peripheral neuropathy was productive of moderately severe symptomology. 11. For the entire period on appeal, the Veteran’s service-connected bilateral upper and lower extremity peripheral neuropathy precluded him from following and maintaining substantially gainful employment. 12. From April 18, 2019, the Veteran has been awarded a single 100 percent disability rating for coronary artery disease and had additional separate and distinct service-connected disabilities rated at least 60 percent. CONCLUSIONS OF LAW 1. The reduction in the evaluation for peripheral neuropathy of the right upper extremity, from 40 percent to 20 percent, was improper. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.105(e), 3.344, 4.124a, Diagnostic Code 8513. 2. The reduction in the evaluation for peripheral neuropathy of the left upper extremity, from 30 percent to 20 percent, was improper. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.105(e), 3.344, 4.124a, Diagnostic Code 8513. 3. The reduction in the evaluation for peripheral neuropathy of the right lower extremity, from 20 percent to 10 percent, was improper. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.105(e), 3.344, 4.124a, Diagnostic Code 8520. 4. The reduction in the evaluation for peripheral neuropathy of the left lower extremity, from 20 percent to 10 percent, was improper. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.105(e), 3.344, 4.124a, Diagnostic Code 8520. 5. The criteria for a disability rating in excess of 40 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8513. 6. The criteria for a disability rating in excess of 30 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8513. 7. The criteria for a disability rating in excess of 20 percent for right lower extremity peripheral neuropathy, prior to September 11, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8520. 8. The criteria for a disability rating of 40 percent for right lower extremity peripheral neuropathy, beginning on September 11, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8520. 9. The criteria for a disability rating in excess of 20 percent for left lower extremity peripheral neuropathy, prior to September 11, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8520. 10. The criteria for a disability rating of 40 percent for left lower extremity peripheral neuropathy, beginning on September 11, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8520. 11. The criteria for an award of a TDIU have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.1-4.14, 4.21, 4.16. 12. From April 18, 2019, the criteria for a SMC pursuant to 38 U.S.C. § 1114(s) have been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1967 to August 1970. These matters come before the Board of Veterans’ Appeals (Board) on appeal from March 2015 and June 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Rating Reductions Generally, 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. §§ 3.321, 4.1. 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. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). To properly reduce a disability rating, VA must satisfy both procedural and substantive criteria. Procedurally, where the reduction in the rating of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). Specifically, the Veteran must be notified at his or her latest address of record of the contemplated action, furnished detailed reasons thereof, and given 60 days to present additional evidence to show that compensation payments should be continued at their present level. Id. The Veteran must also be informed that he or she may request a predetermination hearing, provided that the request is received by the VA within 30 days from the date of the notice. If additional evidence is not received within the 60-day period, and no hearing is requested, final rating action will be taken, and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the Veteran expires. Id. Here, a March 2015 proposed reduction rating decision provided the Veteran with appropriate notice of a proposed reduction of his right upper extremity peripheral neuropathy, from 40 percent to 20 percent, his left upper extremity peripheral neuropathy, from 30 percent to 20 percent, and his bilateral lower extremity peripheral neuropathy, from 20 percent to 10 percent for each lower extremity. The Board notes that this proposed rating reduction appears to indicate that a prior July 2014 rating decision clearly and erroneously assigned evaluations for the bilateral upper and lower extremities consistent with moderate symptomology when the evidence of record reflected that ratings were warranted for mild symptomology. By way of background, the July 2014 rating decision granted entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, assigning a 30 percent rating for the left upper extremity and a 40 percent rating for the right upper extremity. This rating decision also increased the disability ratings for the Veteran’s already service-connected peripheral neuropathy of the bilateral lower extremities from 10 percent to 20 percent. While the March 2015 proposed rating reduction appeared to indicate that the rating reduction was based on clear and unmistakable error (CUE) with the July 2014 rating decision, a March 2015 notification letter sent to the Veteran indicated that the proposed rating reductions were being made because the medical records reflected some improvement in the Veteran’s disabilities. Further, the June 2015 rating decision on appeal did not make any CUE findings with regards to the July 2014 rating decision. Thus, the Board will interpret this claim as one for a rating reduction rather than one based on CUE. Regarding the necessary procedural requirements, the Board notes that the Veteran was notified that he had 60 days to submit evidence and/or request a hearing. During the 60-day period, the Veteran did not submit any additional evidence or request a hearing. Subsequently, in the June 2015 rating decision, the RO effectuated the proposed rating reductions, effective September 1, 2015. Based upon these facts, the Board finds that the RO’s reduction of the Veteran’s disability ratings for his bilateral upper and lower extremities was procedurally in accordance with the notice provisions under 38 C.F.R. § 3.105. Substantively, the regulations provide that when a rating has continued for a long period at the same level (i.e., five years or more), stringent criteria must be met before a rating may be reduced. However, where, as in this case, a rating has been in effect for less than five years, the regulatory requirements under 38 C.F.R. § 3.344(a) are inapplicable, as set forth in 38 C.F.R. § 3.344(c). In such cases, an adequate reexamination that discloses improvement in the condition will warrant a reduction in rating. See 38 C.F.R. §§ 3.344(c). A rating reduction requires an inquiry as to “whether the evidence reflects an actual change in the disability, and whether the examination reports reflecting such a change are based upon thorough examinations.” Brown v. Brown, 5 Vet. App. 413, 421 (1993). Significantly, in a rating reduction case, the burden is on VA to show improvement, and it is not on the Veteran as is the case in a typical increased rating claim. See 38 U.S.C. § 5112; 38 C.F.R. § 3.105. A rating reduction case focuses on the propriety of the reduction. See Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991). In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the condition had demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277 (1991). The question of whether a disability has improved involves consideration of the applicable rating criteria. Here, the Veteran’s bilateral upper extremity peripheral neuropathy is rated under Diagnostic Code (DC) 8513 for impairment of all radicular groups, and his bilateral lower extremity peripheral neuropathy is rated under DC 8520 for impairment of the sciatic nerve. The Board notes that DC 8513 provides a different evaluation progression for the major (dominant) or minor (non-dominant) limb. The evidence of record reflects that the Veteran is right-handed; thus, the evaluation progression for the major limb will be used to rate the Veteran’s right upper extremity peripheral neuropathy, and the evaluation progression for the minor limb will be used to rate the Veteran’s left upper extremity peripheral neuropathy. Under DC 8513, a 20 percent disability rating is warranted for mild incomplete paralysis of the radicular groups of the major and minor limb; a 30 percent rating is warranted for moderate incomplete paralysis of the minor limb, and a 40 percent rating is warranted for moderate incomplete paralysis of the major limb; a 60 percent rating is warranted for severe incomplete paralysis of the minor limb, and a 70 percent rating is warranted for severe incomplete paralysis of the major limb; finally, a maximum 80 percent rating is warranted for complete paralysis of the minor limb, and a maximum 90 percent rating is warranted for complete paralysis of the major limb. 38 C.F.R. § 4.124a, DC 8513. Under DC 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis of the sciatic nerve; and a 60 percent rating is assigned for severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy. 38 C.F.R. § 4.124a, DC 8520. A maximum 80 percent rating is assigned for complete paralysis of the sciatic nerve, where the foot dangles and drops, there is no active movement possible of muscles below the knee, and where flexion of the knee is weakened or (very rarely) lost. Id. The Board observes that the terms “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the Ratings Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of terminology such as “moderate” or “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. On June 2014 VA diabetic sensory-motor peripheral neuropathy examination, the Veteran was provided diagnoses of bilateral lower extremities and bilateral hands diabetic peripheral neuropathy. The Veteran reported numbness in both feet, with intermittent tingling and hyperalgesia. He also reported burning and discomfort in both calves. The Veteran reported mild intermittent pain (usually dull) in both upper extremities, and moderate intermittent pain in both lower extremities. He further reported moderate paresthesias and/or dysesthesias in both lower extremities. He reported mild numbness in the right upper extremity, and moderate numbness in both lower extremities. Strength testing was normal. Deep tendon reflexes were decreased for both biceps and triceps, absent for both brachioradialis, normal for both knees, and decreased for both ankles. Light touch/monofilament testing was normal. Position sense testing was decreased for the upper extremities and normal for the lower extremities. Vibration sensation testing was normal for the upper extremities and decreased for the lower extremities. Cold sensation testing was normal for the left upper extremity, and decreased for the right upper extremity and lower extremities. There was no muscle atrophy. The VA examiner opined that the Veteran had mild incomplete paralysis of the right and left median and ulnar nerves in both upper extremities, and moderate incomplete paralysis of the sciatic nerves for both lower extremities. It was noted that the Veteran’s diabetic peripheral neuropathy impacted his ability to work. Specifically, it was noted that he developed weakness and mild aching in his thighs and that he was no longer strong enough to arise from a squatting or kneeling position without assistance, such as pulling himself up using a piece of furniture. On March 2015 VA diabetic sensory-motor peripheral neuropathy examination, the Veteran was provided a diagnosis of diabetic peripheral neuropathy. He reported burning paresthesia in both forearms extending into his fingers bilaterally, as well as in his lower extremities and feet. The Veteran reported mild intermittent pain (usually dull) in all extremities. He reported mild paresthesias and/or dysesthesias in the upper extremities, and moderate paresthesias and/or dysesthesias in the lower extremities. He reported mild numbness in the upper extremities and moderate numbness in the lower extremities. Muscle strength and deep tendon reflexes testing was normal. Light touch/monofilament testing was normal for the shoulder area bilaterally, but decreased for the inner/outer forearm, hands/fingers, knees/thighs, ankles/lower legs, and feet/toes. Position sense testing was normal. Vibration sensation testing was normal for the upper extremities and decreased for the lower extremities. Cold sensation testing was normal for the upper extremities and decreased for the lower extremities. There was no muscle atrophy. The VA examiner found there to be mild incomplete paralysis of the median and ulnar nerves of both upper extremities, and moderate incomplete paralysis of the sciatic nerve of each lower extremity. The VA examiner opined that the Veteran’s diabetic peripheral neuropathy did not impact his ability to work; however, no rationale or reasoning for this opinion was provided. On September 2016 VA diabetic sensory-motor peripheral neuropathy VA examination, the Veteran was provided a diagnosis of diabetic peripheral neuropathy of the upper and lower extremities. The Veteran reported numbness in his fingers to forearms and in his lower legs and feet. He also reported a burning sensation in his fingers to forearms and lower legs and feet. He indicated that the burning sensation in his lower legs and feet was exacerbated by prolonged standing, and that the numbness sensation in his lower legs and feet were exacerbated by prolonged sitting. The Veteran reported mild paresthesias and/or dysesthesias and numbness of all extremities. Muscle strength and deep tendon reflex testing was normal. Light touch/monofilament testing was normal for the shoulder area and knees/thighs, but decreased for the inner/outer forearms, hands/fingers, ankle/lower legs, and feet/toes. Position sense testing was normal. Vibration sensation testing was decreased for the upper extremities and absent for the lower extremities. The Veteran did not have any muscle atrophy. The VA examiner opined that there was mild incomplete paralysis of the radial, median, and ulnar nerves of both upper extremities. He was further noted to have mild incomplete paralysis of the sciatic nerve. The examiner noted that the diabetic peripheral neuropathy did not impact the Veteran’s ability to work. The Board notes that in a November 2016 statement, the Veteran challenged the adequacy of this September 2016 VA examination, indicating that the examination lasted only 10 minutes and the examiner was “clearly uninterested” in what the Veteran had to say. However, the Board notes that the Veteran did not point to anything in this September 2016 VA examination that was inaccurate or incomplete. Further, on the face of the examination, the VA examiner appeared to note the Veteran’s reported symptomology and fully complete all questions and document all symptoms. Thus, the Board finds this opinion to be adequate. The Veteran was provided an additional VA examination in September 2019, where he was provided a diagnosis of diabetic peripheral neuropathy. The Veteran reported numbness in his lower legs and feet, burning in his arms, and numbness in his fingertips. The Veteran reported moderate constant pain in his bilateral upper extremities. He reported moderate paresthesias and/or dysesthesias in all extremities. He further reported moderate numbness in both upper extremities, and severe numbness in both lower extremities. Muscle strength testing was normal. Deep tendon reflexes were decreased in the biceps, triceps, brachioradialis, and knees, and absent in the ankles. Light touch/monofilament testing were normal for the shoulder area, inner/outer forearm, and knees/thighs; decreased for the hands/fingers; and absent for the ankles/lower leg, and fingers and toes. Position sense and vibration testing was normal for the upper extremities and absent for the lower extremities. Cold sensation testing was decreased for the upper extremities, and absent in the lower extremities. The Veteran did not have muscle atrophy. However, it was noted that the Veteran experienced trophic changes attributable to diabetic peripheral neuropathy; specifically, shiny skin and absent hair growth. Regarding the severity of the Veteran’s neuropathy, he was noted to have mild incomplete paralysis of the radial, median, and ulnar nerves of both upper extremities. He was further noted to have moderately severe incomplete paralysis of the sciatic nerve of both lower extremities. Finally, the VA examiner indicated that the Veteran’s diabetic peripheral neuropathy would impact his ability to work, in that he would be limited to sedentary types of employment. The Board notes that also of record are the Veteran’s VA treatment records that reflect him receiving acupuncture treatment for his diabetic peripheral neuropathy beginning in December 2018. In January 2019, the Veteran reported neuropathy that was worse on the plantar aspect of his feet, which mostly presented as numbness. He also reported mild neuropathy in his upper extremities, which was not as severe as the neuropathy in his lower extremities. In April 2019, the Veteran continued to experience weakness in his bilateral legs and neuropathy symptoms in his feet and fingers. However, he reported that the acupuncture was improving the numbness overall. As previously discussed, for a reduction to be warranted, the evidence of record must show an improvement in the disability level, which must be established by a preponderance of the evidence. 38 U.S.C. § 5112; 38 C.F.R. § 3.105; Brown, 5 Vet. App. at 420-21. The Board does not find that the evidence of record reflects that there was an improvement in the Veteran’s bilateral upper and lower extremity peripheral neuropathy at the time of the June 2015 rating reduction, which was made effective September 1, 2015. Specifically, with regards to the Veteran’s upper extremities, the Board notes that the Veteran reported a slight increase in severity of symptomology between the June 2014 and March 2015 VA examinations. For example, during the March 2015 VA examination, the Veteran reported an increased burning sensation in his forearms extending to his fingers bilaterally, which was not reported during the June 2014 VA examination. This slight increase in severity was also confirmed on light touch/monofilament testing. The Veteran further reported mild intermittent pain on both examinations for the upper extremities. Additionally, the level of severity of the Veteran’s bilateral upper extremity peripheral neuropathy was noted to be the same during both the June 2014 and March 2015 VA examinations. Similarly, with regards to the Veteran’s lower extremities, the Veteran reported the same level of severity regarding the burning and numbness he was experiencing. While the Veteran reported moderate intermittent pain in the June 2014 VA examination, and mild intermittent pain during the March 2015 VA examination, the Board notes the Veteran reported moderate numbness and paresthesias and/or dysesthesias in the lower extremities during both the June 2014 and March 2015 VA examination. Further, light touch/monofilament testing reflected decreased sensation during the March 2015 VA examination, which was noted to be normal during the June 2014 VA examination; this also reflects a slight worsening of symptomology. Accordingly, in light of the foregoing, the Board finds that the preponderance of the evidence of record does not reflect an improvement of the Veteran’s bilateral upper and lower extremity peripheral neuropathy at the time the reduction in rating was made. Accordingly, a 40 percent rating for the right upper extremity, a 30 percent for the left upper extremity, and 20 percent ratings for each lower extremity are restored. Increased Ratings In light of the restoration of these disability ratings, the Board turns to the question of whether increased disability ratings for the Veteran’s bilateral upper and lower extremity peripheral neuropathy are warranted. Regarding the Veteran’s bilateral upper extremity peripheral neuropathy, in order for a disability in excess of 40 percent to be warranted for the major right upper extremity, and for a rating in excess of 30 percent to be warranted for the minor left upper extremity, the evidence would have to reflect severe incomplete paralysis of all radicular groups. 38 C.F.R. § 4.124a , DC 8513. The Board finds that at no point during the period on appeal was the Veteran’s bilateral upper extremity peripheral neuropathy productive of severe symptomology. During the June 2014, March 2015, September 2016, and the September 2019 VA examinations, the Veteran was found to have mild incomplete paralysis in his upper extremities. Further, the Veteran himself noted during his acupuncture treatment in January 2019 that he was experiencing mild neuropathy in his upper extremities. Thus, as the Veteran is currently being compensated for moderate symptomology, and the evidence does not reflect severe symptomology, the Board finds that increased disability ratings for the Veteran’s bilateral upper extremity radiculopathy are not warranted. Regarding the Veteran’s bilateral lower extremity peripheral neuropathy, the Board finds that disability ratings in excess of 20 percent prior to September 11, 2019, are not warranted. The Board finds that prior to September 11, 2019, the preponderance of the evidence of record reflects that the Veteran’s bilateral lower extremity peripheral neuropathy was productive of, at most, moderate symptomology. Prior to September 11, 2019, the Veteran reported moderate intermittent pain and numbness in his bilateral lower extremities during the June 2014 VA examination. Further, during the March 2015 VA examination, he reported mild intermittent pain, and moderate numbness. During the September 2016 VA examination, he only reported mild symptomology. At no point during these examinations was greater than moderate symptomology reported. Thus, the Board finds that prior to September 11, 2019, disability ratings in excess of 20 percent for bilateral lower extremity peripheral neuropathy are not warranted. However, the Board finds that the evidence reflects that beginning on September 11, 2019, the Veteran’s bilateral lower extremity peripheral neuropathy was productive of moderately severe symptomology. The Board finds that the date of the September 2019 VA examination was the earliest indication of record of the Veteran experiencing moderately severe incomplete paralysis of the sciatic nerves of both lower extremities. Specifically, although the VA treatment records reflect he was receiving acupuncture therapy for his bilateral upper and lower extremity peripheral neuropathy prior to September 2019, he indicated an improvement of his symptoms overall. Thus, the Board finds that entitlement to a 40 percent disability rating for each lower extremity beginning on September 11, 2019, is warranted. However, as there is no evidence of marked muscular atrophy or complete paralysis of the sciatic nerve, the Board finds that disability ratings in excess of 40 percent are not warranted. 38 C.F.R. § 4.124a, DC 8520. TDIU & SMC The Veteran claims that he is unable to obtain and maintain gainful employment as a result of his service-connected disabilities. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. § 4.16. Substantially gainful employment is employment that is ordinarily followed by the nondisabled to earn their livelihoods with earnings common to the particular occupation in the community where the veteran resides. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment will not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned, if the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16(a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system are considered as one disability. Id. Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. The central inquiry is whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Further, the Board notes that the granting of a 100 percent disability rating does not, in and of itself, extinguish a claim for a TDIU. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Specifically, SMC benefits under 38 U.S.C. § 1114(s) are to be accorded when a veteran becomes eligible without need for a separate claim. See Bradley, 22 Vet. App. at 294. Accordingly, given the Veteran’s various service-connected disabilities, their assigned ratings and effective dates for this time period (discussed below), and the evidence herein, the issue of entitlement to a TDIU remains on appeal, and the Board has raised the issue of entitlement to SMC benefits. SMC at the housebound rate is payable where the veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The Veteran does not contend, and the record does not reflect, that the Veteran is housebound in fact, implicating the second prong of the housebound criteria. Accordingly, the Board shall narrow its analysis to the statutory housebound criteria. The United States Court of Appeals for Veterans Claims has held that although a TDIU may satisfy the “rated as total” element of section 1114(s), a TDIU based on multiple underlying disabilities cannot satisfy the section 1114(s) requirement of “a service-connected disability” because that requirement must be met by a single disability. A TDIU based on a single disability alone, however, does not preclude the award of SMC benefits when the Veteran’s remaining service-connected disabilities are collectively ratable at 60 percent or higher. See Buie, 24 Vet. App. at 250. Here, the Veteran is awarded service connected for the following disabilities: coronary artery disease, rated at 30 percent from June 1, 2011, and 100 percent from April 18, 2019; diabetes mellitus, type II, rated at 20 percent from February 9, 2010; peripheral neuropathy of the right upper extremity, rated at 40 percent from January 31, 2014; peripheral neuropathy of the left upper extremity, rated at 30 percent from January 31, 2014; peripheral neuropathy of the right lower extremity, rated at 20 percent from January 31, 2014, and 40 percent from September 11, 2019; peripheral neuropathy of the left lower extremity, rated at 20 percent from January 31, 2014, and 40 percent from September 11, 2019; tinnitus, rated at 10 percent; and a residual scar, which is provided a noncompensable rating. Thus, from the beginning of the period on appeal, the Veteran was in receipt of a combined 90 percent disability rating, and beginning on April 18, 2019, he was in receipt of a combined 100 percent disability rating. Accordingly, the Veteran meets the schedular criteria for consideration for the assignment of a TDIU throughout the entire period on appeal. See 38 C.F.R. § 4.16(a). The Veteran maintained on his initial July 2014 claim for TDIU that he was unable to work as a result of complications from diabetes. Further, in his April 2015 Notice of Disagreement (NOD), the Veteran indicated that he worked in the radiology department as a computed tomography (CT) technologist. He indicated that he was informed by the company that supplied his pacemaker that the high energy output of the newest technology in CT would compromise his pacemaker settings. He also indicated in his NOD that his bilateral upper and lower extremity peripheral neuropathy made it difficult for him to do his job. He specifically indicated that constant pain in his forearms and hands made it difficult to start IV catheters for injection of contrast for certain examinations. Further, the pains in his legs made it difficult to stand for long periods of time, while sitting for long periods of time made it difficult for him to be able to get up. He indicated that he had to wait a while before walking to ensure that he was steady enough to avoid falling. He indicated that out of fear for the safety of his patients, he decided to retire early. With regards to the Veteran’s claim that he was unable to continue working due to his service-connected peripheral neuropathy, the Board finds that the medical evidence of record supports the Veteran’s contentions. Specifically, the June 2014 VA examination discussed above indicated that the Veteran’s bilateral upper and lower extremity peripheral neuropathy would impact his ability to work. It was noted that the Veteran developed weakness and mild aching in his thighs and that he was no longer strong enough to arise from a squatting or kneeling position without assistance, such as pulling himself up using a piece of furniture. Thus, the Board finds that there is sufficient evidence to establish that the Veteran was unable to secure to follow substantially gainful employment during the period on appeal as a result of his service-connected bilateral upper and lower extremity peripheral neuropathy. To the extent that the Veteran maintains that he was unable to work prior to April 18, 2019, solely as a result of his heart disability and pacemaker, the Board finds there to be insufficient evidence of record to support this claim. As discussed above, the Veteran has indicated that he was informed by the company that supplied his pacemaker that the high energy output of the newest technology in CT would compromise his pacemaker settings. However, the Veteran has not submitted any evidence to corroborate this claim other than his lay statement of what was reported to him. While the Veteran is competent to report what he has been told, the exact nature of this warning is unclear and the Board is unable to compare it to other evidence of record. However, even if the Board were to find the Veteran’s statements reporting what was told to him credible, the statement would be outweighed by the other evidence of record. To wit, the record contains an October 2012 VA examination report that was completed after the Veteran received his pacemaker. In this report a VA physician stated that the Veteran’s heart disability would not impact his ability to work. The Board notes that the Veteran has not provided his own medical opinion on the interaction between the energy of a CT machine and his pacemaker, but was reporting what was he was told by the pacemaker manufacturer. Thus, the Board finds that an award of a TDIU based on service-connected coronary artery disease alone is not warranted. Regarding SMC benefits, the Board notes that effective April 18, 2019, the Veteran was in receipt of a 100 percent disability rating for coronary artery disease, and his remaining service-connected disabilities resulted in a combined evaluation of at least 60 percent. Accordingly, as of April 18, 2019, the Board finds that entitlement to a SMC under 38 U.S.C. § 1114(s) is warranted. (Continued on the next page)   However, the Board finds that entitlement to SMC(s) benefits prior to April 18, 2019, is not warranted. Although the Veteran has been awarded TDIU benefits for the entire period on appeal, this TDIU award is based on more than one disability, and therefore cannot serve a single disability rated at 100 percent. See Youngblood v. Wilkie, 31 Vet. App. 412 (2019). M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. DeChiara, Associate 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.