Citation Nr: 20036722 Decision Date: 05/28/20 Archive Date: 05/28/20 DOCKET NO. 13-29 079 DATE: May 28, 2020 ORDER Entitlement to service connection for hypertension, to include as secondary to diabetes mellites, is denied. Entitlement to a rating in excess of 30 percent prior to September 3, 2018 for coronary artery disease (CAD) is denied. Entitlement to a higher initial rating in excess of 10 percent prior to October 30, 2019, and 20 percent thereafter, for left lower extremity diabetic peripheral neuropathy is denied. Entitlement to a higher initial rating in excess of 10 percent prior to October 30, 2019, and 20 percent thereafter, for right lower extremity diabetic peripheral neuropathy is denied. FINDINGS OF FACT 1. The Veteran’s hypertension is not secondary to service-connected diabetes mellitus and is not otherwise related to an in-service injury or disease. 2. Prior to September 3, 2018, the Veteran’s CAD manifests with, at worst, a workload of greater than 5 but not greater than 7 METs with fatigue and dyspnea and left ventricular ejection fraction of greater than 50 percent. 3. The Veteran’s diabetic left lower extremity peripheral neuropathy is manifest by no more than mild incomplete paralysis prior to October 30, 2019, and moderate incomplete paralysis thereafter. 4. The Veteran’s diabetic right lower extremity peripheral neuropathy is manifest by no more than mild incomplete paralysis prior to October 30, 2019, and moderate incomplete paralysis thereafter CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension due to service or secondary to service-connected diabetes mellites are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for an initial rating in excess of 30 percent prior to September 3, 2018, for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.16, 4.100, 4.104, Diagnostic Code (DC) 7005. 3. The criteria for a disability rating in excess of 10 percent prior to October 30, 2019, and 20 percent thereafter, for left lower extremity diabetic peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8520. 4. The criteria for a disability rating in excess of 10 percent prior to October 30, 2019, and 20 percent thereafter, for right lower extremity diabetic peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8520 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1962 to October 1965. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2011, September 2015, and October 2015 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the issue of entitlement to service connection for hypertension in June 2015 and September 2016. In June 2018, the Board granted an earlier effective date of November 10, 2009 for the grant of service connection for bilateral lower extremity peripheral neuropathy and remanded the remaining issues on appeal for additional development. In a November 2018 rating decision, the RO effectuated the Board’s assignment of an earlier effective date. Initial 10 percent ratings were assigned for the left and right lower extremity peripheral neuropathy from November 10, 2009. In a In a March 2020 rating decision, the RO increased the ratings for the left and right lower extremity peripheral neuropathy to 20 percent each, effective October 30, 2019. The RO also retroactively granted a 30 percent rating for CAD effective June 25, 2015; and assigned a 100 percent rating effective September 3, 2018. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307, so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303 (b). 1. Entitlement to service connection for hypertension The Veteran seeks service connection for hypertension. The Veteran contends that his hypertension is related to his exposure to Agent Orange during active duty. Alternatively, he contends that his hypertension is secondary to his service-connected diabetes mellites. For VA purposes, “[h]ypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days,” and “hypertension means that the diastolic blood pressure [the bottom number of the blood pressure ratio] is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure [the top number of the blood pressure ratio] is predominantly 160mm. or greater with a diastolic of less than 90mm.” 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Veteran has recalled treatment for hypertension in the 1980’s and 1990’s. In June 2018, the Board remanded the claim to obtain outstanding VA treatment records from White River VAH in the 1980’s and 1990’s. In December 2018, the RO requested a search and copies of all non-electronic archived records from White River JCT VA Medical Center. In January 2019, White River JCT VA Medical Center responded and indicated that it was disclosing the information per the RO’s request. Notably, no treatment records dating to the 1980’s and 1990’s were available. There has been substantial compliance with this remand directive. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran’s service treatment records are absent of any complaints, treatment, or diagnosis of hypertension. Blood pressure was noted as 120/72 in October 1962 and 128/70 in January 1965. His October 1965 discharge report of medical examination also notes blood pressure of 136/86 and a normal clinical evaluation of the heart and vascular system. The Veteran underwent a VA examination in August 2015. The Veteran reported that he was put on blood pressure medicine in 1980. He indicated that he took continuous medication to manage his hypertension. The examiner diagnosed hypertension. He opined that the hypertension is less likely than not related to the Veteran’s service or to diabetes. The examiner explained that there was no temporal relationship and no evidence of historical kidney damage. He further opined that it is less likely than not the hypertension was aggravated by the diabetes mellites. He explained that there was no a lack of significant kidney damage and no recent worsening of hypertension. In September 2017, another VA examiner offered an addendum opinion. The examiner opined that it is less likely as not the Veteran’s hypertension is etiologically related to exposure to herbicides during active service. He explained that there is no well accepted causal relationship found in the medical literature between active military service, including herbicide exposure in Thailand, and the later development of a hypertension condition. Thus, he concluded that it is less likely as not the Veteran’s hypertension originated in or was caused by service. With respect to whether a causal relationship exists between the Veteran’s hypertension and his service-connected diabetes, the examiner opined that the Veteran’s hypertension is less likely than not caused or aggravated by his diabetes. He explained that it is well accepted that chronic kidney disease can be associated with hypertension. He noted that in diabetics, diabetic kidney disease is not generally felt to cause or aggravate hypertension in the absence of significantly decreased kidney function, which the Veteran has not demonstrated. He concluded that the absence of significant diabetic kidney disease supports a finding that the Veteran’s hypertension is less likely than not related to diabetes, as there is no well accepted physiological mechanism for a direct causal relationship between diabetes and hypertension in the absence of kidney disease. Finally, the examiner addressed the representative’s observation, made to support a secondary relationship, that a much higher percentage of people with diabetes have hypertension than have diabetic kidney disease. He explained, however, that while diabetes and hypertension are commonly found together in the absence of kidney disease in the general population, this was most likely because diabetes and hypertension share risk factors associated with the same general population characteristics, such as aging, weight gain or overweight status, and physical activity. The Board concludes that, while the Veteran has a current diagnosis of hypertension, and evidence shows that exposure to herbicides occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of hypertension began during service or is otherwise related to an in-service injury, event, or disease. In an August 2015 opinion and a September 2017 clarifying addendum opinion, the August 2015 VA examiner opined that the Veteran’s hypertension is not at least as likely as not related to an in-service injury, event, or disease, including herbicide exposure and secondary to diabetes mellites. The examiner explained that the association of hypertension with diabetic kidney disease was well established, but that absent significant kidney disease there was no well accepted physiological mechanism for a relationship between diabetes and hypertension. He further indicated that the reason hypertension and diabetes were commonly found together even absent kidney disease was related to population risk factors, rather than to a specific relationship between hypertension and diabetes. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his hypertension is related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, anatomical relationships, and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the August 2015 VA examination report and September 2017 VA addendum opinion. The Veteran’s representative contends that the September 2017 VA addendum is inadequate, because it did not address whether the Veteran’s service-connected diabetes mellites aggravated the hypertension condition. The Board disagrees. Though adverse, the examiner explained that, absent significant kidney failure, the Veteran’s hypertension is less likely than not cause or aggravated by diabetic kidney disease, and that there was no other well accepted physiological mechanism for a relationship between diabetes and hypertension. Finally, the examiner addressed the representative’s specific observations and supporting medical treatises. He indicated that the fact that diabetes and hypertension are commonly found together was likely related to general population characteristics that are shared as risk factors between hypertension and diabetes, such as aging, weight gain, and physical inactivity. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. Accordingly, service connection for hypertension is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Increased Ratings Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. 2. Entitlement to a rating in excess of 30 percent prior to September 3, 2018 for coronary artery disease The Veteran’s CAD is rated at 30 percent from June 25, 2015 to September 3, 2018, and 100 percent thereafter, pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005. The Veteran generally contends that his condition warrants a higher rating. For the reasons that follow, the Board finds that a higher rating is not warranted. Under DC 7005, a 10 percent rating is warranted for a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted for CAD with a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation or electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. The medical history revealed a history of myocardial infarction in 2013 and a coronary artery bypass in October 2013. The Veteran underwent a VA examination in August 2015. The Veteran reported that he noticed shortness of breath around 2012 when sweeping. He indicated that the frequency of the shortness of breath increased and he began to have pressure in the chest with exertion. He did not report hospitalizations for the treatment of his heart condition. The examiner estimated METs of 3 to 5, consistent with the activities such as light yard work and brisk walking. Ejection fraction on an August 2015 echocardiogram revealed left ventricular ejection fraction of 60 to 65 percent. The examiner opined remarked that it is more likely than not that the ejection fraction on the recent echocardiogram is a better estimate of cardiac function than the estimated METs, due to confounding factors such as aging, history of tobacco abuse, and deconditioning impacting the estimated METs. A November 2015 non-diagnostic exercise treadmill test (ETT) revealed an adequate workload 6 METs, and ST segments that did not meet criteria for diagnosis of ischemia at workload. During a cardiac consult in December 2015, the Veteran reported that he felt well and desired to return to truck driving. The clinician reviewed recent EKG results and indicated the Veteran had CAD without symptoms, excellent exercise capacity and a mildly abnormal perfusion scan (which was performed due to a Department of Transportation physical). The clinician further indicated that the degree of ischemia was relatively mild and given his lack of symptoms and excellent exercise capacity, the Veteran had no need for limitations on his ability to drive. The Veteran underwent a cardiac catherization in April 2017. An October 2017 ETT revealed submax test at good workload of 7 METs, though target heartrate was not achieved. The test was terminated due to symptoms that were not related to the cardiac condition. In December 2017, the Veteran presented for care after a recent admission for dyspnea, shaking chills, and cough. He reported that he felt well since discharge without chest pain, recurrent dyspnea, or palpitations. In September 2018, the Veteran presented to cardiology following a hospitalization for coronary heart failure exacerbation and recurrent atrial fibrillation. In October 2018, the Veteran underwent a cardiac catherization. Providers noted severe 3-vessel CAD with 2 of 3 grafts patent. Pursuant to the June 2018 Board remand, the Veteran underwent a VA examination in October 2019. The examiner noted a diagnosis of CAD from 2013, and diagnoses of congestive heart failure and supraventricular arrhythmia since September 2018. The examiner was asked to clarify whether an October 2013 VA echocardiogram showed findings consistent with cardiac dilatation. The examiner noted findings on an October 2019 echocardiogram consistent with cardiac hypertrophy and cardiac dilation. The examiner did not address the October 2013 echocardiogram. However, in a March 2020 rating decision, the RO assigned a higher schedular 30 percent rating from June 25, 2015, the date of the Veteran’s claim for CAD. Since the Veteran is in receipt of a 30 percent rating, consistent with evidence of cardiac hypertrophy or dilation on echocardiogram, the Board finds that additional development by way of another medical opinion in this case would be redundant and unnecessary. Based on the evidence of record, prior to September 3, 2018, the Veteran’s CAD more nearly approximated the criteria corresponding to a 30 percent rating. That is, the criteria for a rating in excess of 30 percent are not met. The disability manifested with symptoms of fatigue and dyspnea on exertion, and cardiac hypertrophy shown on echocardiogram. Exercise-based stress testing was medically contraindicated at the August 2015 VA examination, so interview-based testing was performed. Those results showed METs, based solely on the heart condition, to be limited to, at worst, greater than 3 but not greater than 5 METs with symptoms of dyspnea and fatigue. However, the VA examiner concluded that the ejection fraction more accurately described the Veteran’s cardiac functioning, due to confounding factors such as age, decondition, and a history of tobacco use. Additionally, subsequent exercise treadmill tests dated November 2015 and October 2017 showed METs to be limited to, at worst, greater than 5 but not greater than 7 METs with symptoms of dyspnea and fatigue. Throughout the claim period, left ventricular ejection fraction was above 50 percent. Given these findings, a 30 percent rating prior to September 3, 2018, is appropriate pursuant to 38 C.F.R. § 4.104, DC 7005. Prior to September 3, 2018, the Veteran’s CAD has not approximated the criteria for a higher 60 percent rating based on congestive heart failure, METs level limitation, or left ventricular ejection fraction percentages. Accordingly, a higher 60 percent rating is not warranted. 38 C.F.R. § 4.104, DC 7005. The Board notes significant worsening of the Veteran’s CAD since September 2018. Medical records show that in September 2018, the Veteran was hospitalized for coronary heart failure and recurrent atrial fibrillation; and subsequently underwent a cardiac catherization in October 2018. The VA examination shows new diagnoses of coronary heart failure and recurrent atrial fibrillation since September 2018. Since September 3, 2018, the Veteran’s CAD was assigned a 100 percent rating under Diagnostic Code 7005. As the maximum benefit possible was assigned during this period, the Board finds that no higher or additional ratings for the Veteran’s CAD disability are possible during this period. There are no additional issues expressly or reasonably raised on the record related to this claim. 3. Entitlement to a higher initial rating in excess of 10 percent prior to October 30, 2019, and 20 percent thereafter, for left lower extremity diabetic peripheral neuropathy is denied 4. Entitlement to a higher initial rating in excess of 10 percent prior to October 30, 2019, and 20 percent thereafter, for right lower extremity diabetic peripheral neuropathy is denied The Veteran seeks higher initial ratings for lower extremity diabetic peripheral neuropathy in each lower extremity. These disabilities are separately rated at 10 percent November 10, 2009 to October 30, 2019; and 20 percent thereafter. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8620 and 8720). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. See 38 C.F.R. § 4.123. VA treatment records from November 2009 show minimal references to lower extremity diabetic neuropathy. On evaluation in December 2009, the Veteran was not noted to have any foot sores. He expressed a desire to walk more, presumably for exercise. Objective observation of the extremities revealed no pedal edema or ulcers. Pedal pulses and foot sensation to monofilament was intact. The notes indicate that a diabetic foot examination was normal. VA treatment notes in January 2011 show the Veteran was evaluated for his diabetes. No lower extremity complaints were reported. On the initial physical examination, the Veteran had a normal gait with palpable pulses. Strength was 5/5, and there was normal tone, normal skin, and intact sensation. However, clinical notes from a different provider on the same day shows diabetic monofilament sensory foot examination was abnormal as the Veteran reported he could not feel two areas in his left foot. The visual diabetic examination was also abnormal due to the toenails having a yellowish discoloration. Diabetic pedal pulses were normal. Diabetic foot assessments in December 2013 and May 2015 shows diabetic monofilament sensory testing was abnormal due to decreased sensation and weak bilateral pulses. The diabetic visual inspection foot inspection was normal. Additional notes show the Veteran was able to ambulate 100 feet without assistance. VA treatment notes all reflect that he was able to selfcare for his feet. The Veteran underwent a VA examination in August 2015. He reported that he noticed decreased sensation about 4 to 5 years prior, and that it had slowly been progressing in intensity and up his feet. He indicated that his wife cuts his toenails because he cannot feel down there well enough. The examiner noted mild bilateral lower extremity paresthesias and numbness. Light touch was decreased. Position sense, vibration sense, and cold sensation were noted as absent. No pain, trophic changes, or muscle atrophy was noted in the feet or legs. The examiner assessed mild incomplete paralysis of the sciatic nerve. VA treatment records show in April 2019, the Veteran was treated for a left plantar hallux ulcer. Diabetic peripheral neuropathy with loss of protective sensation (LOPS) was noted as a risk factor. August 2019 podiatry notes revealed the hallux wound was healed. Physical examination noted intact strength. The Veteran underwent a VA examination in October 2019. The Veteran reported paresthesias starting in the upper “tib./fib.” areas bilaterally, and numbness starting at the ankles. He stated that his feet are numb bilaterally, and that they feel cold at night. He reported that the foot numbness makes him have to concentrate on walking in a straight line. No pain was noted in the feet or legs. Physical examination revealed moderate numbness and paresthesias bilaterally. Light touch was decreased in the lower leg, and absent in the foot/toes. Trophic changes, noted as shiny skin and absence of hair on the sins, were observed. The examiner assessed moderate incomplete paralysis of the sciatic nerve. Prior to October 30, 2019, medical records reveal decreased sensation, including to light touch, and decreased pedal pulses. Neuropathic pain and muscle atrophy were not reported. At the August 2015 VA examination, the Veteran reported decreased sensation that had been slowly progressing in intensity over the last several years, which was consistent with his complaints in the VA treatment records. Physical examination similarly confirmed decreased light touch, and absent position sense, vibration sensation, and cold sensation. The examiner did not note impairment of motor functioning, trophic changes, loss of reflexes, or muscle atrophy. Since October 30, 2019, clinical examination findings indicate impairment of motor function and trophic changes, in addition to the previous symptoms of pain, paresthesias, and numbness noted in earlier treatment records. At the October 2019 VA examination, the Veteran reported some motor functioning difficulty, namely that he needed to concentrate on walking straight due to numbness of the feet. However, no significant gait or ambulation difficulty was reported by the Veteran. Trophic changes, specifically shiny and hairless skin on his shins, was also observed on examination. Motor strength and reflexes remained intact, and no muscle atrophy was observed. Throughout the appeal period, the record is silent for positive findings related to muscle atrophy or complete paralysis. Physical examination by both VA examiners did not note muscle atrophy, reduced motor strength, or complete paralysis of the sciatic nerve. Neither does the VA treatment or podiatry notes of record indicate muscle atrophy or exam findings suggestive of complete paralysis. Based on the above, the Board finds that prior to October 30, 2019 the disability is primarily manifested by sensory disturbance, including decreased sensation, numbness, and paresthesias. The level of impairment is most analogous to mild incomplete paralysis. The probative evidence of record is against a finding that the disability is manifest by greater severity which would reasonably be demonstrated by evidence of impaired motor functions, loss of reflexes, muscle atrophy, or a greater degree of paralysis. The Board finds the 2015 VA examiner’s assessment, based on review of the claims file and clinical observations, that the severity of the incomplete paralysis of the sciatic nerve was of a mild nature. Incomplete paralysis of the sciatic nerve of a mild nature is consistent with the current 10 percent ratings in each lower extremity prior to October 30, 2019. Since October 30, 2019 the disability is primarily manifest by impairment of motor functions, trophic changes, and sensory disturbance. The Board’s review of the probative evidence of record is against a finding that the disability is manifest by loss of reflexes, muscle atrophy, complete paralysis. The 2019 VA examiner’s assessment, that based on review of the claims file and clinical observations the severity of the incomplete paralysis of the sciatic nerve was of a moderate nature, is persuasive. The Board thus finds that the level of impairment is most analogous to moderate incomplete paralysis. Incomplete paralysis of the sciatic nerve of a moderate nature is consistent with the current 20 percent ratings in each lower extremity beginning October 30, 2019. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different diagnostic code is not warranted. The benefit of the doubt doctrine was considered in the decision as to whether higher initial ratings are warranted. However, as the preponderance of the evidence is against the claim, initial ratings in excess of 10 percent prior to October 30, 2019; and 20 percent thereafter for lower extremity diabetic neuropathy in each of the lower extremities, the appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Lauritzen, 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.