Citation Nr: 20053716 Decision Date: 08/13/20 Archive Date: 08/13/20 DOCKET NO. 13-33 596 DATE: August 13, 2020 ORDER Entitlement to a separate compensable rating for service-connected diabetic nephropathy is denied. FINDING OF FACT The Veteran’s diabetic nephropathy is not manifested by constant or recurring albumin with hyaline and granular casts or red blood cells; or transient or slight edema; or hypertension at least 10 percent disabling under Diagnostic Code (DC) 7101. CONCLUSION OF LAW The criteria for entitlement to a separate compensable rating for service-connected diabetic nephropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.115a, 4.115b, Diagnostic Code 7541. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1967 to January 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in January 2018. A transcript of that hearing is of record. This matter was remanded by the Board in March 2018 and August 2019. 1. Entitlement to a separate compensable rating for nephropathy The Veteran’s nephropathy is currently rated as part of his service-connected diabetes mellitus type II with diabetic nephropathy, hypertension, and erectile dysfunction, which is rated as 20 percent disabling. The Veteran contends that he should be assigned a separate compensable rating for his diabetic nephropathy because of the frequency with which he must urinate. Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Evaluation of a service-connected disorder requires a review of the veteran’s entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Renal involvement in diabetes mellitus is rated as renal dysfunction. 38 C.F.R. § 4.115b, DC 7541. A noncompensable rating is assigned for renal dysfunction with albumin and casts with history of acute nephritis; or, hypertension non-compensable under DC 7101. A 30 percent rating is assigned for renal dysfunction where albumin is constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under DC 7101. A 60 percent rating is assigned for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101. An 80 percent rating is assigned for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is assigned for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a. The rating criteria for renal dysfunction reference DC 7101, which governs hypertension. Under DC 7101, a 10 percent rating is assigned when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more, or; as the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. A 40 percent rating is assigned when diastolic pressure is predominantly 120 or more. A 60 percent rating is assigned when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, DC 7101. A March 2015 VA examination noted recurring albuminuria, but normal BUN and EGFR laboratory studies. A July 2018 examination as to nephropathy found persistent albuminuria. The examiner found normal BUN and EGFR laboratory studies. The examiner found that the Veteran’s nephropathy is asymptomatic. The examiner opined that there were no hyaline, granular casts, or red blood cells noted in the medical record. A July 2018 VA examination as to hypertension found that the Veteran does take continuous medication for hypertension, but that the Veteran does not have a history of diastolic blood pressure elevation to predominantly 100 or more. The blood pressure readings obtained that day were 145/77, 130/60, and 128/60. The examination is indicative of a noncompensable rating for hypertension. Although the Veteran has recurring or persistent albuminuria, the record does not reflect hyaline or granular casts or red blood cells. There is no indication of edema related to nephropathy in the record. Additionally, a July 2018 examination reflects that a noncompensable rating for hypertension is appropriate. Therefore, the record does not support assigning a separate compensable rating for the Veteran’s service-connected diabetic nephropathy. The Veteran has argued that his urinary incontinence and frequency are symptoms of diabetic nephropathy that warrant a separate compensable rating. However, VA examiners have opined that these symptoms are related to his nonservice-connected benign prostatic hyperplasia (BPH), not his service-connected diabetic nephropathy. A July 2018 VA examiner found that the Veteran’s urinary frequency and urgency incontinence is due to his nonservice-connected BPH, and that these are not signs or symptoms of nephropathy. The examiner explained that BPH patients present with symptoms of bladder irritation (urinary frequency, urgency, urge incontinence), bladder outlet obstruction (urinary hesitancy, straining to urinate, sensation to incomplete voiding), and/or hematuria. However, there was some inconsistency within the opinion in that the examiner went on to state that the signs and symptoms of diabetic nephropathy include, among others, increased need to urinate. Another medical opinion was requested to clarify whether the Veteran’s increased urinary frequency is an example of an increased need to urinate as a symptom of nephropathy. A December 2019 VA examiner opined that the Veteran’s urinary frequency and incontinence and his service-connected diabetic nephropathy are not medically related. The examiner asserted that the medical literature does not support a medical relationship, and a nexus has not been established. The examiner explained that the classic symptoms of BPH are urinary hesitancy, frequency, urgency, slowing effects on the stream and urinary incontinence. Per the examiner, nephropathy affects urinary production itself, and does not alter the function of the bladder or cause symptoms in the bladder. The examiner concluded that it is less likely than not that the Veteran’s urinary complaints, to include frequency, incontinence, and urgency, are due to nephropathy. The symptoms are more likely than not due to BPH. The examiner explained that urgency, specifically, is almost definitely related to BPH, and was unsure why the previous opinion stated otherwise. The Board recognizes that the Veteran sincerely believes that his urinary symptoms are caused by his service-connected nephropathy. However, the etiology of his urinary symptoms is a medically complex issue that requires knowledge of the interaction between multiple organ systems in the body. There is no indication in the record that the Veteran has medical training necessary to provide a competent opinion on whether his urinary symptoms are related to nephropathy or BPH. 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 VA medical opinions of record. The most probative evidence indicates that the Veteran’s urinary incontinence, urgency, and frequency are not symptoms of his service-connected diabetic nephropathy, and thus cannot be considered when rating that disability. The record, as discussed above, does not indicate that the Veteran meets the criteria for   a separate compensable rating for diabetic nephropathy. Therefore, the Veteran’s claim must be denied. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Budd, 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.