Citation Nr: 21000191 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 15-22 842 DATE: January 4, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, diagnosed as nightmare disorder, is granted. Entitlement to a rating in excess of 20 percent for diabetes mellitus type II is denied. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity prior to June 20, 2018, is denied. Entitlement to an initial rating of 30 percent, and no higher, for peripheral neuropathy of the left upper extremity, effective June 20, 2018, is granted. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the right upper extremity prior to February 23, 2016, is denied. Entitlement to an initial rating of 40 percent, and no higher, for peripheral neuropathy of the left upper extremity, effective February 23, 2016, is granted. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity prior to June 20, 2018, and in excess of 20 percent thereafter, is denied. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity prior to June 20, 2018, and in excess of 20 percent thereafter, is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to June 10, 2019, is remanded. FINDINGS OF FACT 1. The evidence is in relative equipoise as to whether the appellant’s diagnosed nightmare disorder was incurred in or is otherwise causally related to his active service. 2. The preponderance of the evidence is against the appellant having been prescribed insulin to treat his service-connected diabetes mellitus type II, or having required any regulation of activity, during any portion of the period on appeal. 3. Prior to June 20, 2018, the appellant’s peripheral neuropathy of the left upper extremity was manifested by no more than mild incomplete paralysis primarily affecting the lower radicular group. 4. From June 20, 2018, the appellant’s peripheral neuropathy of the left upper extremity was manifested by no more than moderate incomplete paralysis primarily affecting the lower radicular group. 5. Prior to February 23, 2016, the appellant’s peripheral neuropathy of the right upper extremity was manifested by mild incomplete paralysis primarily affecting the lower radicular group. 6. From February 23, 2016, the appellant’s peripheral neuropathy of the left upper extremity was manifested by moderate incomplete paralysis primarily affecting the lower radicular group. 7. The most probative evidence establishes that the appellant’s peripheral neuropathy of the right lower extremity was manifested by incomplete paralysis no greater than mild in severity prior to June 20, 2018, and no greater than moderate incomplete paralysis thereafter. 8. The most probative evidence establishes that the appellant’s peripheral neuropathy of the left lower extremity was manifested by incomplete paralysis no greater than mild in severity prior to June 20, 2018, and no greater than moderate incomplete paralysis thereafter. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an acquired psychiatric disorder, diagnosed as nightmare disorder, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for a disability rating in excess of 20 percent for service-connected diabetes mellitus type II have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code (DC) 7913. 3. The criteria for entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity prior to June 20, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, DC 8512. 4. The criteria for entitlement to an initial rating of 30 percent, and no higher, for peripheral neuropathy of the left upper extremity effective June 20, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, DC 8512. 5. The criteria for entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the right upper extremity prior to February 23, 2016, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, DC 8512. 6. The criteria for entitlement to an initial rating of 40 percent, and no higher, for peripheral neuropathy of the right upper extremity effective February 23, 2016, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, DC 8512 7. The criteria for entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity prior to June 20, 2018, and in excess of 20 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, DC 8520. 8. The criteria for entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity prior to June 20, 2018, and in excess of 20 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the U.S. Army from November 1970 to August 1973, including service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). A January 2013 rating decision, inter alia, denied entitlement to a rating in excess of 20 percent for diabetes mellitus and awarded service connection for peripheral neuropathy of the bilateral upper and lower extremities, and assigned initial 20 percent ratings for the left and right upper extremities, and initial 10 percent ratings for the left and right lower extremities. Such rating decision also confirmed and continued the previous denial of service connection for PTSD. An April 2015 rating decision, inter alia, denied entitlement to a TDIU. The appellant was scheduled for a hearing before a Decision Review Officer (DRO) in March 2015. The record indicates that he failed to appear for such hearing. The appellant was afforded a hearing before the undersigned Veterans Law Judge by videoconference in June 2018. A transcript is of record. A February 2019 rating decision, inter alia, increased the evaluations of right upper extremity peripheral neuropathy to 30 percent, left lower extremity peripheral neuropathy to 20 percent, and right lower extremity peripheral neuropathy to 20 percent, effective November 10, 2018. Although higher ratings were granted, the issues remain in appellate status, as the maximum schedular ratings were not assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In June 2019, the Board, inter alia, remanded the issues of entitlement to service connection for an acquired psychiatric disability, to include PTSD, a rating in excess of 20 percent for diabetes mellitus, an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity, an initial rating in excess of 20 percent for peripheral neuropathy of the right upper extremity prior to November 10, 2018, and a rating in excess of 30 percent thereafter, an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity prior to November 10, 2018, and a rating in excess of 20 percent thereafter, an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity prior to November 10, 2018, and a rating in excess of 20 percent thereafter, and a TDIU. As previously observed by the Board, the appellant again filed a claim for, inter alia, an increased rating for diabetes mellitus in May 2019. It is unclear why the appellant filed a claim for an increased rating, given that his appeal of the issue was pending. A June 2019 rating decision, denied entitlement to increased ratings for diabetes mellitus type II and peripheral neuropathy of the bilateral upper and lower extremities. An October 2020 rating decision, in pertinent part, awarded a 30 percent evaluation for right upper extremity peripheral neuropathy and 20 percent ratings for right and left lower extremity peripheral neuropathy, each effective June 20, 2018. Entitlement to a TDIU was granted, effective June 10, 2019. AB, supra. A Supplemental Statement of the Case (SSOC) was issued in October 2020. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’—the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including psychoses, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). 1. Entitlement to service connection for an acquired psychiatric disability, diagnosed as nightmare disorder, is granted. The Board finds that the evidence is in relative equipoise as to whether entitlement to service connection for the appellant’s current nightmare disorder is warranted. Service treatment records reveal that the appellant’s May 1973 separation examination was essentially normal with respect to psychiatric. On his accompanying Report of Medical History, the appellant endorsed having, or having had, depression or excessive worry and nervous trouble of any sort. He denied frequent trouble sleeping. Service treatment records are otherwise negative for complaints or findings of a psychiatric disability. A November 1995 social work note states that the appellant reported that he served as a military policeman while in Vietnam and that he believed he had developed posttraumatic stress disorder (PTSD) as a result of his experiences. He also reported that a child died from a house fire in 1994, and that he had been more troubled about his Vietnam experiences following the fire. The appellant incurred a gunshot wound to the neck in December 1996. The appellant was afforded a VA examination in October 2012. While the VA examiner stated that the appellant did not meet DSM-IV criteria for a diagnosis of PTSD or any other mental disorder, the examiner opined that the appellant’s service as a military policeman in the Republic of Vietnam was a stressor which was adequate to support a PTSD diagnosis. Since that examination was conducted, however, VA amended 38 C.F.R. § 4.125 (a) to indicate that a diagnosis of a mental disorder, to include PTSD, must conform to the standards set in the DSM-5. The amendments are applicable to the appellant’s claim. See 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015) (final) (providing that for claims that were initially certified for appeal to the Board, the Court of Appeals for Veterans Claims (CAVC), or the U.S. Court of Appeals for the Federal Circuit prior to August 4, 2014, DSM-IV will apply. For all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, DSM-5 will apply). As the appellant’s claim was certified on appeal in August 2016, DSM-5 applies to his claim. To that end, the appellant was afforded a VA examination in February 2020 which was conducted under DSM-5. Following examination of the appellant and review of the claims file, the VA psychologist diagnosed nightmare disorder and opined that it was at least as likely as not that such was the result of the appellant’s traumatic in-service experiences. The examiner also noted that it was also likely that the experience of having been shot in 1996, well after separation, served to exacerbate or intensify the appellant’s mental health symptoms, but it would be impossible to separate the causative influence without resort to speculation. The examiner explained that the appellant did not meet the full criteria for a diagnosis of PTSD under DSM-5. An addendum opinion was requested by the RO in July 2020 from the February 2020 examiner. The examiner determined that it was not possible, without resort to mere speculation, to determine exactly what depressive or anxiety symptoms the appellant was experiencing at the time of separation, essentially because there was very little detail provided on the examination report and report of medical history. The examiner then opined that it was less likely than not that the appellant’s diagnosed nightmare disorder was incurred in or otherwise causally related to his reported in-service depression, excessive worry, and nervous trouble. However, the examiner again opined that it was at least as likely as not that the appellant’s nightmare disorder was related to or caused by his in-service traumatic experiences and his experience of being shot in 1996, as had been explained in the February 2020 opinion. The Board finds the February 2020 VA examiner’s opinion and July 2020 addendum probative because such were based on a clinical examination of the appellant, a review of the claims file, consideration of the relevant medical history, and the opinions were accompanied by a detailed rationale. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award entitlement to service connection for an acquired psychiatric disorder, diagnosed as nightmare disorder. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether an [initial] rating on appeal was erroneous. . . .” Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Id. Where a claimant appeals the denial of a claim of an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA’s adjudication of the claim for increase is lengthy, and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different, or “staged,” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The words “mild,” “moderate,” and “severe” are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” See 38 C.F.R. § 4.6. The term “incomplete paralysis,” with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a, DCs 8510 – 8730. 2. Entitlement to a rating in excess of 20 percent for diabetes mellitus type II is denied. The Board finds that the most probative evidence establishes that entitlement to a rating in excess of 20 percent for diabetes mellitus type II is not warranted for any portion of the period on appeal. The appellant’s service-connected diabetes mellitus has been evaluated under Diagnostic Code 7913. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, DC 7913 Note 1. Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’s favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). For example, and as illustrated below, if a claimant does not require daily injections of insulin, the claimant is unable to receive a rating greater than 20 percent for diabetes mellitus. The question in this appeal is whether the appellant’s diabetes mellitus required one or more daily injections of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. This criterion requires medical evidence. Camacho v. Nicholson, 21 Vet. App. 360, 364-65 (2007). The Board finds that the appellant’s diabetes mellitus type II required only restricted diet and an oral glycemic agent during the period on appeal. Neither the appellant’s private nor VA treatment records reveal that the appellant has required daily injections of insulin or regulation of activities to manage his diabetic symptoms during any of the period on appeal. VA examinations during the period on appeal do not record that the appellant requires daily injections of insulin or regulation of activities to manage his diabetic symptoms. The October 2012, February 2016, December 2018, and June 2019 VA examination reports state that the appellant’s diabetes mellitus type II was managed by restricted diet and prescribed oral hypoglycemic agents. However, regulation of activities was not required, nor was insulin. The appellant does not contend otherwise. Indeed, during his June 2018 Board hearing, he noted that he was not yet on insulin. Service connection for erectile dysfunction was denied in the January 2013 rating decision. However, the appellant did not include the issue in his April 2013 Notice of Disagreement (NOD), nor did he file any other NOD, formal or informal, regarding erectile dysfunction. As such, the issue is not before the Board. In any event, the Board notes that, while the appellant has contended that his erectile dysfunction is the result of his diabetes mellitus, the October 2012 examiner determined that the appellant’s erectile dysfunction was less likely than not due to diabetes mellitus. The February 2016, December 2018, and June 2019 examiners also did not attribute erectile dysfunction to diabetes mellitus; rather, their reports indicate that the only complication was peripheral neuropathy of the bilateral upper and lower extremities. The appellant’s bilateral upper and lower extremity peripheral neuropathy, secondary to his diabetes mellitus type II, have been assigned separate compensable ratings. The initial increased rating claims for such are discussed below. Accordingly, the preponderance of the evidence is against assigning a rating in excess of 20 percent for any portion of the period on appeal for service-connected diabetes mellitus type II, as the evidence does not demonstrate that the appellant at least as likely as not required one or more daily injections of insulin or regulation of activities during any of the period on appeal. 38 C.F.R. § 4.119, DC 7913. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is inapplicable. 38 C.F.R. § 4.3. 3. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity prior to June 20, 2018, is denied. 4. Entitlement to an initial rating of 30 percent, and no higher, for peripheral neuropathy of the left upper extremity, effective June 20, 2018, is granted. 5. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the right upper extremity prior to February 23, 2016, is denied. 6. Entitlement to an initial rating of 40 percent, and no higher, for peripheral neuropathy of the left upper extremity, effective February 23, 2016, is granted. The Board finds that the most probative evidence establishes that entitlement to (a) an initial rating in excess of 20 percent for left upper extremity peripheral neuropathy prior to June 20, 2018, is not warranted; (b) an initial rating of 30 percent, and no higher, for left upper extremity peripheral neuropathy, effective June 20, 2018, is warranted; (c) an initial rating in excess of 20 percent for right upper extremity peripheral neuropathy prior to February 23, 2016 is not warranted; and (d) an initial rating of 40 percent, and no higher, for right upper extremity peripheral neuropathy, effective February 23, 2016, is warranted. The appellant’s service-connected peripheral neuropathy of the bilateral upper extremities has been evaluated under Diagnostic Code 8514 for the radial nerve. Under Diagnostic Code 8514, which evaluates paralysis of the musculospiral nerve (radial nerve), a 20 percent evaluation is warranted for mild incomplete paralysis of the major or the minor extremity, or moderate incomplete paralysis of the minor extremity. A 30 percent evaluation is warranted for moderate incomplete paralysis of the major extremity. Severe incomplete paralysis warrants a 50 percent evaluation for the major extremity and a 40 percent evaluation for the minor extremity. Finally, complete paralysis of the radial nerve, noted as: drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; and, total paralysis of the triceps occurs only as the greatest rarity, warrants a 70 percent evaluation for the major extremity and a 60 percent evaluation for the minor extremity. See 38 C.F.R. § 4.124a, DC 8514. Lesions involving only “dissociation of extensor communis digitorum” and “paralysis below the extensor communis digitorum” will not exceed the moderate rating under Diagnostic Code 8514. See Id., Note. DC 8512 pertains to the lower radicular group, which includes the radial, median, and ulnar nerves. Pursuant to applicable law and regulation, a 20 percent evaluation is warranted where there is evidence of mild incomplete paralysis of the major lower radicular group, which is to say, the intrinsic muscles of the hand and some or all of the flexors of the wrist and fingers. A 40 percent evaluation is warranted where there is evidence of moderate incomplete paralysis, with a 50 percent evaluation indicated for severe incomplete paralysis of the major lower radicular group. A 70 percent evaluation is warranted for complete paralysis of the major lower radicular group, in which all intrinsic muscles of the hand, and some or all of flexors of the wrist and fingers are paralyzed (substantial loss of use of hand). A 20 percent evaluation is warranted where there is evidence of mild incomplete paralysis of the minor lower radicular group, with a 30 percent evaluation indicated for moderate incomplete paralysis of that same group. A 40 percent evaluation is indicated where there is evidence of severe incomplete paralysis of the minor lower radicular group. Finally, a 60 percent evaluation is indicated for complete paralysis of the minor lower radicular group, in which all intrinsic muscles of the hand, and some or all of flexors of the wrist and fingers are paralyzed (substantial loss of use of hand). 38 C.F.R. § 4.124a, DC 8512. The evidence of record establishes that the appellant is right-hand dominant. As such, his right upper extremity is the major extremity and his left upper extremity is the minor extremity. The appellant was afforded a VA diabetic neuropathy examination in October 2012. The appellant endorsed symptoms of numbness and occasional tinging, more so in the feet than in the hands. There was no pain or motor involvement. He had not received any treatment. Symptoms were intermittent and it was noted that the appellant was right-hand dominant. Examination revealed mild paresthesias and/or dysesthesias and mild numbness of the bilateral upper extremities. There was no pain in any extremity, constant or intermittent. There was no reduction in muscle strength in any extremity and there was no atrophy. Deep tendon reflexes were all normal. Light touch/monofilament testing revealed decreased sensation of the bilateral feet and toes, but was otherwise normal. Position sense, vibration sensation, and cold sensation were normal for all extremities. There were no trophic changes. The examiner opined that the appellant experienced mild incomplete paralysis of the radial (musculospiral), median, and ulnar nerves of the bilateral upper extremities. There was no functional impact. The appellant was afforded a VA examination on February 23, 2016. At present, the appellant experienced intermittent numbness of the upper extremities, with tingling in all fingers. He experienced occasional pain and stiffness, with “cramping” of his fingers, mostly in his right hand. He still experienced a recurrent numb/tingling sensation in the upper arm and elbow area. There was no constant hand pain, weakness, or dropping of objects. The appellant takes over-the-counter anti-cramping pills. There was no constant pain of any extremity, and there was no intermittent pain of the upper extremities. There were mild paresthesias and/or dysesthesias and mild numbness of all extremities. Muscle strength testing revealed right grip and right pinch strength to be 4/5, less than normal strength. However, strength was otherwise normal in all extremities. Deep tendon reflexes were absent in the right biceps, bilateral triceps, and bilateral brachioradialis. Deep tendon reflexes were decreased in the left biceps. Light touch/monofilament testing was normal for all extremities. Position sense was decreased in the bilateral upper extremities. Vibration sensation and cold sensation were normal in all extremities. There was no muscle atrophy and there were no trophic changes. The examiner opined that the appellant experienced mild, incomplete paralysis of the radial (musculospiral) and ulnar nerves of the bilateral upper extremities. There was no functional impact. During his Board hearing before the undersigned in June 2018, the appellant reported that his hands will cramp and his fingers will stiffen. He has to then straighten out his hand. He stated that he cannot exercise much because he experiences stiffness and cramping if he tries. The appellant described his neuropathy as an electrical shock throughout his bones in his arms. He can have difficulty reaching when his cramps are bad. When he has an episode, he cannot do anything with his hands. He must massage his hands and fingers and wait for them to loosen. He cannot grasp a pen or eating utensils or press buttons on a phone or keyboard during the cramps. The episodes last about 20 minutes at a time. He indicated that his right upper extremity symptoms bother him more, primarily because he is right-hand dominant and does most things with his right hand. He stated that his symptoms had worsened since his last examination. The appellant was afforded a VA examination in December 2018. The appellant reported numbness and dysesthesias in both upper extremities. There was no pain in any extremity, constant or intermittent. The appellant experienced moderate paresthesias and/or dysesthesias and moderate numbness in all extremities. Muscle strength was normal. Deep tendon reflexes were all normal. Light touch/monofilament testing was normal. Position sense, vibration sensation, and cold sensation were all normal. There was no atrophy. Trophic changes were present in the form of smooth, hairless skin distal to knees bilaterally. The examiner opined that the appellant experienced moderate, incomplete paralysis of the radial nerve in the bilateral upper extremities. There was no functional impact. The appellant was afforded a VA examination in June 2019. The appellant reported that his hands are cramping more since the last examination. He is not taking gabapentin except as needed because Advil works better. There was mild intermittent pain of the bilateral lower extremities. There were moderate paresthesias and/or dysesthesias and moderate numbness affecting all extremities. Notably, however, the appellant experienced sharp, shooting pain which was worse at night. Muscle strength and deep tendon reflexes were all normal. Light touch/monofilament test, position sense, and vibration sense were all normal. There was no atrophy. Trophic changes were present in the form of loss of hair on the lower legs from the knees to feet and shiny, dry, and smooth skin. The examiner opined that the appellant experienced moderate, incomplete paralysis of the radial (musculospiral) nerve in the bilateral upper extremities. Regarding functional impact, it was noted that the appellant can no longer use his hands to perform rapid stacking in an assembly line setting. The examiner indicated that the appellant’s diabetic peripheral neuropathy was essentially unchanged from December 2018, except there was now mild lower extremity pain and increased “cramping” of the upper extremities. The appellant is currently in receipt of an initial 20 percent rating for peripheral neuropathy of the left upper extremity under DC 8514 and an initial 20 percent rating for peripheral neuropathy of the right upper extremity prior to June 20, 2018, and a 30 percent rating thereafter, also under DC 8514. For the reasons that follow, the Board finds that the most probative evidence establishes that entitlement to (a) an initial rating in excess of 20 percent for left upper extremity peripheral neuropathy prior to June 20, 2018, is not warranted; (b) a rating of 30 percent, and no higher, for left upper extremity peripheral neuropathy, effective June 20, 2018, is warranted under DC 8512; (c) an initial rating in excess of 20 percent for right upper extremity peripheral neuropathy prior to February 23, 2016 is not warranted; and (d) a rating of 40 percent, and no higher, for right upper extremity peripheral neuropathy, effective February 23, 2016, is warranted under DC 8512. All the VA examiners indicated that the appellant’s bilateral upper extremity peripheral neuropathy had involvement of the musculospiral (radial) nerve. However, the October 2012 examination also revealed involvement of the median and ulnar nerves bilaterally, and the February 2016 examination revealed involvement of the ulnar nerve bilaterally. While the December 2018 and June 2019 VA examination reports indicate involvement of only the radial nerve bilaterally, the Board observes that the appellant’s upper extremity symptoms have primarily caused functional impairment in the hands and fingers throughout the period on appeal, causing locking and difficulty with gripping and typing. As such, the Board finds that DC 8512, which pertains to paralysis of the lower radicular group, better fits the severity and manifestations of the appellant’s bilateral upper extremity peripheral neuropathy. As DC 8512 provides higher ratings for moderate incomplete paralysis of the major and minor arms than DC 8514, and the same ratings for mild incomplete paralysis of the major and minor arms as DC 8514, this change of diagnostic code is favorable to the appellant. As delineated above, prior to June 20, 2018, the appellant’s peripheral neuropathy of the left upper extremity resulted in mild intermittent numbness and paresthesias/dysesthesias. There was no reduction in muscle strength, reflexes were normal, and there were no trophic changes. Apart from absent deep tendon reflexes in the left brachioradialis and triceps, and decreased reflexes in the left biceps noted during the February 2016 examination, reflexes were normal. Sensation was decreased to for position sense, but normal on vibration, cold, and light touch/monofilament. The Board thus finds that the level of left upper extremity impairment is most analogous to mild incomplete paralysis prior to June 20, 2018. From June 20, 2018, the appellant’s peripheral neuropathy of the left upper extremity resulted in cramping and stiffness of the hand and fingers, numbness, and dysesthesias. There was no reduction in strength or deep tendon reflexes. There were no trophic changes and sensation was normal. The Board thus finds that the level of left upper extremity impairment is most analogous to moderate incomplete paralysis from June 20, 2018. Prior to February 23, 2016, the appellant’s peripheral neuropathy of the right upper extremity resulted in intermittent numbness and tingling. There was no pain, reduction in muscle strength, decreased sensation, trophic changes, atrophy or deep tendon reflexes. The Board thus finds that the level of right upper extremity impairment is most analogous to mild incomplete paralysis prior to February 23, 2016. From February 23, 2016, the appellant’s peripheral neuropathy of the right upper extremity resulted in cramping of the fingers, in addition to numbness and tingling in the upper arm and elbow. Right grip and pinch strength were decreased in 2016, but returned to normal as of December 2018, but there was no atrophy at any point. Deep tendon reflexes were absent in the biceps, triceps, brachioradialis. Sensation was decreased to for position sense, but normal on vibration, cold, and light touch/monofilament. There were no trophic changes. When he has symptomatic episodes, which generally last 20 minutes at a time, he cannot grasp a pen or eating utensil, or press buttons on a phone or keyboard due to cramping. He must massage his hand and wait for it to loosen. The Board thus finds that the level of left upper extremity impairment is most analogous to moderate incomplete paralysis from February 23, 2016. The appellant has not experienced severe incomplete, or complete, paralysis of either upper extremity at any point during the period on appeal. Indeed, no medical professional characterized the appellant’s right upper extremity disability as more than mild prior to February 23, 2016, or more than moderate thereafter. Likewise, no medical professional characterized the appellant’s left upper extremity disability as more than mild prior to June 20, 2018, or more than moderate thereafter. Further, neither the appellant nor his attorney has pointed to any evidence which would support higher ratings for any portion of the period on appeal. 38 C.F.R. § 4.124a, DC 8512. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award an initial rating of 20 percent, and no higher, for peripheral neuropathy of the left upper extremity prior to June 20, 2018, and an initial rating of 30 percent, and no higher, thereafter, under DC 8512, and an initial rating of 20 percent, and no higher, for peripheral neuropathy of the right upper extremity prior to February 23, 2016, and an initial rating of 40 percent, and no higher, thereafter, also under DC 8512. 7. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity prior to June 20, 2018, and in excess of 20 percent thereafter, is denied. 8. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity prior to June 20, 2018, and in excess of 20 percent thereafter, is denied. The Board finds that the most probative evidence establishes that entitlement to initial ratings in excess of 10 percent for right and left upper extremity peripheral neuropathy, ratings in excess of 20 percent thereafter, are not warranted. The appellant’s service-connected peripheral neuropathy of the bilateral lower extremities has been evaluated under Diagnostic Code 8520 for the sciatic nerve. Under these rating criteria, an 80 percent rating is warranted for complete paralysis resulting in the foot dangling and dropping, no possible active movement of muscles below the knee, and weakened or (very rarely) lost flexion of the knee. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. A 10 percent rating is warranted for mild incomplete paralysis. 38 C.F.R. § 4.124a, DC 8520. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The appellant was afforded a VA diabetic neuropathy examination in October 2012. The appellant endorsed symptoms of numbness and occasional tinging, more so in the feet than in the hands. There was no pain or motor involvement. He had not received any treatment. Symptoms were intermittent. Examination revealed mild paresthesias and/or dysesthesias and mild numbness of the bilateral upper and lower extremities. There was no pain in any extremity, constant or intermittent. There was no reduction in muscle strength in any extremity and there was no atrophy. Deep tendon reflexes were all normal. Light touch/monofilament testing revealed decreased sensation of the bilateral feet and toes, but was otherwise normal. Position sense, vibration sensation, and cold sensation were normal for all extremities. There were no trophic changes. The examiner opined that the appellant experienced mild incomplete paralysis of the sciatic and femoral (anterior crural) nerves of the bilateral lower extremities. There was no functional impact. The appellant was afforded a VA examination on February 23, 2016. The appellant reported that he continued to receive diabetic shoes and orthoses from VA. Notably, the appellant also had severe limitations from unrelated bilateral knee arthritis and chronic lumbar spine pain without radiculopathy. The appellant takes over-the-counter anti-cramping pills. He endorsed more consistent numbness in the bilateral feet. There was tingling, but not above the ankles. The appellant attributed his unsteadiness when walking on his back and knee symptoms. At night, there were no feet symptoms, only cramps which occurred primarily in the calves. The appellant uses VA shoes with custom inserts which help, although his chief foot complaint was unrelated painful calluses. Examination revealed intermittent, usually dull, pain of the bilateral lower extremities. There was no constant pain of any extremity, and there was no intermittent pain of the upper extremities. There were mild paresthesias and/or dysesthesias and mild numbness of all extremities. strength was normal in both lower extremities. Deep tendon reflexes were absent in the bilateral ankles. Deep tendon reflexes were decreased in the bilateral knees. Light touch/monofilament testing was normal for all extremities. Position sense was in the bilateral lower extremities. Vibration sensation and cold sensation were normal in all extremities. There was no muscle atrophy and there were no trophic changes. The examiner opined that the appellant experienced mild, incomplete paralysis of the sciatic nerves of the bilateral lower extremities. It was noted that the femoral (anterior crural) nerve was normal bilaterally. There was no functional impact. During his Board hearing before the undersigned in June 2018, the appellant reported that his symptoms of neuropathy affect his balance. He cannot walk barefoot due to pain and requires thick-soled shoes. If his legs hurt, he sits down and massages them. Due to his foot pain, his balance is affected and he cannot take a step back without losing his balance. Falls, or near-falls, happen twice weekly. He stated that his symptoms had worsened since his last examination. The appellant was afforded a VA examination in December 2018. The appellant reported numbness and dysesthesias in both the upper and lower extremities. There was no pain in any extremity, constant or intermittent. The appellant experienced moderate paresthesias and/or dysesthesias and moderate numbness in all extremities. Muscle strength was normal. Deep tendon reflexes were all normal. Light touch/monofilament testing revealed decreased sensation on the bilateral feet and toes, but was otherwise normal. Position sense, vibration sensation, and cold sensation were all normal. There was no atrophy. Trophic changes were present in the form of smooth, hairless skin distal to knees bilaterally. The examiner opined that the appellant experienced moderate, incomplete paralysis of the sciatic nerve in the bilateral lower extremities. There was no functional impact. The appellant was afforded a VA examination in June 2019. The appellant reported that he is not taking gabapentin except as needed because Advil works better. There was mild intermittent pain of the bilateral lower extremities. There were moderate paresthesias and/or dysesthesias and moderate numbness affecting all extremities. Notably, however, the appellant experienced sharp, shooting pain which was worse at night. Muscle strength and deep tendon reflexes were all normal. Light touch/monofilament test, position sense, and vibration sense were all normal. There was no atrophy. Trophic changes were present in the form of loss of hair on the lower legs from the knees to feet and shiny, dry, and smooth skin. The examiner opined that the appellant experienced moderate, incomplete paralysis of the sciatic nerve in the bilateral lower extremities. Regarding functional impact, it was noted that the appellant can no longer stand for more than two to three hours without an increase in numbness and tingling. The examiner indicated that the appellant’s diabetic peripheral neuropathy was essentially unchanged from December 2018, except there was now mild lower extremity pain. Notably, a June 2019 podiatry note indicated that the appellant endorsed sharp, shooting, tingling pain in the feet, worse sometimes at night. Applying the facts to the criteria set forth above, the Board finds that the preponderance of the evidence is against the award of initial ratings in excess of 10 percent for right or left lower extremity peripheral neuropathy prior to June 20, 2018, or ratings in excess of 20 percent thereafter. Prior to June 20, 2018, the appellant’s bilateral lower extremity peripheral neuropathy was manifested by intermittent numbness and tingling. There was no pain, reduction of muscle strength, atrophy, decreased deep tendon reflex, or trophic changes. Sensation was decreased for light touch/monofilament in the bilateral feet and toes, but otherwise normal. The Board thus finds that the level of bilateral lower extremity impairment is most analogous to mild incomplete paralysis prior to June 20, 2018. Since June 20, 2018, the appellant’s bilateral lower extremity peripheral neuropathy has been manifested by numbness, tingling, and intermittent pain. There was no reduction of muscle strength, atrophy, or decrease deep tendon reflex. There were trophic changes in the form of loss of hair on the lower legs with shiny, dry, and smooth skin bilaterally. Sensation was decreased for light touch/monofilament in the bilateral feet and toes, but otherwise normal. The Board thus finds that the level of bilateral lower extremity impairment is most analogous to moderate incomplete paralysis from June 20, 2018. The Board notes that, while the October 2012 VA examiner indicated that the appellant experienced mild incomplete paralysis of both the sciatic and femoral nerves bilaterally, the February 2016 examiner clarified that there was, in fact, no involvement of the femoral nerve. No other medical professional has indicated that there was involvement of the femoral nerve. As such, the Board affords the notation in the October 2012 VA examination report regarding femoral nerve involvement minimal probative weight. In any event, the Board has considered all of the appellant’s neurological symptoms of the lower extremities as attributable to service-connected peripheral neuropathy. Thus, all symptoms and functional impairment have been taken into account when finding that the appellant’s bilateral lower extremity symptomatology was most analogous to mild, incomplete paralysis prior to June 20, 2018, and moderate, incomplete paralysis thereafter. See also Mittleider v. West, 11 Vet. App. 181, 182 (1998). While the appellant attributed his imbalance and risk of falls to his peripheral neuropathy during his June 2018 Board hearing, the February 2016 examiner explained that the appellant experienced severe limitations from bilateral knee arthritis and chronic lumbar spine pain without radiculopathy. During the February 2016 examination, however, the appellant himself attributed his unsteadiness when walking to his back and knee symptoms. The appellant is competent to report symptoms and observations because this requires only personal knowledge as it comes through an individual’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant in this case is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. The Board finds the VA examination reports to be of greater probative weight than the appellant’s lay assertions. The appellant has not experienced severe incomplete, or complete, paralysis of either lower extremity at any point during the period on appeal. Indeed, no medical professional characterized the appellant’s right or left lower extremity disability as more than mild prior to June 20, 2018, or more than moderate thereafter. Further, neither the appellant nor his attorney has pointed to any evidence which would support higher ratings for any portion of the period on appeal. 38 C.F.R. § 4.124a, DC 8520. As the evidence preponderates against the award of initial ratings in excess of 10 percent for bilateral lower extremity peripheral neuropathy prior to June 20, 2018, and ratings in excess of 20 percent thereafter, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to a TDIU prior to June 10, 2019, is remanded. Entitlement to a TDIU, effective June 10, 2019, was awarded in an October 2020 rating decision based upon the combined effects of all of his then-service-connected disabilities: diabetes mellitus type II and associated peripheral neuropathy of the bilateral upper and lower extremities. At issue before the Board is whether the appellant was unable to secure or follow a substantially gainful occupation due to service-connected disabilities prior to June 10, 2019, the current effective date of the award of a TDIU. See AB v. Brown, 6 Vet. App. 35, 38 (1993). However, as discussed above, the Board has awarded entitlement to service connection for nightmare disorder. The Board does not assign a disability rating or effective date in the first instance; rather, the grant of service connection is a full grant of the benefits sought on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). The AOJ will issue a rating decision to assign an initial rating and effective date for nightmare disorder. The Board observes that, even before the award of service connection for nightmare disorder and increased ratings for bilateral upper extremity peripheral neuropathy, the appellant met the schedular criteria for consideration of a TDIU for the entire period on appeal. Indeed, prior to the instant decision, since March 27, 2011, service connection has been in effect for diabetes mellitus type II and peripheral neuropathy of the bilateral upper and lower extremities, associated with diabetes mellitus type II. While his combined evaluation for compensation was 60 percent prior to June 20, 2018, when such increased to 80 percent, all of the appellant’s service-connected disabilities have a common etiology – diabetes mellitus. Thus, the schedular criteria delineated in 38 C.F.R. § 4.16(a) have been met since March 27, 2011. In any event, entitlement to TDIU is inextricably intertwined with the forthcoming AOJ rating of his nightmare disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined); see also Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). (Continued on the next page)   The matter is REMANDED for the following action: After the issuance of a rating decision effectuating the award of service connection for nightmare disorder which assigns and initial rating and effective date, the TDIU issue must be readjudicated. If the benefits sought on appeal remain denied, a Supplemental Statement of the Case must be provided to the appellant and his representative. After an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Behlen, 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.