Citation Nr: 21064543 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 17-02 192 DATE: October 20, 2021 ORDER Entitlement to service connection for a neurological disability of the right upper extremity to include peripheral neuropathy, including as due to herbicide exposure and/or diabetes mellitus, type II, is denied. Entitlement to service connection for a neurological disability of the left upper extremity to include peripheral neuropathy, including as due to herbicide exposure and/or diabetes mellitus, type II, is denied. Entitlement to an initial rating higher than 10 percent for diabetic peripheral neuropathy of the left lower extremity from May 8, 2001 to May 29, 2017 and higher than 20 percent from May 30, 2017 onward is denied. Entitlement to an initial rating higher than 10 percent for diabetic peripheral neuropathy of the right lower extremity is denied. Entitlement to an initial compensable rating for residuals of prostate cancer from June 1, 2015 to June 9, 2020 and higher than 20 percent from June 10, 2020 onward, is denied. Entitlement to an initial rating higher than 20 percent for diabetes mellitus type II is denied. Entitlement to an initial rating higher than 60 percent for ischemic heart disease is denied. REMANDED Entitlement to an initial compensable rating for erectile dysfunction (associated with diabetes mellitus) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A neurological disability of the right upper extremity, was manifested many years after service, may not be presumed to have been incurred therein, is not etiologically related to service, to include as due to herbicide exposure, and is not secondary to the service-connected diabetes mellitus, type II. 2. A neurological disability of the left upper extremity, was manifested many years after service, may not be presumed to have been incurred therein, is not etiologically related to service, to include as due to herbicide exposure, and is not secondary to the service-connected diabetes mellitus, type II. 3. From May 8, 2001 to May 29, 2017 diabetic peripheral neuropathy of the left lower extremity at most is productive of mild incomplete paralysis of the sciatic nerve; from May 30, 2017 to the present diabetic peripheral neuropathy of the left lower extremity at most is productive of moderate incomplete paralysis of the sciatic nerve. 4. For the entire appeal period diabetic peripheral neuropathy of the right lower extremity is productive of mild incomplete paralysis of the sciatic nerve. 5. From June 1, 2015 to June 9, 2020 residuals of prostate cancer were not manifested by voiding dysfunction, urinary tract/kidney infection, and renal dysfunction; from June 10, 2020 onward residuals of prostate cancer have been manifested by daytime voiding interval between 2 and 3 hours and nighttime awakening to void 3 to 4 times. 6. During the appeal period, the Veteran's diabetes mellitus has not required insulin and a regulation of activities. 7. The Veteran's service-connected ischemic heart disease is manifested by a workload of greater than 3 METs, without evidence of acute or chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. A neurological disability of the right upper extremity to include peripheral neuropathy, including as due to Agent Orange exposure, did not manifest during service, may not be presumed to have been incurred therein, is unrelated to service, and is not secondary to a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. A neurological disability of the left upper extremity to include peripheral neuropathy, including as due to Agent Orange exposure, did not manifest during service, may not be presumed to have been incurred therein, is unrelated to service, and is not secondary to a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. From May 8, 2001 to May 29, 2017 the criteria for an initial rating higher than 10 percent and from May 30, 2017 onward the criteria for an initial rating higher than 20 percent for diabetic peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8520. 4. For the entire appeal period the criteria for an initial rating higher than 10 percent for diabetic peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8520. 5. From June 1, 2015 to June 9, 2020 the criteria for an initial compensable rating and from June 10, 2020 onward the criteria for an initial rating higher than 20 percent for residuals of prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.7, 4.115a, 4.115b, Diagnostic Code 7528. 6. For the entire appeal period the criteria for an initial rating higher than 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.119, Diagnostic Code 7913. 7. For the entire appeal period the criteria for an initial rating higher than 60 percent for ischemic heart disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1957 to November 1973. The issues on appeal arise from rating decisions dated in August 2013, October 2016, and June 2017. The issue of entitlement to TDIU has been raised as part of the increased rating claims on appeal and is currently before the Board pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). In a June 2020 rating decision, the Regional Office (RO) granted a 20 percent rating for diabetic peripheral neuropathy of the left lower extremity effective May 30, 2017 and a 20 percent rating for residuals of prostate cancer effective June 10, 2020. Thus, these issues have been characterized as reflected herein. The RO in the June 2020 rating decision also granted service connection for erectile dysfunction with a noncompensable evaluation effective June 26, 2003 and the service-connected diabetes mellitus was recharacterized as diabetes mellitus, type II with erectile dysfunction. However, as further development is necessary to evaluate the Veteran's erectile dysfunction, the issues of diabetes mellitus and erectile dysfunction at this juncture are recharacterized separately as reflected herein. The Board notes that the Veteran's attorney in May 2021 filed a higher level review claim for the increased rating claims on appeal and TDIU. In an accompanying cover letter he stated that the Veteran filed the appeal out of an abundance of caution and expressly appealed the increased rating claims for the heart, diabetes, lower extremities, and TDIU in the Legacy appeal system. In the July 2021 rating decision the Agency of Original Jurisdiction (AOJ) continued the ratings and denials of service connection claims for all issues except the increased rating claim for residuals of prostate cancer and TDIU. On August 18, 2021 VA sent the Veteran a letter stating that his request for further review could not be processed as his VA Form 20-0996, Decision Review Request: Higher-Level Review, was ineligible because he did not sign it and instead it was signed by his attorney who was not his representative at the time the request was signed. The Veteran was asked to resubmit a signed VA Form 20-0996 and his attorney was copied on this letter. To date, the Veteran has not responded and the issues will be addressed in the Legacy system. Issues 1-2: Entitlement to service connection for a neurological disability of the right upper extremity to include peripheral neuropathy, including as due to herbicide exposure and/or diabetes mellitus, type II; entitlement to service connection for a neurological disability of the left upper extremity to include peripheral neuropathy, including as due to herbicide exposure and/or diabetes mellitus, type II. 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. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for nephritis and other organic diseases of the nervous system if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board notes that the RO in the October 2016 rating decision conceded exposure to Agent Orange based on the Veteran's service in Thailand. Certain diseases associated with Agent Orange exposure in service are presumed to be service connected if the disease is manifested to a compensable degree within a specified time period. 38 C.F.R. §§ 3.307, 3.309(e). If a Veteran was exposed to a herbicide agent, including Agent Orange, during active military, naval, or air service, certain diseases shall be service-connected if the requirements of 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6) are met, even though there is no record of such disease during service. Such diseases include early-onset peripheral neuropathy manifested to a degree of 10 percent or more within one year after the last date on which the Veteran was exposed to an herbicide agent during active service. See 38 C.F.R. § 3.307 (a)(6)(ii). The Board notes that effective September 6, 2013, the provisions of 38 C.F.R. § 3.309 were revised to replace the term "acute and subacute" peripheral neuropathy with "early-onset" peripheral neuropathy and removing the note stating that the term "acute and subacute peripheral neuropathy" meant transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. See 78 Fed. Reg. 54,763 (Sept. 6, 2013). It was further noted that the amendment clarifies that VA will not deny presumptive service connection for early-onset peripheral neuropathy solely because the condition persisted for more than two years after the date of the last herbicide exposure. However, it was noted it does not change the requirement that peripheral neuropathy must have become manifest to a degree of 10 percent or more within one year after a veteran's last in-service exposure in order to qualify for the presumption of service connection. Notwithstanding the provisions of 38 U.S.C. § 1116 and 38 C.F.R. § 3.309(e), relating to presumptive service connection due to exposure to Agent Orange, which arose out of the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98- 542, § 5, 98 Stat. 2,725, 2,727-29 (1984), and the Agent Orange Act of 1991, Pub. L. No. 102-4, § 2, 105 Stat. 11 (1991), a claimant is not precluded from establishing service connection with proof of actual causation, that is, proof the exposure to Agent Orange actually causes a disability, which is not included in the list in 38 C.F.R. § 3.309(e). See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disorder. 38 C.F.R. § 3.310(a). Secondary service connection may be found in certain instances in which a service-connected disability aggravates another condition. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The Veteran contends that he has neuropathy in his upper extremities due to service, to include exposure to Agent Orange during service, or secondary to his service-connected diabetes mellitus. See April 2012 statement from the Veteran, September 2016 VA examination for peripheral nerves, and April 2019 statement from the Veteran's attorney. The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of peripheral neuropathy, numbness or tingling. In fact, the Veteran's March 1973 separation examination found his neurologic system, as well as his upper extremities to be clinically normal. After service, medical records in February 1998 show bilateral carpal tunnel syndrome. In December 1998 the records show that the Veteran had arthritis and underwent surgery to include carpal tunnel release. In April 2004 EMG studies show findings that are consistent with bilateral distal median neuropathy, motor and sensory, much worse on the right, and distal ulnar neuropathy on the right. On VA examination for diabetic sensory-motor peripheral neuropathy in September 2016, the examiner opined that the Veteran did not have diabetic peripheral neuropathy in the upper extremities. On VA examination for peripheral nerves in September 2016, the diagnoses were left carpal tunnel syndrome and right cubital tunnel syndrome. The examiner noted that the Veteran claimed that his carpal tunnel syndrome was secondary to his service-connected diabetes mellitus and herbicide exposure. The examiner found that both carpal tunnel and cubital tunnel released surgically and there were no current signs or symptoms. The examiner opined that it is less likely than not that the Veteran's left carpal tunnel syndrome and right cubital tunnel are due to herbicide exposure in service as both are compressive/entrapment neuropathy that did not require diabetes mellitus to occur. Median nerve compression at the wrist and ulnar entrapment at the elbow are not presumed based on herbicide exposure and diabetes mellitus. The examiner noted that surgery would not alleviate signs and symptoms of true diabetic neuropathy. In an opinion in November 2016, the examiner opined that the Veteran's bilateral carpal tunnel syndrome was not aggravated beyond normal progression by his service-connected diabetes mellitus type II based on the rationale that the September 2016 examination does not support the aggravation as both carpal and cubital were released surgically and exam was within normal limits in 2016 and thus no signs of progression were evident. In an addendum opinion in January 2018 the examiner opined that there was no convincing evidence that entrapment neuropathy began in service and explained that entrapment neuropathy does not usually manifest years after being initiated. In a March 2019 VA opinion the examiner opined that there is no objective evidence of a diagnosed upper extremity neurological condition including left carpal tunnel syndrome and right cubital tunnel syndrome in service and no evidence of continued care and treatment. Thus, the examiner opined that it is less likely than not that any diagnosed neurological disability of the upper extremities to include left carpal tunnel syndrome and right cubital tunnel syndrome had its clinical onset during service or is otherwise related to service. In an April 2019 VA opinion the examiner agreed with the previous examiner that there is no relationship given the lack of objective evidence demonstrating related symptoms during service as well as the lack of likely exposures during service. The examiner noted that the etiology of both conditions can be repetitive tasks such as typing or bending, however in the Veteran's case the precise etiology is unknown. In June 2019 the Veteran's attorney contended that the March 2019 and April 2019 VA opinions were based on an inaccurate premise as the Veteran was treated for the condition on multiple occasions and it became so severe that he needed surgery in 1998. On the March 1973 separation examination the Veteran noted that he experienced arthritis in his thumbs and was self-treating. The attorney stated that it is now clear that the symptoms the Veteran was experiencing were later diagnosed as cubital tunnel and carpal tunnel syndrome. The examiner noted that the Veteran is competent to report symptoms and continuously has complained of numbness and pain in his hands. In a VA opinion in January 2020, the examiner opined that it is less likely than not that the Veteran has a neurological disability of the upper extremities to include peripheral neuropathy that is related to service. The examiner acknowledged that the Veteran during service had arthritis of the left thumb and in April 2004 EMG studies show bilateral distal median neuropathy motor and sensory much worse on the right and distal ulnar neuropathy on the right. The examiner explained that the bilateral median nerve neuropathy shown on the EMG was consistent with carpal tunnel syndrome and is a separate condition from the complaints of bilateral thumb pain during service. The examiner stated that medical literature supports carpal tunnel syndrome as a median nerve compression in the wrist and it is not related to the left thumb laceration during service in 1963, the probable left thumb posttraumatic arthritis on x-ray in 1967, and the complaint of arthritis to both thumbs noted in 1973. The examiner further explained that the right distal ulnar neuropathy on EMG was consistent with a right cubital tunnel syndrome, which the medical community supports as a compression of the ulna nerve in the elbow, which is separate and unrelated to the left thumb laceration in 1963, the probable left thumb posttraumatic arthritis on x-ray in 1967, and the complaint of arthritis to both thumbs noted in 1973. The Board finds the VA examinations and opinions including in January 2016, September 2016, November 2016, and January 2020 to be probative as to whether the Veteran's neurological disabilities were caused by service, or presumed to have been incurred therein, or secondary to his service-connected diabetes mellitus type II as they were based on medical principles and applied to the facts of the case. Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008). The examiners considered the nature of the Veteran's bilateral upper extremity neurological disability in proffering the opinions. The opinions are uncontroverted by the other competent evidence of record. As a lay person, the Veteran is competent to report symptoms pertaining to his upper extremities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, the etiology of the bilateral upper extremity neurological disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). The Veteran's bilateral upper extremity neurological disability is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating such disorder. Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. As the lay evidence is not competent, the matter of whether it is credible is not reached. Accordingly, because the preponderance of the evidence is against the claims of service connection for a neurological disability of the right upper extremity to include peripheral neuropathy, including as due to herbicide exposure and/or diabetes mellitus, type II, and a neurological disability of the left upper extremity to include peripheral neuropathy, including as due to herbicide exposure and/or diabetes mellitus, type II, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Claims A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Hart v. Mansfield, 21 Vet. App. 505 (2007). Issues 3-4: Entitlement to an initial rating higher than 10 percent for diabetic peripheral neuropathy of the left lower extremity from May 8, 2001 to May 29, 2017 and higher than 20 percent from May 30, 2017; and, entitlement to an initial rating higher than 10 percent for diabetic peripheral neuropathy of the right lower extremity. The Veteran's peripheral neuropathy of the lower extremities has been rated under Diagnostic Code 8520. Under Diagnostic Code 8520, complete paralysis of the sciatic nerve is demonstrated when the foot dangles and drops, when there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. This is evaluated as 80 percent disabling. Severe incomplete paralysis, with marked muscular atrophy, is evaluated as 60 percent disabling. Moderately severe paralysis is evaluated as 40 percent disabling. Moderate paralysis merits a 20 percent evaluation, and mild paralysis warrants a 10 percent rating. 38 C.F.R. § 4.124a Diagnostic Code 8520. The term "incomplete paralysis," with this and other peripheral nerve injuries, 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 should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. The Board observes that the words "mild," "moderate," and "severe" as used in the various codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. By way of history, in a rating decision in October 2016 the RO granted service connection for the lower extremities effective May 8, 2001 with a 10 percent rating for each lower extremity. As discussed above, in a June 2020 rating decision, the RO granted a 20 percent rating for diabetic peripheral neuropathy of the left lower extremity effective May 30, 2017. For the entire appeal period the evidence does not more nearly approximate the criteria for an initial rating higher than 10 percent for diabetic peripheral neuropathy of the right lower extremity, from May 8, 2001 to May 29, 2017 the evidence does not more nearly approximate the criteria for an initial rating higher than 10 percent for diabetic peripheral neuropathy of the left lower extremity, and from May 30, 2017 to the present the evidence does not more nearly approximate the criteria for an initial rating higher than 20 percent for the following reasons. On VA examination for diabetic sensory-motor peripheral neuropathy in September 2016, the examiner opined that the Veteran had diabetic sensory-motor peripheral neuropathy in the lower extremities. Physical examination shows that the Veteran had mild paresthesias and/or dysesthesias and mild numbness in the lower extremities. Knee extension, knee flexion, ankle plantar flexion, ankle dorsiflexion had normal muscle strength. Reflexes in the lower extremities were normal. Light touch was normal in the knees/thighs and decreased in the ankles, lower legs, feet, and toes. Position sense was normal in the lower extremities. Cold sensation was decreased in the lower extremities. There was no muscle atrophy. The examiner opined that the Veteran did have diabetic peripheral neuropathy in the lower extremities manifested by mild incomplete paralysis affecting the sciatic nerve in each lower extremity. On VA examination for diabetic peripheral neuropathy in January 2020, the Veteran had moderate constant pain in the left lower extremity. He mild intermittent pain in the right lower extremity. He had mild paresthesias and/or dysthesias in both lower extremities, mild numbness in the right lower extremity, and moderate numbness in the left lower extremity. There was no movement against resistance in knee extension and flexion in the left lower extremity. Ankle plantar flexion and dorsiflexion in the left lower extremity was less than normal. Deep tendon reflexes were normal and light touch testing was decreased in the ankles/lower legs and foot/toes in both lower extremities. Position sense and vibration was decreased in both lower extremities. There was no muscle atrophy. The examiner opined that the Veteran had mild incomplete paralysis of the sciatic nerve in the right lower extremity and moderate incomplete paralysis in the sciatic nerve of the left lower extremity. Although VA treatment records in July 2011 show that the Veteran has a history of no feeling on the bottom of his feet, this evidence is outweighed by the VA examinations discussed above whereby the examiners thoroughly evaluated the Veteran's neuropathy of the bilateral lower extremity. To the extent that the Veteran may believe that he is entitled to higher ratings, the Board finds the objective medical findings by skilled professionals are more persuasive which, as discussed above, do not support higher ratings. Thus, the preponderance of the evidence is against the claims for an initial rating higher than 10 percent for diabetic peripheral neuropathy of the right lower extremity, higher than 10 percent for diabetic peripheral neuropathy of the left lower extremity from May 8, 2001 to May 29, 2017 and higher than 20 percent from May 30, 2017 to the present, and the benefit of the doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Issue 5: Entitlement to an initial rating higher 10 percent for residuals of prostate cancer from June 1, 2015 to June 10, 2020 and higher than 20 percent from June 9, 2020 onward. The Veteran's service-connected residuals of prostate cancer have been rated under Diagnostic Code 7528 for malignant neoplasms of the genitourinary system. Diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. The rating schedule provides descriptions of various levels of disability in each of these symptom areas. Where diagnostic codes refer the decision maker to these specific areas of dysfunction, only the predominant area of dysfunction shall be considered for rating purposes. Since the areas of dysfunction do not cover all symptoms resulting from genitourinary diseases, specific diagnoses may include a description of symptoms assigned to that diagnosis. See 38 C.F.R. § 4.115a. Malignant neoplasms of the genitourinary system are to be rated 100 percent during active malignancy or antineoplastic chemotherapy. Six months following completion of such treatment, residual disability is to be determined by a mandatory VA examination conducted at that time. If there has been no recurrence or metastasis, the residuals are to be rated as voiding dysfunction or renal dysfunction, whichever is predominant. Changes in evaluation are to be done in accordance with the provisions of 38 C.F.R. § 3.105(e). 38 C.F.R. § 4.115b, Diagnostic Code 7528. Voiding dysfunction is rated based on urine leakage, frequency or obstructed voiding. Urinary leakage which requires the wearing of absorbent materials, which must be changed less than 2 times per day warrants a 20 percent rating. Urinary leakage which requires the use of absorbent materials which must be changed 2 to 4 times a day warrants a 40 percent rating. Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence warrants a maximum rating of 60 percent when it requires the use of an appliance or the wearing of absorbent materials that must be changed more than 4 times per day. 38 C.F.R. § 4.115a. Daytime voiding interval between 2 and 3 hours or awakening to void 2 times per night warrants a 10 percent rating. Daytime voiding interval between one and two hours or awakening to void 3 to 4 times per night warrants a 20 percent rating. Daytime voiding interval of less than one hour, or awakening to void 5 or more times per night warrants a 40 percent rating. 38 C.F.R. § 4.115a. Obstructed voiding higher than 10 percent is for urinary retention requiring intermittent or continuous catherization warranting a 30 percent rating. By way of history, in a June 2017 rating decision the RO granted service connection for residuals of prostate cancer and assigned a 100 percent rating effective October 31, 2014 and a noncompensable evaluation effective June 1, 2015. As discussed above, in a June 2020 rating decision the RO granted a 20 percent rating for residuals of prostate cancer effective June 10, 2020. The evidence does not more nearly approximate the criteria from an initial compensable rating from June 1, 2015 to June 9, 2020 and an initial rating higher than 20 percent from June 10, 2020 onward for residuals of prostate cancer for the following reasons. On VA examination in September 2016 for prostate cancer, the examiner noted that the disease was in remission. The examination shows that the Veteran did not have voiding dysfunction, urinary tract/kidney infection, and renal dysfunction. On VA examination for prostate cancer in June 2020, the examiner noted that the Veteran's cancer was in remission. The Veteran had voiding dysfunction but did not have urine leakage and did not require the use of an appliance. The Veteran had daytime voiding interval between 2 and 3 hours and nighttime awakening to void 3 to 4 times. The Veteran had symptoms of obstructed voiding that were not markedly severe but included hesitancy, slow stream, weak stream, and decreased force of stream. The Veteran did not have a history of recurrent symptomatic urinary tract or kidney infections, renal dysfunction or any other residual conditions and/or complications due to prostate cancer. The above findings are uncontroverted by the other competent evidence of record. All potentially applicable Diagnostic Codes have been considered in deciding the Veteran's claims for higher initial ratings. Thus, the preponderance of the evidence is against an initial compensable rating from June 1, 2015 to June 9, 2020 and higher than 20 percent from June 10, 2020 onward for residuals of prostate cancer, and the benefit of the doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Issue 6: Entitlement to an initial rating higher than 20 percent for diabetes mellitus type II. The Veteran's service-connected diabetes mellitus is rated under Diagnostic Code 7913 of 38 C.F.R. § 4.119. The Veteran currently is rated at 20 percent, which, under Diagnostic Code 7913, is awarded where the disorder requires insulin and a restricted diet, or requires an oral hypoglycemic agent and a restricted diet. A 40 percent rating is awarded when diabetes mellitus requires insulin, a restricted diet, and regulation of activities. A 60 percent rating is for application when the disorder requires insulin, a 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 maximum 100 percent rating is warranted where the disorder requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational 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. 38 C.F.R. § 4.119, Diagnostic Code 7913. Effective December 10, 2017, VA revised the portion of the Rating Schedule that addresses endocrine conditions and disorders of the endocrine system. See 82 Fed. Reg. 50802 - 50807 (November 2, 2017) (codified at 38 C.F.R. pt. 4 ). The effect of this action is to ensure that VA's Schedule for Rating Disabilities uses current medical terminology and to provide detailed and updated criteria for evaluation of endocrine disorders. Id. at 50802. Under Diagnostic Code 7913, the above revision adds the phrase "one or more daily injection of" before the word "insulin." The revisions are clarifying in nature. Thus, under the revised criteria, a rating of 10 percent is assigned for diabetes mellitus that is managed by a restricted diet only. A rating of 20 percent is assigned for diabetes mellitus requiring one or more daily injection of insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. The next higher rating of 40 percent is assigned for diabetes mellitus requiring one or more daily injection of insulin, restricted diet, and regulation of activities. A 60 percent disability rating is warranted for diabetes mellitus requiring 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 maximum 100 percent rating is warranted if diabetes mellitus requires more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations a year or weekly visits to a diabetic provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119 (December 10, 2017). Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under DC 7913). Noncompensable complications are considered part of the diabetic process under DC 7913. Note (2) to Diagnostic Code 7913 provides that, when diabetes mellitus has been conclusively diagnosed, the adjudicator is not to request a glucose tolerance test solely for rating purposes. In addition, the Federal Circuit Court has held that the "insulin" treatment requirement of Diagnostic Code 7913 is not satisfied by use of a different treatment, even one that causes the body to produce insulin. Middleton v. Shinseki, 727 F.3d 1172, 1176 (Fed. Cir. 2013). In other words, insulin cannot be substituted by the administration of another medical compound or pharmaceutical agent. Id. Moreover, "[r]equiring insulin" means that a Veteran must actually be administered insulin. Id. at 1177. Medical evidence is required to establish "regulation of activities," namely, avoidance of strenuous occupational and recreational activities, for a 40 percent rating under Diagnostic Code 7913. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). Because of the successive nature of the rating criteria for diabetes, e.g., the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the three criteria listed in the 40 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Stated another way, if a component is not met at any one level, a veteran can only be rated at the level that did not require the missing component. Id. By way of history, the RO in an October 2016 rating decision granted service connection for diabetes mellitus, type II associated with herbicide exposure and a assigned a 20 percent rating effective May 8, 2001. The evidence does not more nearly approximate the criteria for an initial rating higher than 20 percent as the weight of the evidence does not show that the Veteran requires insulin, a restricted diet, and regulation of activities. On VA diabetes examination in September 2016, the examiner noted that the Veteran's diabetes is managed by a restricted diet and prescribed oral hypoglycemic agent. The Veteran did not require regulation of activities as part of medical management of diabetes mellitus. The Veteran visited his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than twice per month. The Veteran did not have any episodes of ketoacidosis or hypoglycemic reactions that required hospitalization over the past 12 months. He did not have progressive unintentional weight loss and loss of strength attributable to diabetes mellitus. His complications included diabetic peripheral neuropathy. On VA diabetes examination in January 2020, the examiner noted that the Veteran was treated with prescribed oral hypoglycemic agents and did not require regulation of activities as part of medical management of his diabetes. He did not have hospitalizations for episodes of ketoacidosis or hypoglycemic reactions in the last 12 months and did not have loss of strength and weight. Diabetic complications included diabetic peripheral neuropathy. Additional treatment records are consistent with the findings discussed above. Under Note (1) to 38 C.F.R. § 4.119, Diagnostic Code 7913, compensable complications of diabetes are rated separately unless they are part of the criteria used to support a 100 percent evaluation. In this regard, the evidence discussed above shows that complications of diabetes mellitus include diabetic peripheral neuropathy, which have been evaluated separately as presented above. As discussed above, the Veteran in a June 2020 rating decision was granted a noncompensable rating for erectile dysfunction associated with diabetes mellitus. However, as the Veteran has not been afforded a VA examination for the male reproductive system, the matter is being remanded below. The Board has also considered the Veteran's statements that describe symptomatology associated with his service-connected diabetes mellitus. The Veteran is certainly competent to describe his observations and the Board finds that his statements are credible. To the extent that the Veteran may believe that he is entitled to higher ratings for his disability, the Board finds the medical findings by skilled professionals are more persuasive which, as indicated above, during the entire appeal period do not support a rating higher than 20 percent for diabetes mellitus. Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against an evaluation in excess of 20 percent for the Veteran's service-connected diabetes mellitus, there is no reasonable doubt to be resolved in this case, and the doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102 Issue 7: Entitlement to an initial rating higher than 60 percent for ischemic heart disease. The Veteran's service-connected ischemic heart disease is rated under Diagnostic Code 7005 for arteriosclerotic heart disease (coronary artery disease), which provides a 10 percent rating 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 assigned when a workload of 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted when there is more than one episode of congestive heart failure in the past year, or a workload of 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or there is 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 results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). By way of history, the RO in an October 2016 rating decision granted service connection for ischemic heart disease associated with herbicide exposure and assigned a 60 percent rating effective August 31, 2010. The evidence does not more nearly approximate the criteria for an initial rating higher than 60 percent under Diagnostic Code 7005. The Board recognizes that the on VA ischemic disease Disability Benefits Questionnaire (DBQ) in April 2012, the Veteran had dyspnea, fatigue, and angina. METs level was 1-3. However, this appears to be an isolated finding and outweighed by the following evidence. On VA heart examination in September 2016, the examiner determined that the Veteran did not have congestive heart failure, cardiac arrhythmia, a heart valve condition, an infectious heart condition, and pericardial adhesions. He had percutaneous coronary intervention and stents in December 2011, May 2014, and 2009. He had a coronary artery bypass in 2008. Interview based METs test show that the Veteran had fatigue and METS greater than 3 to 5. On VA heart examination in January 2020, the examiner determined that the Veteran did not have congestive heart failure, a heart valve condition, an infectious heart condition, or pericardial adhesions. Physical examination shows rhythm was regular and heart sounds were normal. There was no evidence of cardiac hypertrophy or cardiac dilatation. Interview-based METs test showed that the Veteran had METS greater than 5-7. Private medical records including in March 2011 show that ejection fraction was greater than or equal to 55 percent, in December 2010 the records show that the ejection fraction was 65 percent. The Board notes that the Veteran is competent to describe his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, however, the Board finds that the objective medical findings by skilled professionals are more persuasive, which, as indicated above, do not support higher ratings. The Board cannot employ a Diagnostic Code other than 7005 to rate the Veteran's ischemic heart disease/coronary artery disease. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (when a condition is specifically listed in the rating schedule, it may not be rated by analogy and should be rated under the diagnostic code that specifically pertains to it). The Veteran is in receipt of a separate rating for residual surgical chest scarring that is not currently in appellate status. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the Veteran's claim for an initial rating higher than 60 percent for ischemic heart disease must be denied. See 38 U.S.C. § 5107(b). REASONS FOR REMAND Issues 8-9: Entitlement to an initial compensable rating for erectile dysfunction and TDIU. The January 2020 VA diabetes mellitus examination report shows that the Veteran did not have erectile dysfunction due to diabetes mellitus and thus a VA examination of the male reproductive system was not ordered. However, in an addendum to the June 2020 prostate examination the examiner opined that erectile dysfunction was as likely as not related to the Veteran's service-connected diabetes mellitus and as discussed above, service connection for erectile dysfunction was subsequently granted and a noncompensable rating was assigned. However, the Veteran has not been provided a VA examination of the male reproductive system and thus the issue is being remanded for such an examination to be afforded to the Veteran. The issue of entitlement to TDIU is intertwined with the issue of entitlement to an initial compensable rating for erectile dysfunction being remanded herein. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Further, the Veteran's TDIU claim received in May 2017 shows that he last worked for Walmart in 2001 as a truck driver. The Veteran indicated that he earned an Associate Degree. His employment history consisted of truck driving. The Veteran stated that the service-connected disabilities that prevented him from securing or following a substantially gainful occupation included residuals of toe fracture, left ankle disability, low back disability, hearing loss, heart disorder, scar on scalp, diabetes mellitus, and peripheral neuropathy of the lower extremities. There is conflicting evidence as to entitlement to TDIU. In a June 2020 vocational assessment, the examiner, a vocational expert, noted that she reviewed 9,182 pages in the claims filed and conducted a telephone interview with the Veteran in May 2020. The Veteran described having symptoms and limitations of his service-connected residuals to include fracture of the second right toe, left fifth toe, and right first toe; bilateral lower extremity diabetic peripheral neuropathy; and lumbosacral strain since at least May 2001 to the present. He also described symptoms and limitations of his service-connected left knee and left ankle disabilities since at least September 2001, as well as the limitations from his service-connected ischemic heart disease since at least August 2010 to the present. The symptoms include the inability to sit or stand for more than 15 minutes at a time, walk more than 25 feet, inability to kneel, squat or climb, need to elevate the left ankle and knee daily, and impaired sleep due to pain from the orthopedic service-connected disabilities. Since at least May 2001, the Veteran's service-connected bilateral lower extremity peripheral neuropathy, toes, and low back result in constant pain, weakness, and numbness in the lower extremities. He experienced shortness of breath due to his heart condition that further contributed to his walking limitations since August 2010. The examiner explained that the Veteran last worked briefly in 2001 as a semi-truck driver. His service-connected disabilities caused him significant pain and he ultimately left his position after briefly working there in 2001 due to back pain and bilateral peripheral neuropathy. The Veteran briefly worked for Walmart from 2000 to 2001 assembling trays in the seafood department and in the meat department. Prior to that, the Veteran worked as a truck driver from 1996 to 1999. The examiner opined that it is more likely than not that the Veteran has been unable to secure and follow substantially gainful employment as a s result of his service-connected residuals, fracture of the second right toe, left fifth toe, and right first toe; bilateral lower extremity diabetic peripheral neuropathy; and lumbosacral strain since at least May 2001 to rhe present; from September 2001 to the present was unable to follow substantially gainful employment due to symptoms of his service-connected left knee and left ankle disabilities; and from August 2010 to the present from symptoms pertaining to his service-connected ischemic heart disease. The examiner noted that the Veteran has been using a walker to help with instability of his left knee and has dizziness secondary to his heart condition. The examiner cited medical records that reflect the symptoms reported above including records dated in December 2000, July 2005, September 2008, August 2011 VA examination, February 2012 VA knee examination, April 2012 DBQ heart examination, January 2020 back examination, and January 2020 diabetic peripheral neuropathy examination. Conversely, unfavorable evidence regarding entitlement to TDIU includes multiple VA examinations of record. On VA examinations in September 2016 the examiner opined that the Veteran's heart disorder, diabetes mellitus, and diabetic peripheral neuropathy of the lower extremities did not impact his ability to work. In an opinion in February 2020 the examiner opined that the Veteran could perform light work as a result of diabetic sensory motor peripheral neuropathy, back disability, and ischemic heart disorder. The examiner also opined that the Veteran could perform medium work as a result of his ankle disability. The Board acknowledges that although a combined-effects examination is not required in every case, in the instant case the Veteran is service connected for ischemic heart disease; left knee total replacement; diabetes mellitus, type II; erectile dysfunction; diabetic peripheral neuropathy of the left lower extremity; residuals of prostate cancer; diabetic peripheral neuropathy of the right lower extremity; degenerative joint disease of the left ankle; lumbosacral strain; residuals of second right toe fracture; bilateral hearing loss; scalp scar; residuals of left fifth toe fracture; residuals of first right toe fracture; and chest scarring. Thus, a remand is warranted for an examination to address whether the aggregate-effect of all of the Veteran's service-connected disabilities precluded substantially gainful employment to warrant entitlement to TDIU. This would be helpful to the Board when forming our ultimate opinion concerning employability. See 38 U.S.C. § 7104 (d)(1); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 383 (2013). On remand, the Veteran should be asked to provide an accounting of his employment history. By this remand the Board makes no determination, expressed or implied, as to the credibility of any statements on file. The matters are REMANDED for the following action: 1. Obtain an accounting of the Veteran's employment history, including asking the Veteran and his attorney to submit the date he became unable to secure or follow gainful employment due to his service-connected disabilities. 2. Schedule the Veteran for a VA examination to determine the severity of his service-connected erectile dysfunction. The claims file must be made available to the examiner for review in conjunction with conducting the examination of the Veteran. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the disability under the rating criteria to include whether there is deformity. 3. Obtain a VA opinion regarding the Veteran's employability from an appropriate VA examiner, if necessary, the Veteran should be afforded a VA examination. After reviewing the claims folder the examiner is asked to do the following: Address the aggregate effect of all the Veteran's service-connected disabilities on his ability to have substantially gainful employment. The examiner is advised that the Veteran is service connected for the following disabilities: ischemic heart disease; left knee total replacement; diabetes mellitus, type II; erectile dysfunction; diabetic peripheral neuropathy of the left lower extremity; residuals of prostate cancer; diabetic peripheral neuropathy of the right lower extremity; degenerative joint disease of the left ankle; lumbosacral strain; residuals of second right toe fracture; bilateral hearing loss; scalp scar; residuals of left fifth toe fracture; residuals of first right toe fracture; and chest scarring. For all opinions rendered, the examiner should explain the rationale. If the examiner is unable to provide an opinion, he or she should explain why. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mac, 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.