Citation Nr: 21064943 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 16-19 209 DATE: October 22, 2021 ORDER Entitlement to service connection for a left knee disability to include as secondary to multiple myeloma is denied. Entitlement to an initial increased rating of 50 percent, and no higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to restoration of a 20 percent evaluation for peripheral neuropathy, left upper extremity, to include consideration of a yet higher rating, is denied. Entitlement to restoration of a 20 percent disability evaluation for peripheral neuropathy, right upper extremity, to include consideration of a yet higher rating, is denied. FINDINGS OF FACT 1. The Veteran's left knee disability did not have its onset during active duty and was not shown to be related to military service or any service-connected disability. 2. Throughout the period on appeal, the Veteran's PTSD was manifested by symptoms which most closely approximated occupational and social impairment with reduced reliability and productivity. 3. The evidence of record reflects improvement in the Veteran's ability to function in the ordinary conditions of life and work with regard to his peripheral neuropathy, left upper extremity. 4. The evidence of record reflects improvement in the Veteran's ability to function in the ordinary conditions of life and work with regard to his peripheral neuropathy, right upper extremity. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for an initial evaluation of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.130, Diagnostic Code 9411. 3. The reduction from a 20 percent rating to a 10 percent rating for the Veteran's peripheral neuropathy, left upper extremity, effective August 4, 2017, was proper. 38 U.S.C. §§ 1155, 5107, 5112; 38 C.F.R. §§ 3.105(e), 3.344, 4.124A, Diagnostic Code 8515. 4. The reduction from a 20 percent rating to a 10 percent rating for the Veteran's peripheral neuropathy, right upper extremity, effective August 4, 2017, was proper. 38 U.S.C. §§ 1155, 5107, 5112; 38 C.F.R. §§ 3.105(e), 3.344, 4.124A, Diagnostic Code 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1968 to May 1970. The Veteran is the recipient of a Combat Infantry Badge and a Bronze Star Medal among other awards. The Veteran died in December 2020. The Appellant is his surviving spouse. She requested and was granted status as a substituted appellant for purposes of pursuing the Veteran's claims to conclusion. 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2014, October 2017, and July 2019 rating decisions by Agency of Original Jurisdiction (AOJ) of the United States Department of Veterans Affairs (VA). The Veteran testified at an October 2019 videoconference hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. During the pendency of this appeal, in an October 2020 rating decision, service connection for vertebral fracture, osteoarthritis right knee, radiculopathy of the left lower extremity, and radiculopathy of the right lower extremity was granted. These actions constitute full grants of the benefits sought and these issues are no longer on appeal. The issues of entitlement to earlier effective dates for the grants of service connection for vertebral fracture and osteoarthritis of the right knee and increased evaluations for peripheral neuropathy of the left and right lower extremities were improperly included on the supplemental statement of the case issued in October 2020. A review of the file reveals no Notice of Disagreement was filed in response to the October 2020 rating decision. Duty to Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances...we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...."). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38U.S.C. §§1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38C.F.R. §3.303(d). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38C.F.R. §3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38C.F.R. §3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38U.S.C. §5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. The Appellant asserts the Veteran had a left knee disability that was related to his time in service, or was related to his service-connected multiple myeloma. The Veteran's service treatment records (STRs) are negative for treatment for complaints and/or a diagnosis of a left knee injury or disability. The Veteran underwent a VA knee examination in February 2013. The VA examiner determined that it was less likely than not that the Veteran's knee disability was related to service, the opinion did not consider whether or not any left knee disability was related to his service-connected multiple myeloma. In its January 2020 remand, the Board directed that a VA examination should be scheduled and that an opinion should be obtained as to the nature and etiology of the Veteran's left knee disability, to include the theory of service connection for the left knee on a secondary basis to his service-connected multiple myeloma. In September 2020 the Veteran underwent a VA knee examination. The VA examiner noted the Veteran's diagnosis of left knee tendonitis. The VA examiner determined that it was less likely than not that the Veteran's claimed left knee disability was related to service. The VA examiner noted that the Veteran's left knee issues started in 2002 when he went to the clinic for what was diagnosed as left knee tendonitis. He received steroid shots and physical therapy. The VA examiner noted that the Veteran's entrance and separation physical examinations note no knee issues were present. Therefore, the VA examiner determined that it is likely the left knee issues started after service. The VA examiner also determined that it is less likely than not that the Veteran's left knee disability is due to or the result of his service-connected multiple myeloma. The VA examiner stated that the Veteran's diagnosis is left knee tendonitis which is usually due to an acute injury or strain on the tendon. Multiple myeloma affects the bones. After a careful review of the evidence of record, the Board finds that service connection for a left knee disability must be denied on both a direct and secondary basis. The Board finds there is no competent evidence of record which links the Veteran's left knee tendonitis to his active duty service. The medical evidence of record first documents a diagnosis of a left knee disorder in 2002, which is 32 years after the Veteran's discharge from service. Although the Veteran and the Appellant have expressed their belief in a connection between his left knee tendonitis and his service-connected multiple myeloma, they lack the knowledge and training required to render a nexus opinion on a cause and effect relationship unobservable to a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Veteran and Appellant have simply asserted their opinion, without a clear rationale or support; no probative value is given their statements beyond their worth as physical observations. No medical professional has supported the Veteran's position. The Board notes that the award of service connection for the right knee arthritis, a bone condition, was supported by the medical evidence due to the difference in diagnosis. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for a left knee tendonitis, claimed as a left knee disability, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Increased Ratings Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 - 127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). PTSD Pursuant to 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders ("General Rating Formula"). A 30 percent evaluation is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 426, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the General Rating Formula are also associated with objectively observable symptomatology, and the plain language of the regulation makes it clear that a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency and duration. Vazquez-Claudio, 713 F.3d at 118. The Veteran underwent an initial PTSD examination in September 2014. The VA examiner diagnosed the Veteran with PTSD and summarized his occupational and social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran reported that he has been married three times, most recently in April 2014. He stated that he did not have many close buddies in the Army because he felt it did not pay to bond too closely with those you could lose in a heartbeat. He bonded more with those in his unit and squad. He worked for General Motors for 12 years, worked in construction and then for the fire service where he was a firefighter until his retirement in 2005. He was a private contractor teaching fire service courses until 2008 when he was recruited by Mayor and became fire chief, retiring in 2012. The Veteran reported that he realized he had anger issues during the dissolution of his first marriage. He felt that to resolve a problem, violence was the quickest and easiest way. He contemplated doing harm to those he felt were responsible for his problems. The VA examiner noted symptoms including recurrent intrusive memories of traumatic events, recurrent distressing dreams, intense or prolonged psychological distress and marked physiological reactions to internal or external cues that symbolize or represent an aspect of traumatic events. The Veteran reported avoidance or efforts to avoid distressing memories, feelings of detachment from others, persistent inability to experience positive emotions, hypervigilance, problems with concentration, depressed mood, anxiety, and suspiciousness. The VA examiner noted the Veteran was casually dressed with normal grooming and hygiene. The Veteran was calm and cooperative; no unusual behaviors were evidenced, speech was within normal limits, mood was mildly frustrating with mood congruent affect. Thoughts were goal-directed and logical, no suicidal or homicidal ideation were endorsed, no signs of delusions or hallucinations were present. He was oriented in all spheres, memory and concentration were intact and insight and judgment were good. At his hearing, the Veteran testified that he was not taking medication for PTSD. He testified that PTSD was not something that was talked about when he first got out of service, and that he didn't quite understand his behavior. He testified that his anger issues affected his marriages and impacted other relationships. He preferred to be alone when he first came home from the military and that he functions better when doing things on an individual basis. He testified that he was currently attending group therapy. He testified that he experienced flashbacks, and that he avoided groups with the exception of his group therapy. In October 2020, the Veteran submitted a letter from his group therapy counselor, CER. CER stated that the Veteran had been attending weekly counseling groups through the Memphis Vet Center "consistently since February 2017 (originally April 2011) to address his issues with PTSD." CER stated the Veteran had issues with anger, anxiety, guilt, hypervigilance, avoidance, sleep problems, bad dreams/nightmares, health, and relationships. The Veteran reported that he slept about 3 to 5 hours a night with 2 to 3 awakenings per night and experienced bac dreams/nightmares 1 to 2 times per month. He continued to avoid and be triggered by crowds, small spaces, bad news, people wearing masks, fireworks, helicopters, low flying aircraft, car accidents, gun fire, war movies and television news. The Board finds that the evidence is reflective of, at most, a 50 percent disability rating for the appellate period. His symptoms are consistent with those productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. His symptoms primarily consisted of anger issues, hypervigilance, avoidance, anxiety, sleep impairment, and difficulty with relationships. The evidence does not support the criteria for a 70 percent or greater disability rating. The Veteran has denied suicidal and/or homicidal ideation. He did not report or display obsessional rituals which interfere with routine activities. His speech and thought patterns were normal, he did not experience near continuous depression, he did not endorse suicidal or homicidal ideation, intent, or plan, and he functioned independently, appropriately, and effectively. As there is no indication in the medical records that his symptoms are severe enough to cause occupational and social impairment with deficiencies in most areas, a 70 percent rating, or higher, is not warranted. See Vazquez-Claudio, 713 F.3d at 114 (holding that a veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). Bilateral Upper Extremity Peripheral Neuropathy/Propriety of Reduction The Appellant contends that the 20 percent disability evaluations assigned for the Veteran's right and left upper extremity peripheral neuropathy, respectively, should not have been reduced to 10 percent, and are worse than the accounted for by the currently assigned 10 percent evaluations. In a May 2015 rating decision, the AOJ granted 20 percent evaluations, effective August 28, 2014. An October 2017 rating decision then reduced the Veteran's ratings from 20 percent to 10 percent for right and left upper extremity peripheral neuropathies, effective August 4, 2017. Where the reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, special due process protections under 38 C.F.R. § 3.105(e) are triggered. The October 2017 rating decision that implemented the rating reduction did not change the Veteran's overall disability rating; it remained at 100 percent. The compensation payable was never reduced, and so no additional due process was required. Therefore, the remaining question is the propriety of the reduction on a factual basis. The 20 percent ratings for right and left upper extremity peripheral neuropathies were in effect from August 28, 2014 to August 4, 2017. Because the ratings were in effect for less than five years, the provisions of 38 C.F.R. § 3.344(a) and (b), which provide additional regulatory hurdles to rating reductions do not apply. The provisions of 38 C.F.R. § 3.344(c) provide that ratings in effect for less than five years can be reduced upon a showing that the disability has improved. Reexamination disclosing improvement will warrant a reduction in rating. 38 C.F.R. § 3.344(c). In Brown v. Brown, 5 Vet. App. 413 (1993), the United States Court of Appeals for Veterans Claims (Court) identified general regulatory requirements applicable to all rating reductions, including those which have been in effect for less than five years. Id at 417. Pursuant to 38 C.F.R. § 4.1, it is essential, both in the examination and in the evaluation of the disability, that each disability be viewed in relation to its history. Id at 420. Similarly, 38 C.F.R. § 4.2, establishes that "[i]t is the responsibility of the rating specialist to interpret reports of examination in light of the whole record history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of the disability present." Id. The Court has held that these provisions "impose a clear requirement" that rating reductions be based on the entire history of the veteran's disability. Id. Furthermore, 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Additionally, in any rating reduction case, not only must it be determined that an improvement in a disability has occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. See Brown, 5 Vet. App. at 420; see also 38 C.F.R. §§ 4.2, 4.10. A claim as to whether a rating reduction was proper must be resolved in the Veteran's favor unless VA concludes that a fair preponderance of the evidence weighs against the claim. Brown, 5 Vet. App. at 421. The Board finds that a preponderance of the evidence supports a finding of material improvement in the Veteran's right and left upper extremity peripheral neuropathies. The Veteran's right and left peripheral neuropathies are rated under the criteria associated with incomplete paralysis of the median nerve, 38 C.F.R. § 4.124a, Diagnostic Code 8515. Criteria for rating diseases of peripheral nerves are based on paralysis, neuritis, or neuralgia. Neuritis of a peripheral nerve, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain at times excruciating is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia of a peripheral nerve characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve 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. Diagnostic Code 8515 provides a 10 percent evaluation for mild incomplete paralysis of either extremity. A 20 percent evaluation is assigned for moderate incomplete paralysis of the non-dominant upper extremity and a 30 percent evaluation is assigned for moderate incomplete paralysis of the dominant upper extremity. A 40 percent evaluation is assigned for severe incomplete paralysis of the non-dominant upper extremity and a 50 percent evaluation is assigned for severe incomplete paralysis of the dominant upper extremity. A 60 percent evaluation is assigned for complete paralysis of the non-dominant extremity and a 70 percent evaluation is assigned for complete paralysis of the dominant upper extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Words such as "mild," "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Rather than applying a mechanical formula, VA must evaluate all the evidence in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. 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, "diseases of the peripheral nerves." Complete paralysis of the median nerve is indicated for "griffin claw" deformity, due to flexor contraction of ring and little finger, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse) cannot adduct the thumb; flexion of wrist weakened. 38 C.F.R. §§ 4.124a, Diagnostic Code 8515. The original assignment of 20 percent evaluations for right and left upper extremity peripheral neuropathies was based on the findings of an April 2015 VA peripheral neuropathy examination. The VA examiner noted that the Veteran reported he was diagnosed with multiple myeloma in August 2014 and started treatment in September 2014. He reported that symptoms of neuropathy started around the second cycle of chemotherapy. Symptoms included mild paresthesias and/or dysesthesias and moderate numbness. Muscle strength and sensory examination results were normal. The VA examiner determined that based on a review of medical literature regarding the adverse effects of chemotherapy, including medications the Veteran took for multiple myeloma, it was at least as likely as not that his peripheral neuropathy was secondary to these medications. Based on the findings of this examination, the Veteran was assigned 20 percent disability evaluations for his right upper extremity peripheral neuropathy and for his left upper extremity peripheral neuropathy. The Veteran underwent a VA diabetic peripheral nerves examination on August 4, 2017. The Veteran was noted to be right-handed. The VA examiner noted that the Veteran did not have a diagnosis of diabetic peripheral neuropathy but did have a diagnosis of peripheral neuropathy of the upper extremities. The Veteran reported that he was diagnosed with multiple myeloma in 2014 and underwent chemotherapy. He developed peripheral neuropathy in both upper extremities as a complication. He stated that he felt his symptoms had gotten slightly worse in regard to his sensory and strength, particularly on the left side. Subjective complaints included weakness in both upper extremities, left worse than right. The VA examiner noted that the Veteran had no symptoms attributable to diabetic peripheral neuropathy. Neurologic examination revealed muscle strength of 4 out of 5 for left hand grip and left pinch only; all other muscle movements were normal, including for the right upper extremity. Deep tendon reflexes were normal bilaterally for the upper extremities. Light touch/monofilament testing results were decreased for the left hand and fingers, but normal for remaining left upper extremity areas and for the right upper extremity. Position sense was decreased for the left upper extremity and normal for the right upper extremity. In an October 2017 addendum opinion, the VA examiner determined that the Veteran had mild median nerve neuropathy of the left upper extremity; no neuropathy of the right upper extremity was noted. The Veteran underwent a VA peripheral nerves examination in August 2020. The VA examiner noted the Veteran's diagnosis of peripheral neuropathy of the bilateral upper extremities. The Veteran reported that his symptoms have worsened. The VA examiner noted mild intermittent pain, paresthesias and/or dysesthesias and numbness in the Veteran's bilateral upper extremities. Muscle strength test results were normal. No muscle atrophy was noted. Reflex examination results were normal. Sensory examination results were normal. The VA examiner noted that the Veteran's right and left median nerves were normal. After reviewing the three examinations, the Board finds that the evidence supports an actual change for the better in the Veteran's bilateral upper extremity peripheral neuropathy that is not due simply to a difference in thoroughness of the examiner or the use of different descriptive terms. The 20 percent disability evaluations were based on an examination conducted when the Veteran was undergoing chemotherapy. The Veteran was no longer receiving chemotherapy at the time of his August 2017 and August 2020 examinations. The August 2017 peripheral nerves examination reflected an actual improvement in the Veteran's neuropathy symptoms such that the Veteran's left upper extremity peripheral neuropathy was described as mild, and no peripheral neuropathy of the right upper extremity was documented. The report of the August 2020 examination notes that the Veteran's bilateral median nerves were normal; no neuropathy was present. The Board has determined that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's right and left upper extremity peripheral neuropathies; the reduction in ratings from 20 percent to 10 percent for each upper extremity, effective August 4, 2017 was proper. As such, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Margaret M. Lunger, 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.