Citation Nr: 21065020 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 17-36 307A DATE: October 22, 2021 ORDER Beginning October 10, 2013, but prior to March 12, 2014, entitlement to a disability rating of 60 percent, but no higher, for diabetes mellitus is granted. From March 12, 2014, but prior to December 26, 2017, entitlement to a disability rating of 40 percent, but no higher, for diabetes mellitus is granted. From December 26, 2017, but prior to August 24, 2020, entitlement to a disability rating of 60 percent, but no higher, for diabetes mellitus is granted. From August 24, 2020, entitlement to a disability rating of 40 percent, but no higher, for diabetes mellitus is granted. Beginning October 10, 2013, but prior to October 9, 2020, entitlement to a disability rating of 30 percent, but no higher, for peripheral neuropathy of the right upper extremity is granted. For the period from October 10, 2013, but prior to October 9, 2020, entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is denied. Beginning October 9, 2020, entitlement to a disability rating in excess of 50 percent for peripheral neuropathy of the right upper extremity is denied. Beginning October 9, 2020, entitlement to a disability rating in excess of 30 percent for peripheral neuropathy of the left upper extremity is denied. Beginning October 10, 2013, entitlement to a disability rating of 40 percent, but no higher, for peripheral neuropathy of the sciatic nerve of the right lower extremity is granted. Beginning October 10, 2013, entitlement to a disability rating of 40 percent, but no higher, for peripheral neuropathy of the sciatic nerve of the left lower extremity is granted. Beginning October 10, 2013, entitlement to disability rating of 30 percent, but no higher, for peripheral neuropathy of the femoral nerve of the right lower extremity is granted. Beginning October 10, 2013, entitlement to a disability rating of 30 percent, but no higher, for peripheral neuropathy of the femoral nerve of the left lower extremity is granted. REMANDED 1. Entitlement to a compensable disability rating for erectile dysfunction (ED) is remanded. 2. Entitlement to special monthly compensation based for the need for regular aid and attendance or at the housebound rate is remanded. FINDINGS OF FACT 1. Beginning October 10, 2013, but prior to March 12, 2014, the Veteran's diabetes has required one or more daily injections of insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, plus complications that would not be compensable if separately evaluated. 2. Beginning March 12, 2014, but prior to December 26, 2017, the Veteran's diabetes has required one or more daily injections of insulin, a restricted diet, and regulation of activities. 3. Beginning December 26, 2017, but prior to August 24, 2020, the Veteran's diabetes has required one or more daily injections of insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, plus complications that would not be compensable if separately evaluated. 4. Beginning August 24, 2020, the Veteran's diabetes has required one or more daily injections of insulin, a restricted diet, and regulation of activities. 5. Beginning October 10, 2013, but prior to October 9, 2020, the Veteran's right upper extremity peripheral neuropathy has been manifested by moderate incomplete paralysis. 6. During the period between October 10, 2013, but prior to October 9, 2020, the Veteran's left upper extremity peripheral neuropathy has been manifested by moderate incomplete paralysis. 7. From October 9, 2020, the Veteran's right upper extremity peripheral neuropathy has been manifested by severe incomplete paralysis. 8. From October 9, 2020, the Veteran's left upper extremity peripheral neuropathy has been manifested by severe incomplete paralysis. 9. Beginning October 10, 2013, the Veteran's peripheral neuropathy of the sciatic nerve of the right lower extremity has been manifested by moderately severe incomplete paralysis. 10. Beginning October 10, 2013, the Veteran's peripheral neuropathy of the sciatic nerve of the left lower extremity has been manifested by moderately severe incomplete paralysis. 11. Beginning October 10, 2013, the Veteran's peripheral neuropathy of the femoral nerve of the right lower extremity has been manifested by severe incomplete paralysis. 12. Beginning October 10, 2013, the Veteran's peripheral neuropathy of the femoral nerve of the left lower extremity has been manifested by severe incomplete paralysis. CONCLUSIONS OF LAW 1. Beginning October 10, 2013, but prior to March 12, 2014, the criteria for entitlement to a disability rating of 60 percent, but no higher, for diabetes mellitus have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.119, Diagnostic Code 7913. 2. From March 12, 2014, but prior to December 26, 2017, the criteria for entitlement to a disability rating of 40 percent, but no higher, for diabetes mellitus have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.119, Diagnostic Code 7913. 3. From December 26, 2017, but prior to August 24, 2020, the criteria for entitlement to a disability rating of 60 percent, but no higher, for diabetes mellitus have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.119, Diagnostic Code 7913. 4. From August 24, 2020, the criteria for entitlement to a disability rating of 40 percent, but no higher, for diabetes mellitus have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.119, Diagnostic Code 7913. 5. Beginning October 10, 2013, but prior to October 9, 2020, the criteria for entitlement to a disability rating of 30 percent, but no higher, for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8514. 6. For the period between October 10, 2013, and October 9, 2020, the criteria for a disability rating in excess of 20 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8514. 7. From October 9, 2020, the criteria for a disability rating in excess of 50 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8514. 8. From October 9, 2020, the criteria for a disability rating in excess of 30 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8514. 9. Beginning October 10, 2013, the criteria for entitlement to a disability rating of 40 percent, but no higher, for peripheral neuropathy of the sciatic nerve of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8520. 10. Beginning October 10, 2013, the criteria for entitlement to a disability rating of 40 percent, but no higher, for peripheral neuropathy of the sciatic nerve of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8520. 11. Beginning October 10, 2013, the criteria for entitlement to a disability rating of 30 percent, but no higher, for peripheral neuropathy of the femoral nerve of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8526. 12. Beginning October 10, 2013, the criteria for entitlement to a disability rating of 30 percent, but no higher, for peripheral neuropathy of the femoral nerve of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, Diagnostic Code 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 2005 to June 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was most recently before the Board in August 2020, at which time the Board remanded it for additional development. More specifically, the Board instructed the RO to obtain outstanding VA treatment records, authorization to obtain outstanding private treatment records, schedule new VA examinations with respect to peripheral neuropathy, and procure supplemental VA medical opinions regarding the severity of the Veteran's diabetes mellitus and ED. In January 2021, the RO issued a supplemental statement of the case. The matters now return to the Board. At the outset, the Board notes that the RO undertook appropriate steps to obtain and associate with the claims file outstanding VA treatment records, as well as to request authorization to obtain private treatment records, such as records from Sentara Leigh Hospital. Additionally, the RO scheduled and obtained the requested VA medical examinations and supplemental opinions. As such, the Board finds there has been substantial compliance with its remand directives, and remand for corrective action is not necessary. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where, as here, entitlement to service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each piece of evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. Diabetes The Veteran's diabetes is currently rated 20 percent under 38 C.F.R. § 4.119. Under diagnostic code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes requiring 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 for diabetes requiring 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. Within the criteria for a 100 percent rating, "regulation of activities" is defined as "avoidance of strenuous occupational and recreational activities." This definition also applies to the "regulation of activities" criterion for a 40 percent rating under diagnostic code 7913. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Moreover, medical evidence is required to support this criterion for a 40 percent rating. Id. at 364. In addition, although VA regulations generally provide that symptoms need only more nearly approximate the criteria for a higher rating in order to warrant such a rating, see 38 C.F.R. §§ 4.7, 4.21, those regulations do not apply where, as here, the conjunction "and" is used and the criteria are successive, with the criteria for the lower ratings encompassed within those for higher ratings. See Camacho, 21 Vet. App. at 366; Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). Here, the evidence indicates that shortly before the beginning of the rating period on appeal (i.e., when the Veteran's claim for an increased rating was received on October 10, 2013), the Veteran was hospitalized at the Sentara Leigh Hospital in Norfolk, Virginia, for diabetic ketoacidosis (DKA) and hyperglycemia on January 15, 2013. He was hospitalized there again on March 11, 2013, with an assessment of viral gastroenteritis, pancreatitis, dehydration, DKA, and a urinary tract infection. He underwent a VA examination with respect to the severity of his diabetes mellitus in March 2014. In the examination report, the examiner indicated that the Veteran visited the doctor less than twice a month due to DKA or hypoglycemic reactions, but that he required regulation of activities due to the discomfort caused by diabetic peripheral neuropathy. The VA examiner indicated that he visited the doctor less than twice a month for DKA or hypoglycemic reactions and had no hospitalizations in the past 12 months. There was no progressive, unintentional weight loss or progressive loss of strength. Complications of his diabetes included ED and an eye condition. A November 2014 VA treatment note reflects that he attended an endocrinology clinic appointment for evaluation and management of uncontrolled type I diabetes mellitus. The assessment noted that there was poor glycemic control, as well as hypoglycemia. When his blood sugar was less than 150, he experienced headaches, while he experienced sweating, lightheadedness, and tremors when his blood sugar was less than 100. The clinician doubted that he had been complying with his medication regimen. He had no history of pancreatitis but endorsed episodes of nausea, vomiting, and abdominal pain. Complications included severe peripheral neuropathy symptoms, symptoms of gastroparesis, symptoms of autonomic neuropathy, and diabetic retinopathy. His doctor recommended that he continued taking various medications, eat three meals per day, stop drinking high-sugar beverages, check his blood sugar at meals and at bedtime, see a podiatrist, and follow up with ophthalmology. His treatment provider also noted that he did not have an exercise program due to poor balance. In an April 2015 VA treatment record, the Veteran reported that he was not very compliant with his prescribed insulin injection regimen. He also reported that his typical meals comprised of meat and vegetables like corn, peas, and carrots, with beverages including coffee with creamer and sugary sodas throughout the day. Although he stayed active at work, he reported that his blood sugar would fall between 80 and 120 around noon, which would make him feel "symptomatic." He also felt like his blood sugar would drop on the days when he was active. His treatment provider advised him on correct diet and vegetable choices, and also advised him to stop smoking and drinking sodas regularly. VA treatment records indicate that he was admitted to the hospital for hyperglycemia in March 2016 and September 2016. He attended another VA examination in February 2017. On this examination report, the VA examiner indicated that more than one injection of insulin was required per day, but that regulation of activities was not required. The report also stated that he saw a provider for episodes of DKA or hypoglycemia less than twice a month, with no hospitalizations in the past 12 months or progressive unintentional weight loss or loss of strength. A June 2017 VA treatment record noted that he was hospitalized at Sentara Leigh Hospital from June 20th to June 23rd after presenting with an altered mental status and hyperglycemia. In July 2017 VA treatment records, his clinician noted that the Veteran had been encouraged to continue taking medications as directed and to maintain good glucose control. In a July 2017 lay statement, the Veteran's wife indicated that the Veteran could not stand too long and had limited mobility because of his service-connected conditions. As a result, he could not drive, so she did all the shopping for the household and completed all their errands. She also reported that she took care of the housekeeping, cleaning, cooking, laundry, and yardwork, as well as assisted him with preparing and distributing his medication and watched him while he took showers to make sure he did not fall. In December 2017, the Veteran was admitted to a VA hospital after presenting with nausea, vomiting, and chest pain and diagnosed with DKA. He stated that he forgot to take his insulin for the past two days, as well as blood in his emesis. While admitted to the hospital, he underwent a colonoscopy, which indicated that he was classified at ASA III under the American Society of Anesthesiologists' physical status classification system. VA treatment records indicate that this classification corresponds with "severe systemic disease with exercise limitations; uncontrolled systemic disease." In March 2018, he was hospitalized once more for DKA after presenting with abdominal pain, nausea, and vomiting. November 2018 VA treatment records reflect that the Veteran's doctor reviewed the signs and symptoms of low blood glucose and action steps, as well as stressed the importance of therapeutic lifestyle changes. A separate VA treatment record from November 2018 emphasizes that compliance with his treatment regimen was a major factor complicating his care, in light of numerous and repeated missed appointments. A low carbohydrate, low salt diet was recommended, as well as referrals to various other departments, such as nephrology, and fall precautions. August 2019 VA treatment records indicate that the Veteran was admitted to Sentara Leigh Hospital for DKA on the same day that he had been scheduled for a vascular surgery with VA. In September 2019 VA treatment records, his wife reported that he had been throwing up all night and was advised to take him to the emergency room for another workup to ensure he was not experiencing DKA again. An October 2019 VA treatment record noted that he had uncontrolled diabetes with recurrent DKA and frequent hospitalizations. The Veteran underwent a third VA examination in December 2019. The December 2019 VA examiner indicated that he used prescribed oral hypoglycemic agents but not that he required daily insulin or regulation of activities. Regarding frequency of diabetic care, the VA examiner indicated he visited the doctor or episodes of DKA or hypoglycemia less than twice a month and that he had no hospitalizations for episodes of DKA or hypoglycemic reactions over the past 12 months or progressive and unintentional weight loss and loss of strength. Complications included ED and peripheral neuropathy. In May 2020 VA treatment records, the Veteran's treatment providers noted that the Veteran's blood sugar had dropped to 12 in the past month, which he attributed to being "more active" and had caused him to "almost" faint. His doctor noted that his hypoglycemia was severe, with complications including neuropathy, retinopathy, foot ulcers, and gastroparesis. The doctor advised him to take long-acting insulin daily and to count his carbohydrates. He reported being afraid of hypoglycemia, that episodes of hypoglycemia would occur once a month, and that at the 60 mark he experienced dizziness and confusion. In a January 2021 VA addendum medical opinion, a VA examiner opined that the Veteran did not require regulation of activities as part of the medical management of his diabetes. As rationale, the examiner stated that his 2018 and 2019 hospitalizations for DKA were indicators that his diabetes was poorly controlled, but there was insufficient information to explain why his diabetes was poorly controlled. January 15, 2013, to March 12, 2014 The Board notes that, during the one-year period prior to his claim for an increased rating for diabetes mellitus, the Veteran's symptomatology was consistent with a 60 percent rating for diabetes mellitus beginning on January 15, 2013. To that end, the Veteran was hospitalized twice for DKA in 2013, first in January and then in March. At the same time, treatment records clearly reflect that during this time he required one or more daily injections of insulin and a restricted diet, and that he had other complications of diabetes mellitus that were separately evaluated. Last, the evidence is in relative equipoise with respect to whether regulation of activities was required during this timeframe. Regarding regulation of activities, the medical evidence of record indicates that the Veteran had been hospitalized for hypoglycemia outside of the appellate period, including the one-year lookback period. Moreover, the March 2014 VA examiner noted that he had required regulation of activities. It is reasonable to assume that the Veteran also had to regulate his activities prior to attending the March 2014 VA examination. Although the February 2017 VA examination report reflects that the Veteran did not require regulation of activities, the probative value of this examination report is significantly diminished, as the VA examiner did not indicate that he had reviewed any of his medical records prior to making this finding. Affording him the benefit of the doubt, the Board finds that all the criteria for a 60 percent rating under diagnostic code 7913 are thus satisfied from January 15, 2013, to March 5, 2014. The Board notes, however, that a 100 percent rating was not warranted, as not all the criteria for a 100 percent rating would have been satisfied during this timeframe. Indeed, the Veteran had not been hospitalized for hypoglycemia at least three times in 2013, nor did he require weekly visits to a diabetic care provider. As such, a 100 percent rating was not warranted during this portion of the period on appeal. March 12, 2014, to December 26, 2017 Starting on March 12, 2014, the Board finds that only a 40 percent rating is warranted under diagnostic code 7913, because as of March 11, 2014, he had not been hospitalized for either DKA or hypoglycemia with the past year. To that end, he was last discharged from the hospital after being admitted for DKA on March 11, 2013. Although he was subsequently hospitalized for other medical problems, such as hyperglycemia, following this date, he was not hospitalized for hypoglycemia or DKA at any point during this segment of the appeal period. Nonetheless, the record indicates that he continued to require at least one insulin injection per day, as well as a controlled diet and regulation of activities, consistent with a 40 percent rating. Concerning the regulation of activities, the medical evidence from this portion of the period on appeal continues to show that the Veteran had to forego strenuous activities in order to avoid hypoglycemic episodes. For instance, the Veteran's November 2014 and April 2015 VA treatment records indicate that he frequently suffered from hypoglycemia, with episodes of lightheadedness, sweating, and tremors when his blood sugar was too low, particularly on the days when he was active. Despite being counseled numerous times by his doctors to make lifestyle changes, such as eating more healthfully or complying with his medication regimen, recommendations to exercise are noticeably absent. It stands to reason that his doctors did not recommend exercise in light of his hypoglycemic episodes and poor medication compliance. As such, the Board finds that the evidence remains in relative equipoise concerning whether the regulation of activities was required. Resolving the benefit of the doubt in his favor, the Board finds that a 40 percent rating is thus warranted during this portion of the appeal period. As set forth above, however, his symptoms were not consistent with a 60 percent rating during this time, as he was not hospitalized as a result of hypoglycemia or DKA until December 2017 and did not require twice a month visits to a diabetic care provider. From December 26, 2017, to August 24, 2020 On December 26, 2017, the record reflects that the Veteran was hospitalized for DKA. He was hospitalized again in March 2018 and August 2019. As such, the Veteran was hospitalized for DKA once a year for three consecutive years. At the same time, VA treatment records clearly reflect that he required at least one injection of insulin each day and a controlled diet, that he had complications of diabetes that were separately evaluated, and that his activities were restricted due to his diabetes. For instance, the Veteran's December 2017 VA treatment records state that he was classified at level ASA III, indicating severe systemic disease with exercise limitations or uncontrolled systemic disease. Moreover, his May 2020 VA treatment records indicate he had a history of multiple hypoglycemic episodes, including dizziness and confusion, that were happening once a month. Despite recommendations to count his carbohydrates and take insulin, his treatment providers did not counsel him to exercise. This medical evidence demonstrates that regulation of activities was still necessary during this timeframe. The Board notes that the December 2019 VA examiner opined that regulation of activities was not necessary with respect to his diabetes. However, the Board finds that the probative value of this VA examination is diminished, as it appears that the VA examiner did not address all relevant evidence in the examination report. For instance, the December 2019 VA examiner failed to address the Veteran's prior hospitalizations for DKA in December 2017, March 2018, or August 2019. Moreover, the December 2019 VA examiner stated that he had not been hospitalized as a result of hypoglycemia or DKA within the past 12-month period, which is inaccurate. An opinion based on an inaccurate factual premise is entitled to no probative weight. Reonal v. Brown, 5 Vet. App. 458 (1993). As such, the Board finds that a 60 percent rating is warranted from December 26, 2017 (i.e., when he was again admitted to the hospital for DKA), until August 24, 2020 (i.e., one year following his most recent hospitalization for DKA). A rating in excess of 60 percent is not warranted during this timeframe, however, because the record does not indicate that he been hospitalized at least three times in one year at any point during this timeframe, nor had he required weekly visits to a diabetic care provider. From August 24, 2020 From August 24, 2020 (i.e., the day after his last hospitalization for DKA one year prior), the Board finds that a 40 percent rating is once again warranted. As with the other stages of the rating period, the Veteran required at least one injection of insulin daily and a controlled diet. Moreover, the evidence indicates that he continued to require regulation of activities during this time. Although the January 2021 VA examiner indicated that the Veteran did not require regulation of activities, her opinion is entitled to little probative value. To that end, her rationale was that no regulation of activities was warranted because the Veteran's 2018 and 2019 hospitalizations were indicators that his diabetes was poorly controlled, but also that there was insufficient information to explain why his diabetes was poorly controlled. The VA examiner failed to explain why the information available was insufficient. Moreover, whether the Veteran's diabetes was poorly controlled is a separate question from whether his diabetes requires regulation of activities. Accordingly, the Board ascribes little probative weight to this opinion. Resolving reasonable doubt in the Veteran's favor, the Board finds that a 40 percent rating is thus warranted from August 24, 2020. However, because the record does not indicate that he has had any subsequent hospitalizations due to hypoglycemia or DKA, or that he must see a diabetic care provider twice a month due to these conditions, a rating in excess of 40 percent is not warranted. 2. Peripheral neuropathy The Veteran's peripheral neuropathy of the bilateral upper extremities is currently rated under diagnostic code 8514, for paralysis of the radial nerve. 38 C.F.R. § 4.124a. The relevant rating criteria concerning incomplete paralysis provide that mild paralysis warrants a 20 percent rating in the major and minor extremities, while moderate paralysis warrants a 30 percent rating in the major extremity and a 20 percent rating in the minor extremity, and severe paralysis warrants a 50 percent rating in the major extremity and a 40 percent rating in the minor extremity. Where there is complete paralysis, a 70 percent rating is available for the major extremity and a 60 percent rating for the minor extremity. Here, the Veteran's bilateral upper extremities are each rated at 20 percent disabling from October 10, 2013. From October 9, 2020, the Veteran's right arm (his major extremity) is rated at 50 percent disabling, while his left arm (his minor extremity) is rated at 40 percent disabling. Additionally, the Veteran is currently receiving separate ratings for peripheral neuropathy of sciatic and femoral nerves of the bilateral lower extremities. With respect to the sciatic nerve, he is currently in receipt of a 10 percent rating in each extremity from March 19, 2010, under diagnostic code 8520. With respect to the femoral nerve, he is currently rated at 10 percent in each extremity from October 10, 2013, and at 30 percent disabled from October 9, 2020, under diagnostic code 8526. 38 C.F.R. § 4.124a. Under diagnostic code 8520, with respect to incomplete paralysis of the sciatic nerve, mild symptoms warrant a 10 percent rating, while moderate symptoms warrant a 20 percent rating, moderately severe symptoms warrant a 30 percent rating, and severe symptoms with marked muscular atrophy warrant a 60 percent rating. For complete paralysis of the sciatic nerve, an 80 percent rating is available. Under diagnostic code 8526, with respect to incomplete paralysis of the femoral nerve, mild symptoms warranted a 10 percent rating, while moderate symptoms warrant a 20 percent rating, and severe symptoms warrant a 30 percent rating. A 40 percent rating will be awarded for complete paralysis of the quadriceps extensor muscles. Before determining the appropriate ratings for the Veteran's bilateral upper and lower extremities, the Board will first review the relevant evidence of record. At a March 2014 VA examination, the Veteran's upper and lower extremities were normal with peripheral pulses within normal limits. However, the VA examiner noted that he had peripheral neuropathy in the bilateral upper and lower extremities, including some symptoms of pain in a stocking-like distribution in the mid- to lower-legs and feet bilaterally, as well as in the tips of his fingers and thumbs bilaterally, that had worsened over time. Although he did not endorse intermittent pain or numbness, he endorsed severe constant pain in the bilateral lower extremities, as well as moderate paresthesias/dysesthesias in the bilateral upper extremities and severe paresthesias/dysesthesias in the bilateral lower extremities. Strength testing and deep tendon reflexes were normal, with normal results on light touch testing. No muscle atrophy or trophic changes were reported. The VA examiner characterized his upper extremity peripheral neuropathy as mild incomplete paralysis, while the lower extremity peripheral neuropathy was described as mild incomplete paralysis of the sciatic nerve. No EMG testing was performed. Ultimately, the examiner opined that his peripheral neuropathy had no functional impact. A November 2014 VA treatment record indicated that he had a history of severe peripheral neuropathy symptoms with respect to his lower extremities. He endorsed symptoms such as allodynia and hyperesthesia with burning, a pins-and-needles sensation, and sharp, stabbing pains, as well as numbness. The symptoms were described as up to his knees. A February 2017 VA examination indicates a history of diabetic peripheral neuropathy in the bilateral upper and lower extremities. The VA examiner noted that there were no reports of constant pain in the bilateral upper extremities, but there was severe constant pain in the right lower extremity and mild constant pain in the left lower extremity. There was mild intermittent pain in the bilateral upper extremities, while there was no intermittent pain in the right lower extremity and severe intermittent pain in the left lower extremity. No paresthesias or dysesthesias were reported, but there was mild numbness in the bilateral upper extremities, severe numbness in the right lower extremity, and moderate numbness in the left lower extremity. Strength and reflexes were normal. On light touch testing, there was decreased sensation to the hands and fingers, ankles and lower legs, and feet and toes, but normal sensation in the shoulders and on the inner and outer forearms and knees and thighs. No muscle atrophy or trophic changes were present. Confusingly, the VA examiner stated that there was upper and lower extremity diabetic peripheral neuropathy, but that all nerves were normal. Again, no EMG studies were performed. With respect to functional impact, the examiner opined that the Veteran could not operate machinery or do fine dexterity activities due to peripheral neuropathy. July 2017 VA treatment records reflect that the Veteran reported longstanding pain in his legs and feet due to diabetic neuropathy. In the July 2017 statement from the Veteran's wife, she reported that he could not stand for too long or drive, and that she had to make sure he did not fall while he was in the shower. The Veteran underwent an additional VA examination in December 2019. At his examination, the VA examiner diagnosed peripheral neuropathy of the bilateral lower extremities with femoral nerve involvement, as well as bilateral upper extremity peripheral neuropathy. He reported that the numbness in his legs continued to worsen. He did not endorse constant pain in the bilateral upper extremities but indicated there was severe constant pain in the right lower extremity and mild constant pain in the left lower extremity. Mild intermittent pain was present in the bilateral upper extremities, while none was reported in the right lower extremity and severe intermittent pain was reported in the left lower extremity. There were no paresthesias or dysesthesias. With respect to numbness, the Veteran reported mild numbness in the bilateral upper extremities, severe numbness in the right lower extremity, and moderate numbness in the left lower extremity. Muscle strength testing, reflexes, and light touch testing were normal in all extremities. No muscle atrophy or trophic changes were reported. With respect to the lower extremities, the VA examiner stated that both the sciatic and femoral nerves were involved, but that the sciatic nerve showed mild incomplete paralysis and that the femoral nerve was normal. No EMG was performed. The Veteran underwent a fourth VA examination in October 2020. At this examination, he reported pain in his bilateral arms and fingers with numbness and occasional tingling on both hands, as well as pain in the bilateral legs with numbness and tingling. The pain was worse in the bilateral lower extremities than in the upper extremities. He endorsed severe constant pain, numbness, and paresthesias/dysesthesias in all extremities. Strength was less than normal on the neurological examination, while reflexes were decreased in both brachioradiales and ankles. Light touch testing was normal in the shoulder area, decreased in the inner and outer forearms, absent in the hands and fingers, decreased in the knee and thigh, decreased in the ankles and lower legs, and absent in the feet and toes. Position test was decreased in all extremities, while vibration and cold sensation were decreased in the bilateral upper extremities and absent in the bilateral lower extremities. No muscle atrophy or trophic changes were present. With respect to the upper extremities, the VA examiner characterized the disability as incomplete paralysis with severe symptoms. Regarding the lower extremities, the VA examiner indicated that the sciatic nerves and femoral nerves were both involved. With respect to functional limitations, the Veteran was unable to hold items, lift or grasp items, or stand or sit for extended periods of time. The VA examiner clarified that the Veteran's polyneuropathy was both motor and sensory, but primarily a distal symmetric sensory polyneuropathy. In October 2020, VA also obtained a supplemental VA medical opinion that stated that the Veteran's polyneuropathy involved both his upper and lower extremity nerves, which caused pain, numbness, tingling, decreased muscle strength, decreased sensation, decreased light touch, decreased position and vibration sense, and decreased or absent cold sensations. This symptomatology could limit his activities in the sense that he was unable to hold, lift, or grasp items, stand or sit for extended periods of time, or tolerate touch on his hands or feet. At the outset, the Board notes that the words "mild," "moderate," "moderately severe," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Having carefully reviewed the evidence of record, the Board finds that the Veteran is entitled to a 30 percent rating in the right upper extremity and a 20 percent rating in the left upper extremity from October 10, 2013, but prior to October 9, 2020. Additionally, the Board finds that he is entitled to 40 percent ratings in both bilateral lower extremities under diagnostic code 8520, as well as 30 percent ratings in both bilateral lower extremities under diagnostic code 8526, throughout the period on appeal. Upper extremities First, the Board finds that the evidence that the Veteran's bilateral upper extremity disabilities more closely approximate moderate incomplete paralysis prior to October 9, 2020, is relatively evenly balanced. For instance, the Veteran reported moderate paresthesias/dysesthesias in the bilateral upper extremities during his March 2014 VA examination. Although the VA examiner characterized his upper extremity peripheral neuropathy as "mild," this finding is not binding on the Board. Indeed, the VA examiner did not perform all indicated testing, such as light touch testing, before offering his opinion on the overall severity of his peripheral neuropathy. Later examination reports are entitled to less probative weight, as the examination reports are somewhat incomplete or inconsistent. For instance, although the February 2017 and December 2019 VA examination reports also reflects "mild" intermittent pain and numbness in the bilateral upper extremities, various tests were not performed. Furthermore, the Board finds that the December 2019 VA examination, although more thorough than the March 2014 or February 2017 VA examinations, is inconsistent with the results of a VA examination in October 2020, less than one year later. Relevantly, that October 2020 VA examination indicates that he experienced severe symptoms, such as constant pain, in his upper extremities. Taking the evidence in the light most favorable to the Veteran, to the Board finds that, prior to October 9, 2020, a 30 percent and 20 percent rating, for moderate incomplete paralysis, is warranted for the right and left upper extremity, respectively. The Board notes that the ratings for mild and moderate incomplete paralysis are the same for the minor extremity; as such, the percentage rating assigned to the left upper extremity is unchanged. Higher ratings are not available prior to October 9, 2020, as the evidence from prior to that point suggests that his overall disability picture more closely approximates moderate incomplete paralysis, as opposed to severe complete paralysis. Indeed, the Veteran did not endorse severe symptoms on any VA examination up to that point. From October 9, 2020, the current 50 and 40 percent ratings for the right and left upper extremities, respectively, are appropriate. However, at no point in the period on appeal has the evidence demonstrated that the nerves in his upper extremities have been completely paralyzed. As such, the highest available rating has already been assigned from October 9, 2020. Lower extremities Turning to the bilateral lower extremities, the Board finds that 40 percent ratings under diagnostic code 8520, for the sciatic nerve, and 30 percent ratings under diagnostic code 8526, for the femoral nerve, are warranted throughout the entire period on appeal. As an initial matter, the Board acknowledges that the various VA examination reports are inconsistent with respect to whether the sciatic nerve, the femoral nerve, or both nerves are affected. Resolving the doubt in the Veteran's favor, the Board finds that both nerves are involved. To that end, the VA examination reports vary widely in their descriptions of the Veteran's peripheral neuropathy symptoms. Despite the wide variations in the descriptions of exact symptoms, however, they consistently indicate that moderately severe to severe symptoms are present. For instance, the March 2014 VA examination indicates that there is severe paresthesias/dysesthesias in the bilateral lower extremities but no intermittent pain or numbness, whereas February 2017 VA examination indicates that no paresthesias/dysesthesias are present but intermittent pain was severe in the left lower extremity and absent in the right lower extremity, while numbness was severe in the right lower extremity and moderate in the left. Similarly, the December 2019 VA examination shows that there was no paresthesias/dysesthesias in either lower extremity but also severe constant pain in the right lower extremity and mild constant pain on the left, with severe numbness in the right lower extremity and moderate numbness in the left lower extremity. The October 2020 VA examination, on the other hand, shows severe constant pain, numbness, and paresthesias and dysesthesias in the bilateral lower extremities. Viewed in the light most favorable to the Veteran, the Board finds that these results more closely approximate 40 percent ratings under diagnostic code 8520, for moderately severe symptoms of incomplete paralysis of the sciatic nerves, and 30 percent ratings under diagnostic code 8526, for severe symptoms of incomplete paralysis of the femoral nerves. This is supported by the other evidence of record, including the Veteran's wife lay statement indicating that he cannot drive or take showers without the risk of falling, as well as VA treatment records indicating he has poor balance. The Board has also considered whether higher ratings are available under either diagnostic code 8520 or 8526. With respect to diagnostic code 8526, however, the highest rating available for incomplete paralysis has already been assigned. Because the evidence of record does not indicate that complete paralysis has been present in the femoral nerve of either lower extremity at any point during the period on appeal, a rating in excess of 30 percent is not warranted. Concerning diagnostic code 8520, a rating for severe paralysis with marked muscular atrophy is not warranted, as the medical evidence does not indicate that muscle atrophy is present. As such, ratings in excess of 40 percent are not available under diagnostic code 8520. REASONS FOR REMAND 1. ED The Board has previously remanded the Veteran's claim for a compensable rating for ED to obtain findings with respect to whether he has any penile deformity, including an internal deformity. Pursuant to the Board's most recent remand, the RO obtained an October 2020 supplemental medical opinion regarding whether the Veteran had a penile deformity. In that opinion, the VA examiner stated that there was insufficient evidence to provide a response without resorting to mere speculation. The October 2020 VA examiner based her opinion on prior disability benefits questionnaires from February 2017 and December 2019, which indicated that the penis had not been physically examined because it was "not deemed relevant to the diagnosed ED." The VA examiner is correct that there is insufficient evidence as to whether a penile deformity is present. Nonetheless, the examiner also indicated that it would be possible to offer an opinion if a physical examination were performed. As such, remand is warranted to obtain a new VA examination, including a physical examination of his penis, to address whether any penile deformity is present. 2. Special Monthly Compensation As a final matter, VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). This duty to maximize benefits requires VA to assess all a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to total disability based on individual employability (TDIU) or to special monthly compensation (TDIU) under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280 (2008). Here, however, the Veteran is already in receipt of a combined 100 percent disability rating throughout the period on appeal. Moreover, none of his disabilities are rated as totally disabling. As such, the issue of TDIU is moot throughout the rating period. Id. With respect to SMC, conversely, the record contains evidence suggesting he has such significant disabilities to be in need of regular aid and attendance or that he is confined to his place of residence as a result of his service-connected disabilities. For example, his wife's July 2017 letter indicates that she must assist him with various activities of daily living, such as bathing, dressing, transferring, and taking insulin, due to the limitations posed by his service-connected disabilities. As such, the issue of entitlement to SMC at the (l) and (s) rates has been reasonably raised by the record. To date, however, no development has been undertaken with respect to SMC based on regular aid and attendance or housebound status. On remand, the RO should afford him an examination for purposes of assessing housebound status or the need for regular aid and attendance. Accordingly, the matters are REMANDED for the following action: 1. After obtaining appropriate authorization, obtain and associate with the claims file all outstanding VA treatment records and outstanding, relevant private treatment records. 2. Thereafter, schedule the Veteran for an appropriate examination in order to determine the nature and severity of his ED. The claims file and a copy of this remand must be made available to the examiner, who must acknowledge receipt and review of these materials. All indicated tests, including a physical examination of the Veteran's penis, should be conducted and the results reported. Thereafter, the examiner is asked to opine as to whether there is external or internal distortion of the penis. In doing so, please address the article found at https://medlineplus.org/erectiledysfunction.html. The examiner is reminded that, on its face, nerve damage pathology may be characterized as an internal deformity of the nerves. A complete rationale should be provided for all opinions rendered. 3. Additionally, schedule the Veteran for an appropriate examination in order to determine whether it is at least as likely as not (approximately 50 percent or greater probability) that he is in need of the regular aid and attendance of another individual and/or is permanently housebound due to his service-connected impairments. The claims file and a copy of this remand must be made available to the examiner, who must acknowledge receipt and review of these materials. All indicated tests should be conducted and the results reported. In determining the need for aid and attendance, the examiner's considerations must include, but are not limited to, whether the Veteran is able to dress or undress himself, keep himself ordinarily clean and presentable, adjust any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid, feed himself, attend to the wants of nature, and/or protect himself from the hazards or dangers of his daily environment. With regard to housebound status, the examiner(s) must opine as to whether the Veteran's service-connected disorders alone substantially confine him to his dwelling and the immediate premises or, if institutionalized, to a ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. If the examiner determines that it is at least as likely as not the Veteran is housebound and/or in need of regular aid and attendance as a result of his service-connected disabilities, the examiner should, to the extent feasible, offer a retrospective opinion as to the approximate point in time when the Veteran's need for regular aid and attendance, and/or housebound status, first arose. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rademacher, 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.