Citation Nr: 21066745 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 18-50 176A DATE: November 2, 2021 ORDER A reduction of the rating for the Veteran's diabetes mellitus, type II, from 20 percent to 10 percent was not proper; the 20 percent rating is restored effective March 21, 2017. A rating in excess of 20 percent for diabetes mellitus, type II, is denied. A rating in excess of 50 percent prior to March 19, 2021, and in excess of 70 percent thereafter, for posttraumatic stress disorder (PTSD), is denied. Service connection for peripheral neuropathy of the right lower extremity, to include as secondary to diabetes mellitus, type II, is denied. Service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes mellitus, type II, is granted. FINDINGS OF FACT 1. In an April 2017 rating decision, the RO reduced the Veteran's 20 percent disability rating of the service-connected diabetes mellitus, type II, to a 10 percent rating, effective March 21, 2017. 2. The reduction of the diabetes mellitus, type II, was not carried out in accordance with applicable procedures and is void ab initio. 3. For the entire period of the appeal, management of the Veteran's service-connected diabetes mellitus, type II, has required an oral hypoglycemic agent and a restricted diet as well as visits to his diabetic care provider less than twice per month; it has not required regulation of activities as defined by VA regulations. 4. Prior to March 19, 2021, the Veteran's PTSD is shown to have been productive of symptoms that include anxiety, hypervigilance, nightmares, irritability, and difficulty establishing and maintaining effective relationships; his PTSD is not shown to have resulted in occupational and social impairment with deficiencies in most areas or worse. 5. From March 19, 2021, the Veteran's PTSD is shown to have resulted in occupational and social impairment with deficiencies in most areas, but has not caused total occupational impairment and total social impairment. 6. The weight of the evidence is against a finding that the Veteran's peripheral neuropathy was caused or aggravated by his service or by his service-connected diabetes mellitus, type II. CONCLUSIONS OF LAW 1. The reduction in rating for diabetes mellitus, type II, from 20 percent to 10 percent was not proper, and is void ab initio. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105 (e). 2. The criteria for an evaluation in excess of 20 percent for the service-connected diabetes mellitus, type II, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.119, Diagnostic Code (DC) 7913. 3. Prior to March 19, 2021, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130, DC 9411. 4. For the period from March 19, 2021, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130, DC 9411. 5. The criteria for service connection for peripheral neuropathy of the right lower extremity, to include as secondary to the service-connected diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for a peripheral neuropathy of the left lower extremity, to include as secondary to the service-connected diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1965 to July 1967. The Veteran and his daughter testified before the undersigned Veterans Law Judge at a September 2020 Board hearing. A copy of the transcript has been obtained and associated with the claims file. In November 2020, the Board remanded these issues for additional development. As the requested development regarding the Veteran's claims have been completed, this matter is now properly returned to the Board for adjudication. See Stegall v. West, 11 Vet. App. 268 (1998). Propriety of a Reduction To properly reduce a disability rating requires VA to meet both procedural and substantive requirements. Procedurally, where the reduction in the rating 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, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. 38 C.F.R. § 3.105 (e). The beneficiary will be notified at his latest address of record of the contemplated action and furnished detailed reasons therefore, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. Id. The beneficiary must also be informed that he may request a predetermination hearing prior to the reduction. Id. at § 3.105(i)(1). Following this 60 day period, a final rating action will be taken, and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. Id. at § 3.105(e). Here, although no reduction notification procedures were undertaken in this case, the Board finds that none were required, as there was no reduction in the overall compensation paid to the Veteran. The special procedural requirements outlined in 38 C.F.R. § 3.105 (e) are therefore not applicable. See VAOPGCPREC 71-91 (Nov. 7, 1991); Stelzel v. Mansfield, 508 F.3d 1345, 1347-49 (Fed.Cir.2007) (holding that provisions of § 3.105(e) do not apply when there is no change in the overall disability rating). Reducing a rating also brings concurrent substantive requirements that must be followed. Where a disability rating has been in effect less than five years, a rating reduction is warranted where reexamination of the disability discloses improvement of that disability. 38 C.F.R. § 3.344 (c). In making this determination, VA is required to comply with several regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13; Brown v. Brown, 5 Vet. App. 213, 413, 420 (1993). The Board notes that for ratings in effect for five years or more, there are other specific requirements that must be met before VA can reduce a disability rating; however, as the Veteran's ratings were in effect for less than five year those additional requirements are not for application here. See 38 C.F.R. § 3.344. These provisions impose a clear requirement that VA rating reductions be based upon review of the entire history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Such review requires VA to ascertain, based upon review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability, and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating reduction case not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. 38 C.F.R. §§ 4.2, 4.10, 4.13; Faust v. West, 13 Vet. App. 342, 350 (2000). Further, though a rating reduction must have been supported by the evidence on file at the time of the reduction, pertinent post-reduction evidence favorable to restoring the rating also must be considered. Dofflemeyer v. Derwinski, 2 Vet. App. 277 (1992). Following the Veteran's February 2017 claim for an increased rating in excess of 20 percent for his service-connected diabetes mellitus, type II, an April 2017 rating decision reduced the rating to 10 percent, effective March 21, 2017. A review of the April 2017 rating decision, which pertained to the reduction, shows that the RO (Regional Office) appears to have essentially analyzed the issue of reduction of the 20 percent evaluation just as it would a claim for an increased rating. Specifically, the RO failed to discuss the provisions of 38 C.F.R. §§ 3.105 or 3.344 in its analysis. Of particular note, at no time did its analysis discuss the issue of whether there was "an actual improvement in the Veteran's ability to function under the ordinary conditions of life and work." Brown, 5 Vet. App. at 421. The RO merely discussed the rating criteria. The Court has stated that both decisions by the RO and by the Board that do not apply the provisions of 38 C.F.R. § 3.344, when applicable, are void ab initio (i.e., at their inception). Lehman v. Derwinski, 1 Vet. App. 339 (1991); Brown v. Brown, 5 Vet. App. 413 (1993); see also Hayes v. Brown, 9 Vet. App. 67, 73 (1996) (where VA reduces the appellant's rating without observing applicable laws and regulations the rating is void ab initio and the Court will set aside the decision). Since the rating decision that accomplished the reduction of the 20 percent rating for the Veteran's service-connected diabetes mellitus, type II, did not properly apply the provisions of 38 C.F.R. § 3.344, the reduction is void. The appropriate remedy in this case is a restoration of the 20 percent for diabetes mellitus, type II, effective on the date of the reduction. See Hayes, 9 Vet. App. at 73 (improper reduction reinstated effective date of reduction). The Board finds that the Veteran's disability rating for diabetes mellitus, type II, was improperly reduced, and the reduction of the disability rating is void ab initio. Therefore, the 20 percent disability rating for diabetes mellitus, type II, is restored. Increased Disability Ratings 1. A rating in excess of 20 percent for diabetes mellitus As determined above, a Veteran's service-connected diabetes mellitus, type II, is rated as 20 percent for the entire period on appeal. He contends a higher rating is warranted. The 20 percent evaluation was awarded pursuant to 38 C.F.R. § 4.119, DC 7913. Under this code section, diabetes mellitus type II requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, is rated 20 percent disabling. 38 C.F.R. § 4.119. Diabetes mellitus type II requiring insulin, restricted diet, and regulation of activities, is rated 40 percent disabling. Id. Diabetes mellitus type II 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, is rated 60 percent disabling. Id. Diabetes mellitus type II requiring 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, is rated 100 percent disabling. Id. The rating schedule in Note 1 also instructs VA to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process. Pursuant to Note 1 of the code section, the Veteran is currently assigned a separate rating for chronic kidney disease, addressed above. There is no evidence of retinopathy, cardiovascular disease, peripheral vascular disease, gastroparesis, or skin changes directly attributable to the Veteran's diabetes mellitus type II. At the outset, the Board acknowledges that the management of the Veteran's diabetes mellitus, type II, has required the use of an oral hypoglycemic agent and a restricted diet for control, thus warranting the currently assigned 20 percent rating. To merit a rating in excess of 20 percent, it must be shown that regulation of activities (doctor mandated avoidance of strenuous occupational and recreational activities) is required. During the appeal period, the Veteran was afforded VA examinations in March 2017, May 2021, and June 2021 to evaluate the severity of his diabetes mellitus, type II, and none of the VA examiners found that management of the condition on its own mandated a regulation of the Veteran's activities. Specifically, these VA examiners found no evidence that the diabetes mellitus, type II, had any impact on the Veteran's ability to work. The VA examiners also noted that the Veteran required fewer than two visits per month to a diabetic care facility for episodes of ketoacidosis and/or hypoglycemia. Ultimately, the VA examinations reflect that the diabetes mellitus, type II, is managed with restricted diet and the use of a prescribed oral hypoglycemic agent. Overall, the Veteran has not submitted any evidence or argument which demonstrates that his diabetes mellitus, type II, requires a regulation of his activities. The objective medical evidence includes the three VA examinations as well as the available VA medical records, all of which indicate that the diabetes mellitus, type II, does not require any regulation of activity. Therefore, the preponderance of the evidence is against a finding that the diabetes mellitus, type II, mandates any regulation of activities as would be necessary to award a higher 40 percent rating and, as such, the Board concludes that a rating in excess of 20 percent for diabetes mellitus, type II, is not warranted. Furthermore, the benefit-of-the-doubt doctrine does not apply, and the increased rating claim must be denied. 2. A rating in excess of 50 percent for PTSD prior to March 19, 2021, and in excess of 70 percent thereafter The Veteran's PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. He contends that a higher rating is warranted for his current disability. Under 38 C.F.R. § 4.130, DC 9411, a 50 percent rating is warranted when an acquired psychiatric disability causes 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. Id. Under 38 C.F.R. § 4.130, DC 9411, a 70 percent rating is assigned when an acquired psychiatric disability causes 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 ideations; obsessional rituals that 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 work-like setting); inability to establish and maintain effective relationships. Id. Under 38 C.F.R. § 4.130, DC 9411, a 100 percent schedular evaluation is warranted when an acquired psychiatric disability causes 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 or place; memory loss of names of close relatives, own occupation, or own name. Id. Although some of the Veteran's recorded symptoms are not specifically provided for in the ratings schedule (e.g., such symptoms as nightmares), the symptoms listed at 38 C.F.R. § 4.130 are not an exclusive or exhaustive list of symptomatology which may be considered for a higher rating claim. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held 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. Id. at 118. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. Prior to March 19, 2021 The Veteran seeks a rating in excess of 50 percent for his PTSD for the period prior to March 19, 2021. At the September 2020 Board hearing, the Veteran testified that he had difficulty establishing and maintaining effective relationships. He stated he lived alone and stayed to himself. The Veteran's daughter testified that his rapport with his family was very poor and that he had no friends. She stated that he would not answer is phone and sometimes sat on his porch at night with a gun. The Veteran had difficulty adapting to stressful circumstances, getting along with others, flashbacks of his military service, and nightmares. The Veteran's daughter testified the Veteran had a fascination with guns and that he shot his brother in 1977. She stated her father had a short temper with poor impulse control and that he and her mother divorced twenty years prior because of the violence. Upon review of the evidence of record, the Board finds that the weight of the evidence is against a rating in excess of 50 percent prior to March 19, 2021. In reaching this conclusion, the Board acknowledges the Veteran's and his daughter's testimony that his PTSD symptoms included anger, impaired impulse control, nightmares, isolation, and hypervigilance. However, the Veteran's symptoms, while not confirming rigidly to one rating category, are of a similar severity, frequency, and duration as those of the 50 percent category. See Mauerhan, 16 Vet. App. at 442-43. The clinical evidence dated August 2016 indicated that the Veteran denied worsening of his nightmares, to include "vague auditory sounds of war or sleep disturbances." He acknowledged he was able to recognize triggers to his anxiety and avoid those situations. An October 2016 VA treatment record indicated little improvement to his symptoms secondary to poor medication compliance. He was concerned taking his medication would prevent him from responding to situations in a timely manner. He denied suicidal and homicidal thoughts and plans but endorsed seeing images or hearing noises of Vietnam. The VA clinician identified these not as auditory or visual hallucinations but as intrusive thoughts. In March 2017, the Veteran stated he satisfied with his life; did not drop many of his activities and interests; did not feel his life was empty; did not often become bored; was in good spirits most of the time; felt happy most of the time; did not often feel helpless; did not feel he had more problems with memory than most; thought it was wonderful to be alive; did not feel worthless or his situation was hopeless; and felt full of energy. The Veteran however, did indicate he preferred to stay home rather than going out and doing new things and that he was afraid that "something bad is going to happen to [him]." In March 2017, the VA examiner determined that the Veteran's level of occupational and social impairment was best described as with reduced reliability and productivity. The VA examiner indicated the Veteran's PTSD symptoms included depressed mood; anxiety; suspiciousness; chronic sleep impairment; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. In October 2019, the Veteran stated he was at "status quo by keeping his mind occupied with positive activities to precent all those bad thoughts from rising up." In January 2020, the Veteran denied worsening of symptoms and stated he kept in touch with his daughter and girlfriend to avoid being lonesome. The record during this period reflects that the Veteran consistently denied suicidal and homicidal ideation. Overall, the Board finds that the evidence most closely corresponds to a 50 percent evaluation for the service-connected PTSD for the period prior to March 19, 2021. Overall, the Veteran has reported having sleep difficulties, nightmares, hypervigilance, and irritability. There is little or no evidence during this period of appeal of impairment in speech, thought process, or thought content, orientation, judgment, insight, hallucinations, inappropriate behavior, panic attacks, homicidal or suicidal thoughts, or episodes of violence. The record reflects that the Veteran was able to maintain a relationship with his daughter and his girlfriend. The Veteran reported that his activities with friends were limited but he enjoyed singing at funerals, fishing, and woodworking. The Veteran's treatment records reflect that he was able to avoid triggers to his anxiety and manage his self-care. The Board recognizes that while the Veteran and his daughter testified that he shot his brother and divorced his wife due to impaired impulse control and violence, these episodes occurred well-outside of the appeal period. In summary, the evidence is insufficient to show that the Veteran has such symptoms as suicidal ideation with plan or intent; obsessional rituals; defects in speech; near-continuous panic or depression which affect his ability to function independently, appropriately, and effectively; spatial disorientation; neglect of personal appearance and hygiene; or difficulty in adapting to stressful circumstances, nor are there other psychiatric symptoms shown to have resulted in such impairment, such that a 70 percent rating was warranted for the Veteran's PTSD for the period prior to March 19, 2021. See 38 C.F.R. § 4.130; Vazquez-Claudio. Based on the foregoing, the Board concludes that the Veteran's service-connected PTSD is not manifested by symptomatology that approximates, or more nearly approximates, the criteria for a rating in excess of 50 percent under DC 9411 prior to March 19, 2021. See 38 C.F.R. § 4.7. Period from March 19, 2021 The Board finds that the criteria for a rating in excess of 70 percent for PTSD for the period from March 19, 2021, have not been met. The clinical findings during the relevant time period on appeal, notably during an October 2020 VA examination, did not show that the Veteran's PTSD was manifested by such symptoms as gross impairment in thought processes or communication; persistent delusions, or hallucinations; grossly inappropriate behavior; or persistent danger of hurting self or others. The March 2021 VA examiner concluded that the Veteran's level of occupation and social impairment with regard to his PTSD was best summarized as with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. This corresponds to no more than a 70 percent evaluation under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Notwithstanding the findings of an inability to establish and maintain effective relationships, the Veteran is shown to have been able to live independently at his residence and able to perform activities of daily living and maintain his property and had good family support. As such, he cannot be said to be totally socially impaired and totally occupationally impaired. This is not to an effort to minimize the Veteran's difficulty interacting with others. However, a 70 percent rating contemplates the inability to establish and maintain effective relationships. As such, the Veteran can be squarely within the confines of a 70 percent rating, while still experiencing significant difficulty with relationships. The Board therefore finds that the Veteran's PTSD symptoms are not of such severity to approximate, or more nearly approximate, the criteria for an evaluation in excess of 70 percent under DC 9411 for the period from March 19, 2021. See 38 C.F.R. § 4.7; Vazquez-Claudio. In summary, there is insufficient evidence of 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; disorientation to time or place; memory loss of names of close relatives, own occupation, or own name; nor are other psychiatric symptoms shown to have resulted in the required level of impairment. Vazquez-Claudio. Given the foregoing, the Board finds that the Veteran's PTSD symptoms are not of such severity to approximate, or more nearly approximate, the criteria for a 100 percent rating under DC 9411. See 38 C.F.R. § 4.7; Vazquez-Claudio (38 C.F.R. § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas). The Board also acknowledges the Veteran's belief that his PTSD symptoms are of such severity as to warrant ratings in excess of 50 and 70 percent for the prescribed periods on appeal. However, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. Here, the Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran's assessment of the severity of his PTSD. The examination also considered the Veteran's competent (subjective) statements with regard to the severity of his PTSD. Accordingly, the Veteran is not entitled to a rating in excess of 70 percent from March 19, 2021, for his service-connected PTSD. Service Connection Service connection can be established by evidence that shows "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service the so-called "nexus" requirement." 38 C.F.R. § 3.310 (a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). 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. Id. When the disease identity is established, there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303 (b) is limited to a chronic disease listed at 38 C.F.R. § 3.309 (a)). A grant of service connection under 38 C.F.R. § 3.303 (b) does not require proof of the nexus element; it is presumed. Id. As the Veteran has not been shown to have a chronic disability during the appeal period, the theory of continuity of symptomatology is not for application with respect to the service connection claims decided herein. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Additionally, when aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran claims that he has peripheral neuropathy of the right and left lower extremities as a result of his service-connected diabetes mellitus, type II. The Veteran's service treatment records are absent of any complaints, treatment, or diagnosis of a neurologic disability of the bilateral lower extremities. The April 1965 entrance examination and the April 1967 separation examination did not identify any abnormalities of the lower extremities. It is noted that peripheral neuropathy is a disease that is presumptively associated with herbicide exposure, but only if it manifests within a year of the last exposure to herbicides. Here, there is no indication that the Veteran began experiencing his lower extremity symptoms within a year of service, and as such presumptive service connection will not be discussed further. According to the VA treatment records, the Veteran was diagnosed with right leg sciatica as result of this degenerative joint disease (DJD) in the low back as early as 2002. There is one instance, however, in September 2002 where he reported pain in his low back radiating down to his left leg. There is no diagnosis of left leg sciatica. In April 2007, the Veteran reported mild low back pain and numbness in his right toes for approximately one month. A review of the Veteran's medical records reveals sciatica is listed as an active medical problem as recently as February 2021. In a February 2016 VA examination, the chief of neurology at a VA facility wrote, that the Veteran had mild incomplete sensory loss in the feet due to polyneuropathy. He explained that neuropathy caused by agent orange is typically acute to subacute in onset and subsides over time. Here, he felt that the extremely long interval between exposure and onset of symptoms make agent orange an unlikely cause, explaining that neuropathy in diabetes is thought to arise from sustained significant hyperglycemia causing shunting of glucose down the sorbitol pathway with subsequent damage to myelin and/or due to vascular involvement of the vasa nervorum causing axonal loss. Here, the examiner noted that the Veteran has had neither significant nor prolonged elevation in serum glucose, making his diabetes mellitus a less likely cause of the peripheral neuropathy. The Veteran's representative argued the examiner had not realized how severe the Veteran's diabetes mellitus was, and the Board remanded for another opinion. Pursuant to the Board's November 2020 remand, the Veteran was afforded a VA examination for diabetic sensory-motor peripheral neuropathy in June 2021 where the Veteran reported a gradual onset of burning and stinging pain of his feet and lower legs along with numbness and tingling of the feet and lower legs. Upon a physical examination, a review of the medical evidence of record, and the Veteran's lay statements, the VA examiner determined that the Veteran's claimed conditions were at least as likely than not (50 percent or greater probability) proximately due to, or the result of, his service-connected conditions. The VA examiner stated that the Veteran's diabetic peripheral neuropathy of the bilateral lower extremities were directly due to his diabetes mellitus, type II. The VA examiner explained that the "Veteran has signs and symptoms consistent with diabetic peripheral neuropathy of bilateral lower extremities. This is a common complication of type II diabetes mellitus due to elevated glucose levels over time causing nerve damage. Veteran has a history of diabetes mellitus since 2013." However, this examiner, a nurse practitioner, did not delve beneath the surface of the claim, merely concluding that diabetes mellitus was a risk factor for causing peripheral neuropathy, and thus concluding that the Veteran's diabetes mellitus caused his peripheral neuropathy. Because this opinion did not rule out our consider other potential causes of the Veteran's neurologic pain, a second opinion was sought. However, a July 2021 VA opinion from another VA examiner determined that upon a review of the evidence of record, the Veteran's peripheral neuropathy was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. This VA examiner explained that according to an April 2007 medical treatment record, there was a presence of peripheral neuropathy secondary to sciatica stemming from a back condition. The VA examiner further stated that this condition is not secondary to diabetes as it preexisted the Veteran's diagnosis of diabetes mellitus, type II, which was approximately in 2014. Additionally, this VA examiner noted that the February 2016 examination report indicated intermittent mild pain, numbness and tingling of the lower extremities without necessitating medication. The VA examiner explained that "[t]his falls within the projected natural history of condition and does not represent aggravation." After consideration of the record, the Board finds that the Veteran's bilateral peripheral neuropathy of the right lower extremity is not related to service or to a service-connected disability, and service connection is not established. The Board acknowledges the Veteran has a confirmed diagnosis of peripheral neuropathy in both lower extremities, however, there were no objective evidence of record that indicates injury or symptomatology pertaining to the current disability during service. Therefore, the Board finds that direct service connection is denied. The Veteran has not presented any medical evidence to support a finding of direct service connection. Regarding the secondary theory of entitlement, the Board recognizes there is one positive and several negative nexus opinions within the record. However, the Court has held that in comparing positive and negative evidence, the Board may favor the opinion of one competent medical professional over that of another, as long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). With regard to medical opinions, the credibility and weight to be attached to a medical opinion are within the Board's province as finder of fact. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one opinion over another depending on factors such as reasoning employed and whether the examiner was informed of the relevant facts. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). While June 2021 VA examiner provided a positive nexus opinion, the Board finds that the opinions of February 2016 and July 2021 VA examiners were most probative. First the opinion in 2016 was provided by the Chief of Neurology, and the July 2021 opinion was provided by a doctor. Conversely, the positive opinion came from a nurse practitioner. While a nurse practitioner is certainly competent to provide an opinion, and the presumption is that a VA examiner is competent to answer the question that was asked, the fact remains that the authors of the two negative opinions necessarily have greater training in the field, and are thus felt to be more capable of answering the highly technical medical question here. Here, the June 2021 VA examiner failed to consider the VA treatment records reflecting that prior to the diagnosis of diabetes mellitus, type II, the Veteran was diagnosed with sciatica along with reports of numbness and tingling in his toes which were associated to his DJD of the low back. Therefore, the Board affords this opinion to have little probative weight as it appear to be based on an incomplete set of facts. Conversely, the July 2021 VA examiner offered a strong rationale and an analysis for the opinion that incorporate both the facts of the case and the pertinent medical principles. Given the July 2021 VA examiner's access to the claims folder and the thoroughness and detail of the opinion, the Board finds his opinion to be highly probative in determining whether the Veteran's peripheral neuropathy of the lower extremities is secondary to his service-connected diabetes mellitus, type II. Likewise, the 2016 examiner also provided a well-reasoned opinion. While the Veteran's representative suggested that the examiner did not know the severity of the Veteran's diabetes mellitus, there is no actual evidence of this. The examiner was the Chief of Neurology and is presumed to know more about the severity of the Veteran's diabetes mellitus than someone without medical training. To the extent that the Veteran believes that he has peripheral neuropathy of the right lower extremity, is the result of, or is aggravated by his diabetes mellitus, type II, or due to his military service, such a medical opinion requires medical expertise, and that determination cannot simply be made by lay observation alone; and the Veteran is not considered competent (meaning medically qualified by training or experience) to provide a medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection for peripheral neuropathy of either lower extremity. As such, this claim is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Yoo, 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.