Citation Nr: 21069194 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 17-48 524 DATE: November 17, 2021 ORDER Entitlement to a rating in excess of 40 percent disabling for diabetes mellitus type II associated with herbicide exposure is denied. Entitlement to a rating of 20 percent disabling prior to July 30, 2019, and 40 percent thereafter, but no higher, for peripheral neuropathy (sciatic nerve), left lower extremity is granted. Entitlement to a rating of 20 percent disabling prior to July 30, 2019, and 40 percent thereafter, but no higher, for peripheral neuropathy (sciatic nerve), right lower extremity is granted. Entitlement to a compensable rating for hypertension (claimed as high blood pressure) is denied. Entitlement to a compensable rating for erectile dysfunction is denied. A total disability rating based on individual unemployability (TDIU) is granted from May 23, 2013, to May 24, 2016. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's diabetes disease process has not manifested in episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, nor twice a month visits to a diabetic care provider. 2. Prior to July 30, 2019, the Veteran's bilateral lower extremity peripheral neuropathy (sciatic nerve) manifests in no more than moderate incomplete paralysis. 3. From July 30, 2019, the Veteran's bilateral lower extremity peripheral neuropathy (sciatic nerve) manifests in no more than moderately severe incomplete paralysis. 4. Throughout the period on appeal, the Veteran's hypertension has not manifested in diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; a history of diastolic pressure predominantly 100 or more which requires continuous medication for control. 5. Throughout the rating period on appeal, the Veteran's erectile dysfunction has manifested in loss of erectile power (separately compensated with an award of special monthly compensation for loss of use of a creative organ), but not a deformity. 6. The Veteran met the criteria for TDIU as of May 23, 2013. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 40 percent disabling for diabetes mellitus type II associated with herbicide exposure have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.119, Diagnostic Code 7913. 2. The criteria for entitlement to a rating of 20 percent disabling prior to July 30, 2019, and 40 percent thereafter, but no higher, for peripheral neuropathy of the left lower extremity (sciatic nerve) have been met. 38 U.S.C. §§ 1155, 5107, 5110, 7104, 7105; 38 C.F.R. §§ 3.151, 3.155, 3.156, 3.400, 4.3, 4.7, 4.130, Diagnostic Code 8520. 3. The criteria for entitlement to a rating of 20 percent disabling prior to July 30, 2019, and 40 percent thereafter, but no higher, for peripheral neuropathy of the right lower extremity (sciatic nerve) have been met. 38 U.S.C. §§ 1155, 5107, 5110, 7104, 7105; 38 C.F.R. §§ 3.151, 3.155, 3.156, 3.400, 4.3, 4.7, 4.130, Diagnostic Code 8520. 4. The criteria for entitlement to a compensable rating for hypertension (claimed as high blood pressure) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.31, 4.104, Diagnostic Code 7101. 5. The criteria for a compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.115b, Diagnostic Code 7522. 6. The criteria for an effective date of May 23, 2013, for the grant of TDIU have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.155, 3.157. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from May 1969 to June 1972, including service in Thailand. The Board sincerely thanks the Veteran for his service to our country. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). These claims were previously before the Board in May 2019, when the Board remanded them for further development. The Board finds that there has been substantial compliance with its remand directives. Increased Rating Disability ratings are determined by comparing a Veteran's symptomatology during the pertinent period on appeal with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. An exception to this rule is where the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, so 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter 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 layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means 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 mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence pertinent to the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran's disabilities prior to the rating period on appeal to see if it supports a higher rating during the rating period on appeal. Additional references to the Veteran's disabilities are presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran's disabilities that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. 1. Entitlement to a rating in excess of 40 percent disabling for diabetes mellitus type II associated with herbicide exposure The Veteran seeks to establish entitlement to an increased initial rating for his diabetes disease process, currently assigned a 40 percent rating. The rating for the diabetes mellitus, type 2, has been assigned under 38 C.F.R. § 4.119, Code 7913. Under Diagnostic Code 7913, a 10 percent rating is warranted for diabetes mellitus manageable by restricted diet only. A 20 percent rating is warranted when diabetes mellitus requires insulin and a restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes mellitus that requires insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus 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 mellitus requiring more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) and involving 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. The notes to the Code provide, in part, that compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation, and that noncompensable complications are considered part of the diabetic process under Code 7913. 38 C.F.R. § 4.119, Code 7913. "Regulation of activities" has been defined as a situation in which the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in Diagnostic Code 7913). The Veteran's current 40 percent rating for diabetes mellitus already contemplates, as described in the schedular rating criteria: diabetes mellitus that requires insulin, restricted diet, and regulation of activities. To qualify for the next-higher 60 percent rating under Diagnostic Code 7913, the diabetes mellitus must additionally feature 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 January 2020 VA diabetes rating examination report shows that the Veteran visits his diabetic care provider for episodes of ketoacidosis "Less than 2 times per month." The report also shows that the Veteran visits his diabetic care provider for episodes of hypoglycemia "Less than 2 times per month." Furthermore, the report shows that the Veteran did not have any episodes ("0" episodes) of ketoacidosis or hypoglycemia requiring hospitalization over the prior 12 months. The January 2020 VA examination report was prepared by a competent medical professional informed by review of the claims-file together with interview and examination of the Veteran. The January 2020 VA examination report's findings clearly present an accounting of the Veteran's diabetes disease process that does not meet the criteria for a rating in excess of 40 percent. The Board finds that the January 2020 VA diabetes rating examination report is adequate evidence to inform the rating determination. As there is no contrary evidence with regard to the pertinent medical findings presented, the Board finds the January 2020 VA examination report to be persuasive. Under the rating criteria above, the Veteran's diabetes must feature episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider in order to obtain a rating above 40 percent because all ratings higher than 40 percent include this in their criteria. The record contains an affirmative medical statement that the Veteran's diabetes did not meet these criteria as of the time of the January 2020 VA examination, and there is no testimony or other evidence indicating that he has since experienced episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. Accordingly, the Board finds that the Veteran did not meet the schedular criteria for a rating in excess of 40 percent for any portion of the period on appeal. The preponderance of the evidence is against finding that any increased disability rating is warranted for the Veteran's diabetes disease process on appeal. The Board finds the objective medical evidence provided in the VA examination findings and the Veteran's own testimony to be probative for rating purposes. The Board has considered the doctrine of affording the benefit of the doubt to the appellant, under 38 U.S.C. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Beyond what is addressed elsewhere in this decision, neither the Veteran nor his representative has raised any other issues arising from this rating matter, nor have any other associated issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to a rating in excess of 10 percent disabling for peripheral neuropathy, left lower extremity (sciatic nerve) prior to August 1, 2020, and in excess of 20 percent from that date 3. Entitlement to a rating in excess of 10 percent disabling for peripheral neuropathy, right lower extremity (sciatic nerve) prior to August 1, 2020, and in excess of 20 percent from that date The Veteran's right and left lower extremity peripheral neuropathy, associated with diabetes mellitus, are each rated as 10 percent disabling under Diagnostic Code 8520 for the sciatic nerve prior to August 1, 2020. An October 2020 rating decision granted an increased rating, to 20 percent, for lower extremity. [The rating also separately granted service connection and assigned 20 percent ratings for peripheral neuropathy (femoral nerve) of each extremity. As the Veteran did not disagree with the rating assigned for that disability, it will not be addressed further here.] Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8620 and 8720.) Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The terms "mild," "moderate," and "severe," as used in the various Diagnostic Codes, are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the "mild," or at most, the "moderate" degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at Diseases of the Peripheral Nerves. The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). A March 2015 VA examination report shows the Veteran experienced bilateral lower extremity moderate constant pain, severe paresthesias and/or dysesthesias, and moderate numbness. Neurologic examination showed normal strength and deep tendon reflexes but decreased bilateral foot/toes light touch/monofilament testing results and lower extremity vibration sensation. The Veteran did not have muscle atrophy or trophic changes. The examiner stated that the Veteran has bilateral lower extremity mild incomplete paralysis of the sciatic nerve. The examiner described that the Veteran's diabetic peripheral neuropathy impacts his ability to work because he cannot walk long distances. A July 2019 VA examination report shows the Veteran experienced bilateral lower extremity severe paresthesias and/or dysesthesias and severe numbness, but no pain. Neurologic examination showed left knee less than normal strength and decreased bilateral ankle/lower leg and foot/toes light touch/monofilament testing results. Examination also showed decreased right lower extremity and absent left lower extremity vibration sensation and decreased bilateral vibration sensation. The Veteran did not have muscle atrophy but did have trophic changes, consisting of smooth skin with hair loss on legs and feet, atrophy of intrinsic foot muscles, bilaterally; atrophy of first dorsal interossei and abductor digiti minimi bilaterally, and atrophy of right forearm. The examiner stated that the Veteran has mild right, and moderate left, lower extremity incomplete paralysis of the sciatic nerve. The examiner described that the Veteran's diabetic peripheral neuropathy impacts his ability to work because it restricts manipulation with hands, balancing and working with heights. An August 2020 VA examination report shows the Veteran experienced bilateral lower extremity severe intermittent pain, severe paresthesias and/or dysesthesias, and severe numbness. Neurologic examination showed normal strength but decreased deep tendon reflexes of the ankles and decreased bilateral ankle/lower leg and foot/toes light touch/monofilament testing results. Position sense was normal, but vibration sensation was absent bilaterally and cold sensation decreased bilaterally. The Veteran did not have muscle atrophy but did have trophic changes, consisting of loss of extremity hair, smooth and shiny skin on the arms and legs. The examiner stated that the Veteran has bilateral lower extremity moderate incomplete paralysis of both the sciatic nerve and the femoral nerve. The examiner described that the Veteran's diabetic peripheral neuropathy impacts his ability to work because he cannot stand and walk for a prolonged time. As the March 2015 VA examination shows that the Veteran's diabetic neuropathy was characterized by moderate constant pain, severe paresthesias and/or dysesthesias, and moderate numbness, as well as symptoms of decreased touch/monofilament testing results and vibration sensation, and because the examiner indicated that the Veteran is not able to walk long distances, the Board finds that the severity of the Veteran's manifestations of peripheral neuropathy more nearly approximates moderate incomplete paralysis of the sciatic nerve, bilaterally. Because the examination did not show reduced strength, deep tendon reflexes, trophic changes, or muscle atrophy, the Board finds that the severity of the Veteran's manifestations of peripheral neuropathy does not more nearly approximate moderately severe incomplete paralysis of the sciatic nerve. Accordingly, a 20 percent rating, but no higher, is warranted under Diagnostic Code 8520 for each lower extremity from May 23, 2013. The July 2019 and August 2020 VA examinations show a worsening of the severity of the Veteran's peripheral neuropathy. Because the Veteran consistently reported experiencing severe paresthesias and/or dysesthesias and severe numbness, examination showed decreased deep tendon reflexes, decreased bilateral ankle/lower leg and foot/toes light touch/monofilament testing results, decreased or absent vibration sensation, and trophic changes, and the examiners opined that the Veteran's peripheral neuropathy restricts his balancing and working with heights and prohibits standing or walking for long periods of time, the Board finds that the Board finds that the severity of the Veteran's manifestations of peripheral neuropathy more nearly approximates moderately severe incomplete paralysis of the sciatic nerve, bilaterally, from July 30, 2019, the date of VA examination showing an increase in the Veteran's symptoms. Because the Veteran's peripheral neuropathy does not result in marked muscle atrophy, the Board finds that it does not more nearly approximate severe incomplete paralysis of the sciatic nerve at any time during the period on appeal. Accordingly, a 40 percent rating, but no higher, is warranted under Diagnostic Code 8520 for each lower extremity from July 30, 2013. In summary, the Board finds that, for peripheral neuropathy (sciatic nerve) for the right and left lower extremity, an increased 20 percent rating (but no higher) is warranted from May 23, 2013, the beginning of the rating period for consideration, to July 30, 2019. An increased 40 percent rating (but no higher) is warranted from July 30, 2019. The Board has partially granted some of the Veteran's claims on appeal in this case by awarding the above-discussed increased ratings. For the foregoing reasons, the preponderance of the evidence is against awarding any additional or further increased ratings this case. The Board has considered whether there is any other basis for granting further increased and/or additional ratings but has found none. As the preponderance of the evidence is against assignment of any further increased and/or additional ratings in this case, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Beyond what is addressed in this decision, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with the disabilities for consideration in this appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. Entitlement to a compensable rating for hypertension (claimed as high blood pressure) The Veteran's appeal requires consideration of entitlement to a higher rating for hypertension, currently rated as noncompensable. Hypertension is rated by applying the criteria in 38 C.F.R. § 4.104, Diagnostic Code 7101. Under Diagnostic Code 7101, diastolic pressure predominantly 130 or more warrants a 60 percent rating. Diastolic pressure predominantly 120 or more warrants a 40 percent rating. Diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more, warrants a 20 percent rating. Diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, warrants a 10 percent rating. A 10 percent rating is also the minimum rating for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. The criteria for a 10 percent rating are disjunctive. See Johnson v. Brown, 7 Vet. App. 9 (1994) (only one disjunctive or requirement must be met in order for an increased rating to be assigned). The Board notes that the plain language of Diagnostic Code 7101 contemplates the effects of medication. See McCarroll v. McDonald, 28 Vet. App. 267, 273 (2016). For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mmHg or greater. The term isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mmHg or greater with a diastolic blood pressure of less than 90 mmHg. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. A January 2020 VA hypertension examination report presents three blood pressure readings of "135/80," with the first number representing the systolic value, and the second number the diastolic value. The Veteran's medical records do not otherwise show diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, or a history of diastolic pressure predominantly 100 or more with continuous medication for control. As the evidence does not show diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, the Board cannot conclude that the Veteran's rating for hypertension is compensable under Diagnostic Code 7101. The Board finds that the preponderance of the evidence is against finding that any increased disability rating is warranted for the Veteran's hypertension on appeal. The Board finds the objective medical evidence provided in the VA examination findings to be probative for rating purposes. The Board has considered the doctrine of affording the benefit of the doubt to the appellant, under 38 U.S.C. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Beyond what is addressed elsewhere in this decision, neither the Veteran nor his representative has raised any other issues arising from this rating matter, nor have any other associated issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 5. Entitlement to a compensable rating for erectile dysfunction The Veteran's appeal requires consideration of entitlement to a higher rating for erectile dysfunction, currently rated as noncompensable. Erectile dysfunction is not listed in the Rating Schedule; however, when an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology, are closely analogous. 38 C.F.R. §§ 4.20, 4.27. As such, the Veteran's erectile dysfunction would most appropriately be rated under 38 C.F.R. § 4.115b, Diagnostic Code 7522, which provides for a 20 percent rating for deformity of the penis with loss of erectile power. The Veteran has already been granted special monthly compensation on account of loss of use of a creative organ beginning in April 2014. Pursuant to Diagnostic Code 7522, the next higher rating (the lowest compensable rating) of 20 percent requires both loss of erectile power and a physical deformity. Although the rating schedule does not provide a zero percent evaluation for Diagnostic Code 7522, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Although medical evidence, including the report of a January 2020 VA reproductive system rating examination, shows that the Veteran is not "able to achieve an erection sufficient for penetration and ejaculation with medication," his erectile dysfunction is shown to be associated with his diabetes disease process rather than any deformity. The January 2020 VA examination report expressly confirms that: "Veteran reports normal anatomy with no penile deformity or abnormality." There is no contrary indication of record. As the preponderance of the competent medical evidence is against a finding that the Veteran had a corresponding deformity, a rating in excess of 0 percent is not warranted for the erectile dysfunction in this case. The Board finds that the preponderance of the evidence is against finding that any increased disability rating is warranted for the Veteran's erectile dysfunction on appeal. The Board finds the medical evidence provided in the VA examination findings to be probative for rating purposes. The Board has considered the doctrine of affording the benefit of the doubt to the appellant, under 38 U.S.C. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Beyond what is addressed elsewhere in this decision, neither the Veteran nor his representative has raised any other issues arising from this rating matter, nor have any other associated issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 6. Entitlement to an effective date prior to May 25, 2015 for TDIU In May 2019, the Board found the Veteran raised a claim for TDIU citing Rice v. Shinseki, 22 Vet. App. 447, 454-455 (2009). The rating period for consideration spans back to May 23, 2013, the date that marks the beginning of the rating period on appeal for the service-connected diabetic peripheral neuropathy. TDIU was granted in an October 2020 rating decision which awarded the benefit from May 25, 2016, to August 1, 2020, at which time a combined schedular 100 percent rating went into effect, rendering TDIU moot. Therefore, the question in this case is whether a TDIU is warranted prior to May 25, 2016. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is unable, by reason of his or her service-connected disabilities, to secure or follow a substantially gainful occupation consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. A threshold requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a) is that, if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of identifying one 60 percent disability, or one 40 percent disability in combination, disabilities resulting from a common etiology will be considered as one disability. However, even where the Veteran does not meet these schedular requirements, 38 C.F.R. § 4.16(b) codifies VA's policy under which all veterans who are unable to secure a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Thus, if a Veteran fails to meet the schedular requirements above, an extraschedular rating is for consideration where the Veteran is nonetheless unemployable due to service-connected disability. Id.; see also Fanning v. Brown, 4 Vet. App. 225 (1993). The Board may not grant a TDIU on an extraschedular basis in the first instance. Rather, the matter must be referred to the Director of the Compensation and Pension Service (Director) for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. In determining whether the Veteran is entitled to a TDIU, neither nonservice-connected disabilities nor age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Court has held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). During the period in question, from May 23, 2013, to May 24, 2016, the Veteran was service-connected at a compensable rate for diabetes, rated 40 percent; peripheral neuropathy of the left lower extremity, 20 percent; peripheral neuropathy of the right lower extremity, 20 percent; and tinnitus, 10 percent. As one of these disabilities is rated 40 percent and they combine to 70 percent, the schedular criteria for consideration of a TDIU under 38 C.F.R. § 4.16(a) are met for this period. See 38 C.F.R. § 4.25. The Veteran has not asserted, and the evidence does not show that TDIU is warranted based on any single service-connected disability. See October 2020 VA Form 21-8940 (asserting TDIU is warranted based upon consideration of all his service-connected disabilities). The Veteran's August 2020 filing of a VA Form 21-8940 shows that he reported that he was last employed in 2006. He reported a completed high school education and one year of college, and that he last worked as a government quality assurance representative. This information, including the indication that the Veteran's last employment concluded significantly prior to the rating period for consideration in this case, is essentially consistent with the discussion of the Veteran's history presented in VA medical records, including the VA peripheral nerve examination reports discussed earlier in this Board decision. The evidence regarding the Veteran's potential entitlement to a TDIU for the rating period under review is not unequivocally clear. However, the Board has carefully considered potentially favorable evidence, including a June 2009 treatment record indicating that the Veteran's diabetic sensory peripheral neuropathy remained unchanged: he experienced decreased epicritic sensation in both feet, his gait pattern was antalgic, apropulsive, unable to walk, abducted gait, hyperpronatory and the Veteran required crutches to stabilize himself. At the March 2015 Peripheral Neuropathy C&P examination, the examiner noted that the Veteran's ability to work is impacted by his inability to walk long distances. At the March 2015 Diabetes Mellitus C&P examination, the examiner noted that the Veteran must regulate his activities, and restrictions include that walking or standing is difficult for prolonged period, that the Veteran has progressive loss of strength, constant pain in legs, uses can and mobility scooter for short distances. In addition, the October 2013 VA examiner noted that eh Veteran's hearing effects his ability to work in that he misunderstands what is said and has to ask people to repeat what they have said. In December 2020 correspondence, the Veteran reported that he retired from Department of Defense, where he was responsible for inspecting aircrafts, in 2006 because he was not longer physically able to perform his job duties. The Veteran reported extreme difficulty walking to the aircraft from the parking lot, requiring frequent rest from standing, exhaustion, and extreme pain from being on his feet the majority of the day. The Veteran also reported that accommodations were unavailable due to the nature of the job. The Veteran is competent to report his experience and observable symptoms, and his reports of pain and the need to rest or lean against something are reasonably consistent with the medical evidence of record. The Board finds the Veteran's report credible. The evidence is not unequivocally clear with regard to the Veteran's entitlement to a TDIU during the period on appeal. However, resolving reasonable doubt in the Veteran's favor, the Board can conclude that the Veteran has been impaired by his service-connected diabetes and associated diabetic peripheral neuropathy and tinnitus to a degree that has caused him to be unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience during this period. The Board finds that the evidence reasonably shows entitlement to a TDIU throughout the rating period on appeal; this TDIU can be awarded on the basis of the Veteran's diabetes and associated diabetic peripheral neuropathy alone. The Board notes that the 2016 date of entitlement to TDIU was initially based on when the Veteran met the schedular criteria for TDIU. Pursuant to this decision, the Veteran meets the schedular criteria from May 23, 2013. Based on detailed review of the foregoing, resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's service-connected diabetes and associated diabetic peripheral neuropathy and tinnitus has precluded him from all forms of substantially gainful employment consistent with his educational background and occupational experience throughout the period from May 23, 2013, to May 24, 2016. (No earlier effective date is available for this award as service-connected status is not in effect for any disability prior to May 23, 2013.) The Veteran and his representative have not raised any other issues in connection with the issues on appeal, nor have any other issues been reasonably raised by the record in connection with these matters. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board O. Halpern 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.