Citation Nr: 21072718 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 17-48 591 DATE: December 7, 2021 ORDER Service connection for depression is granted. As the reduction of the disability rating for right lower extremity peripheral neuropathy from 20 percent to 10 percent was improper, the 20 percent rating is restored effective September 8, 2020. As the reduction of the disability rating for left lower extremity peripheral neuropathy from 20 percent to 10 percent was improper, the 20 percent rating is restored effective September 8, 2020. A rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with depression is denied. A rating in excess of 20 percent for diabetes mellitus type II is denied. A rating in excess of 20 percent for right lower extremity sciatic nerve peripheral neuropathy is denied. A rating in excess of 20 percent for left lower extremity sciatic nerve peripheral neuropathy is denied. A rating in excess of 10 percent for right lower extremity femoral nerve peripheral neuropathy is denied. A rating in excess of 10 percent for left lower extremity femoral nerve peripheral neuropathy is denied. A total disability rating based on individual unemployability (TDIU) prior to September 8, 2020 is granted. REMANDED Service connection for colon cancer. Service connection for a digestive disorder. FINDINGS OF FACT 1. The Veteran has depression which is associated with his service-connected PTSD. 2. When reducing the Veteran's bilateral lower extremity peripheral neuropathy ratings from 20 percent to 10 percent, effective September 8, 2020, the Regional Office (RO) did not issue a proposed notice of the reduction informing him that he had 60 days to present additional evidence to show that compensation payments should be continued at the current level and that he had 30 days to request a predetermination hearing. 3. The severity, frequency, and duration of the Veteran's PTSD with depression symptoms have not approximated occupational and social impairment with deficiencies in most areas. 4. The Veteran's diabetes mellitus results in dietary restrictions, oral medication, and daily insulin injections, but has not led to regulation of activities. 5. The Veteran's right lower extremity sciatic nerve peripheral neuropathy has manifested in no worse than moderate incomplete paralysis. 6. The Veteran's left lower extremity sciatic nerve peripheral neuropathy has manifested in no worse than moderate incomplete paralysis. 7. The Veteran's right lower extremity femoral nerve peripheral neuropathy has manifested in no worse than mild incomplete paralysis. 8. The Veteran's left lower extremity femoral nerve peripheral neuropathy has manifested in no worse than mild incomplete paralysis. 9. Prior to September 8, 2020, the Veteran was prevented him from securing and following substantially gainful employment due to the combined effects of the PTSD with depression, hypertension and diabetes. CONCLUSIONS OF LAW 1. The criteria for service connection for depression have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The reduction in the right lower extremity peripheral neuropathy rating from 20 percent to 10 percent, effective September 8, 2020, was improper and is void ab initio. 38 U.S.C. § 1155; 38 C.F.R. § 3.105. 3. The reduction in the left lower extremity peripheral neuropathy rating from 20 percent to 10 percent, effective September 8, 2020, was improper and is void ab initio. 38 U.S.C. § 1155; 38 C.F.R. § 3.105. 4. The criteria for a rating in excess of 50 percent for PTSD with depression have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 5. The criteria for a rating in excess of 20 percent for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.119, DC 7913. 6. The criteria for a rating in excess of 20 percent for right lower extremity sciatic nerve peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8520. 7. The criteria for a rating in excess of 20 percent for left lower extremity sciatic nerve peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8520. 8. The criteria for a rating in excess of 10 percent for right lower extremity femoral nerve peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8526. 9. The criteria for a rating in excess of 10 percent for left lower extremity femoral nerve peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8526. 10. The criteria for a TDIU throughout the appeal period have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1967 to December 1968, to include service in the Republic of Vietnam. The case is on appeal from January 2016 and February 2017 rating decisions. The claims came before the Board in January 2020 and were remanded for further development. The record reflects that additional evidence was received following the September 2020 supplemental statement of the case (SSOC), including a VA examination. However, such evidence is not relevant to the issues adjudicated herein. Thus, there is no prejudice to the Veteran in proceeding with appellate review for the matters on appeal. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). I. SERVICE CONNECTION 1. Service connection for depression. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(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." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis The Veteran contends that he has depression which is causally related to his service-connected PTSD. The Board notes the Veteran has been service connected for PTSD since December 19, 2001 and the disorder is currently rated as 50 percent disabling. Following the Veteran's October 2016 claim, the Veteran was afforded a January 2017 VA examination in which he was diagnosed with PTSD. The Veteran denied depressive episodes on examination. Thereafter, the Veteran submitted a September 2017 substantive appeal in which he asserts he has severe depression on a daily basis which is associated with his PTSD. The claim was remanded by the Board in January 2020 for further development, to include a VA examination to determine the etiology of any diagnosed depression. The Veteran was afforded an August 2020 VA examination in which the examiner indicated the Veteran's claim for depression is not needed, as he is already service connected for PTSD. She reported the Veteran has mild symptoms of depression which are subsumed within his PTSD. She stated the depression symptoms do not meet all the criteria for a diagnosis of depressive disorder, although the evidence of record indicated ongoing symptoms of depression. Further, during the August 2020 VA examination to assess the Veteran's PTSD, the Veteran reported he has depression, described as pressure on his peace of mind. The examiner further noted symptoms of depressed mood. The Board determines service connection for depression is warranted, as secondary to his service-connected PTSD. The Board finds the Veteran has a diagnosis of depression which is causally related to his PTSD. The August 2020 VA examiner opined the Veteran has depression which is subsumed within his PTSD. Therefore, service connection for depression is warranted. The Board notes the Veteran is not precluded from pursuing multiple psychiatric conditions. See Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009). However, this does not mean there can be separate ratings for the same symptoms, which is pyramiding. See 38 C.F.R. § 4.14. The Board notes it is adjudicating below the claim for a rating in excess of 50 percent for PTSD. Accordingly, the Board finds that service connection for depression is warranted as secondary to the Veteran's service-connected PTSD. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. II. RATING REDUCTIONS 1. Whether the reduction from a 20 percent rating to a 10 percent rating for right lower extremity peripheral neuropathy, effective September 8, 2020, was proper. 2. Whether the reduction from a 20 percent rating to a 10 percent rating for left lower extremity peripheral neuropathy, effective September 8, 2020, was proper. Legal Criteria Generally, when reduction in the evaluation of a service-connected disability is contemplated and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The veteran must be notified at his latest address of record of the contemplated action and furnished detailed reasons therefore. The veteran must be allowed an opportunity to participate in a personal hearing, with the request received within 30 days of the notice provided, and given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level. 38 C.F.R. § 3.105(e), (i). After the allotted period, if no additional evidence has been submitted, final rating action will be taken, and the rating 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 expires. 38 C.F.R. § 3.105(e). A rating is not reduced unless an improvement in a veteran's disability is shown to have occurred. 38 U.S.C. § 1155. There are greater protections when the rating has been in effect for 5 or more years. 38 C.F.R. § 3.344(a). Analysis Procedurally, the Veteran's claims for bilateral lower extremity peripheral neuropathy were granted in the July 2013 rating decision and he was assigned 20 percent ratings effective May 23, 2012. Thereafter, in a February 2017 rating decision, the lower extremity ratings were reduced to 10 percent effective January 24, 2017. In its January 2020 decision, the Board determined restoration of the bilateral lower extremity peripheral neuropathy ratings was appropriate. Pursuant to this decision, the RO issued a May 2020 rating decision which restored the Veteran's ratings. Thereafter, a September 2020 rating decision decreased the Veteran's bilateral lower extremity peripheral neuropathy ratings to 10 percent effective September 8, 2020. The Board again finds that the reduction by the RO from 20 percent to 10 percent for the bilateral lower extremity ratings is void ab initio for failing to follow all due process requirements. In this regard, the RO failed to send the Veteran a proposed reduction letter which informed him that he had (1) 60 days to present additional evidence to show that compensation payments should be continued at the current level and (2) that he had 30 days to request a predetermination hearing. See 38 C.F.R. § 3.105(e), (i). Contrary to these guidelines, the September 2020 rating decision reduced the Veteran's bilateral lower extremity peripheral neuropathy ratings with no notification of proposal. Thus, because advance notice was not given in regard to this action, the reduction is void ab initio. Thus, the Board determines restoration of the 20 percent bilateral lower extremity peripheral neuropathy ratings is warranted effective September 8, 2020. III. INCREASED RATINGS General Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 1. A rating in excess of 50 percent for PTSD. Specific Legal Criteria The Veteran's service-connected psychiatric disorder, to include PTSD and depression, has been rated under DC 9411, which provides that a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereo-typed 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, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. A 100 percent rating requires 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; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Analysis should not be limited to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board notes that global assessment of functioning (GAF) scores have been found to be unreliable and not sufficient evidence for rating a psychiatric disorder. See Golden v. Shulkin, 29 Vet. App. 221, 226 (2018). Analysis The Veteran is seeking a rating in excess of 50 percent for his PTSD. Following the October 2016 claim for an increased rating, the Veteran was afforded a January 2017 VA examination in which the examiner indicated his PTSD causes occupational and social impairment with reduced reliability and productivity. The examiner indicated he experiences symptoms of avoidance, detachment, irritability, hypervigilance, as well as anxiety, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. The examiner stated the Veteran showed normal speech, thought processes, and memory, with no suicidal or homicidal ideation. The Veteran submitted a September 2017 substantive appeal in which he indicated his PTSD has worsened, including daily symptoms of panic attacks, severe depression, anxiety, anger, social impairment and unprovoked irritability. The claim was remanded by the Board in January 2020 for a VA examination to determine the severity of the disorder. The Veteran was afforded an August 2020 VA examination in which the examiner opined his PTSD causes occupational and social impairment due to mild or transient symptoms. She indicated the Veteran has symptoms of depressed mood, anxiety, chronic sleep impairment, disturbance of motivation and mood, difficulty in adapting to stressful circumstances, including work or a work like setting. The examiner noted he experiences no suicidal or homicidal ideation, and his judgment and insight are within normal limits. She further reported the Veteran has been married for 47 years with 4 children and 2 grandchildren and has a good relationship with his family. The examiner noted the Veteran retired from working in 2015 and enjoys working on cars and home improvements. After engaging in a holistic analysis assessing the severity, frequency and duration of the signs and symptoms of the Veteran's PTSD with depression, recognizing that the symptoms listed in the rating criteria are non-exhaustive examples and when looking at the effects determining the impairment level, the Board finds that a rating of in excess of 50 percent is not warranted at any time during the appeal period. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013); Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); Mauerhan v. Principi, 16 Vet. App. 436 442 (2002). In this regard, the January 2017 VA examiner's opinion indicated the Veteran's PTSD causes occupational and social impairment with reduced reliability and productivity, along with the August 2020 VA opinion which stated his PTSD causes occupational and social impairment due to mild or transient symptoms. While many psychiatric symptoms were noted in the record, such symptoms do not rise to the level demonstrating occupational and social impairment with deficiencies in most areas and a 70 percent rating. The Veteran's psychiatric impairment most closely approximates occupational and social impairment with reduced reliability and productivity. Thus, the current 50 percent rating is supported and a rating in excess of 50 percent for PTSD is not warranted. See 38 C.F.R. § 4.130, DC 9411. The Board acknowledges the severity of the Veteran's symptoms and the social and occupational impact such symptoms have caused. As noted above, he experiences depression, anxiety, chronic sleep impairment, disturbance of motivation and mood, and difficulty in adapting to stressful circumstances. However, overall symptomatology justifying a 70 percent rating has not been exhibited. Specifically, his symptoms do not include suicidal ideation, impaired impulse control, obsession rituals, impaired thought content or speech, neglect of personal appearance or an inability to establish and maintain effective relationships. While the January 2017 examiner noted difficulty in establishing and maintaining relationships, the record shows the Veteran has been married for over 45 years and has children and grandchildren with whom he has good relationships. In sum, the preponderance of the evidence weighs against finding that the Veteran's psychiatric symptoms resulted in the level of impairment required for a 70 percent rating. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Thus, an increased rating in excess of 50 percent for PTSD is denied. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). 2. A rating in excess of 20 percent for diabetes mellitus type II. Specific Legal Criteria The Veteran's diabetes mellitus is rated under 38 C.F.R. § 4.119, DC 7913. DC 7913 provides for a 10 percent rating for diabetes manageable by a restricted diet only; a 20 percent rating is warranted for diabetes requiring one or more daily injection of insulin and restricted diet, or requiring an oral hypoglycemic agent and restricted diet; a 40 percent rating is warranted for diabetes requiring one or more daily injection of insulin, restricted diet, and regulation of activities, defined within the diagnostic code as avoidance of strenuous occupational and recreational activities; a 60 percent rating is warranted for diabetes requiring one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated; and 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. Note 1 following DC 7913 states to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100-percent evaluation, but noncompensable complications are considered part of the diabetic process under DC 7913. Analysis The Veteran contends that a rating in excess of 20 percent is warranted for his service-connected diabetes mellitus. Following the October 2016 claim for an increased rating, the Veteran was afforded a January 2017 VA examination. The examiner reported that he has diabetes that is managed by a restricted diet, prescribed oral hypoglycemic agents, and requires one insulin injection per day. The examiner found the Veteran does not require regulation of activities as part of his medical management. The examiner also found that the Veteran's diabetes mellitus does not impact his ability to work. The Veteran submitted a September 2017 substantive appeal in which he reported that his diabetes mellitus has worsened and that he should be afforded a VA examination to determine the extent of the disorder. In the January 2020 decision, the Board remanded the claim for a VA examination to determine the severity of the disorder. The Veteran was afforded another VA examination in September 2020. The examiner indicated that the Veteran's diabetes is managed by a restricted diet, prescribed oral hypoglycemic agents, and requires one insulin injection per day. The examiner reported that the Veteran does not require regulation of activities as part of his medical management. He indicated the Veteran had no hospitalizations, although he had lost weight due to his diabetes, approximately 10 percent of his total weight. Additionally, the examiner reported the Veteran's diabetes impacts his ability to work, including decreasing his ability to focus or concentrate with hyper or hypoglycemia and related symptoms. The Board finds that a rating in excess of 20 percent for the Veteran's diabetes mellitus is not warranted. In this regard, the evidence shows that the Veteran's diabetes is treated by medication, including insulin injections, but the evidence does not show that it results in required regulation of activities. The term "regulation of activities" means that a veteran must have a medical need to avoid strenuous occupational and recreational activities and medical evidence is needed to show such activities have been restricted. See 38 C.F.R. § 4.119, DC 7913; Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). In this case, the medical evidence does not show that the Veteran's diabetes mellitus resulted in the need for regulation of activities. The September 2020 examiner reported the Veteran's diabetes impacts his ability to work, including decreasing his ability to focus or concentrate. However, the evidence during the appeal period does not show that he has restrictions prescribed by a medical professional and related to his diabetes which cause him to avoid strenuous occupational and recreational activities. The Board notes that the September 2020 examiner reported that the Veteran had lost approximately 10 percent of his total weight due to diabetes. While weight loss is part of the symptomatology listed for a 100 percent rating, the rating criteria for evaluating diabetes mellitus are conjunctive and successive in nature. 38 C.F.R. § 4.119, DC 7913. Therefore, without sufficient evidence of a requirement for regulation of activities, a rating in excess of 20 percent is not warranted. Additionally, the Board notes the Veteran has nephropathy, erectile dysfunction, hypertension, and upper and lower extremity peripheral neuropathy related to his diabetes mellitus, which are all service connected and rated separately. Therefore, the Board finds that the evidence does not support a rating in excess of 20 percent for the Veteran's diabetes mellitus, as the disorder has not resulted in the regulation of activities. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Thus, a rating in excess of 20 percent for diabetes mellitus is not warranted. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). 3. A rating in excess of 20 percent for right lower extremity sciatic nerve peripheral neuropathy. 4. A rating in excess of 20 percent for left lower extremity sciatic nerve peripheral neuropathy. 5. A rating in excess of 10 percent for right lower extremity femoral nerve peripheral neuropathy. 6. A rating in excess of 10 percent for left lower extremity femoral nerve peripheral neuropathy. Specific Legal Criteria All of the Veteran's right and left lower extremity peripheral neuropathies are rated under the peripheral nerve impairment provisions of 38 C.F.R. § 4.124a, DCs 8520, 8526. A 10 percent rating is warranted where there is mild incomplete paralysis of the sciatic nerve; a 20 percent rating is warranted where there is moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is warranted where there is moderately severe incomplete paralysis of the sciatic nerve; a rating of 60 percent is warranted for severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy; and the highest rating of 80 percent is warranted with complete paralysis of the sciatic nerve (where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or lost). For rating disease of the peripheral nerves, 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. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. For the purposes of evaluating these disabilities, moderate is "tending toward the mean or average amount or dimension" and "severe" is "of a great degree." See www.merriam-webster.com/dictionary/moderate; www.merriam-webster.com/dictionary/severe. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, an effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating-as well as for an initial rating or for staged ratings-is predicated on when the increase in the level of disability can be ascertained. Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). In determining when an increase is "factually ascertainable," all of the evidence must be looked to, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, "it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date." Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Analysis As discussed above, the Board restored the Veteran's bilateral lower extremity sciatic nerve peripheral neuropathy ratings to 20 percent effective September 8, 2020. The bilateral lower extremity ratings remain on appeal and the Board will review the claims for potential ratings in excess of 20 percent during the appeal period. Following the October 2016 claims for increased ratings, the Veteran was afforded a January 2017 VA examination in which the examiner indicated he has symptoms in his bilateral lower extremities of mild intermittent pain and mild numbness. The examiner found his neurologic and reflex examinations were normal, but that the Veteran's feet had decreased sensation. She concluded the Veteran has mild incomplete paralysis in both lower extremities. In the Veteran's September 2017 substantive appeal, he stated his lower extremity peripheral neuropathy has worsened. The Board remanded the claims in January 2020 for a VA examination to determine the severity of the disorders. The Veteran was afforded a VA examination on September 8, 2020. The examiner found symptoms of mild intermittent pain, mild paresthesias and/or dysesthesias and mild numbness in both lower extremities. He reported the Veteran's neurologic examination was normal, but found that he has decreased touch, position sense, vibration sense and cold sensation to his lower extremities. He concluded that the Veteran has sciatic nerve impairment causing mild incomplete paralysis in both lower extremities as well as femoral nerve impairment causing mild incomplete paralysis in both lower extremities. The overall severity of the lower extremity sensory neuropathy was determined to be mild. In a September 2020 rating decision, the RO granted separate 10 percent ratings for right and left lower extremity femoral nerve peripheral neuropathies effective September 8, 2020. The Board finds that increased ratings in excess of 20 percent for bilateral lower extremity sciatic nerve peripheral neuropathies and in excess of 10 percent for bilateral lower extremity femoral nerve peripheral neuropathies are not warranted. In this regard, the examinations of record do not show symptoms that approximate moderately severe incomplete paralysis of the lower extremities supportive of higher ratings. Moreover, the January 2017 VA examiner indicated symptoms of mild intermittent pain and numbness in the lower extremities. Further, the September 2020 examiner opined the Veteran has symptoms of mild intermittent pain, paresthesias, and numbness in both lower extremities. The Board notes he reported the Veteran has decreased touch, position sense, vibration sense and cold sensation in his lower extremities. However, the examiner concluded that the Veteran's overall severity of the lower extremity neuropathy to be mild. Thus, the evidence does not support symptoms approximating moderately severe incomplete paralysis of the right or left sciatic nerve or moderate incomplete paralysis of the right or left femoral nerve. The Board has considered whether an earlier effective date prior to September 8, 2020 should be assigned for the Veteran's bilateral lower extremity femoral nerve ratings. However, the VA examination conducted on such date was the first time that the Veteran was found to experience any symptoms related to either his right or left femoral nerves. Therefore, the effective date assigned for such ratings is properly assigned as of the date of such examination as it is the first date these separately compensable disabilities are shown to have been present. 38 C.F.R. § 3.400(o)(1); Swain, 27 Vet. App. at 224. In sum, the preponderance of the evidence shows that the Veteran's right and left lower extremity sciatic nerve peripheral neuropathy has manifested in no worse than moderate incomplete paralysis and his right and left lower extremity femoral nerve peripheral neuropathy has manifested in no worse than mild incomplete paralysis. Thus, the benefit of the doubt doctrine is not applicable, and ratings in excess of 20 percent for right and left lower extremity sciatic nerve peripheral neuropathy and in excess of 10 percent for right and left lower extremity femoral nerve peripheral neuropathy are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the Board is remanding other claims for additional development, remand is not necessary for these issues, as there is no reasonable possibility that further assistance would substantiate the claims. See 38 C.F.R. § 3.159(d). IV. TDIU 1. A TDIU. Legal Criteria Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: The veteran's history, education, skill, and training; Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Analysis The Veteran contends that his service-connected disabilities have prevented him from securing and following substantially gainful employment. Specifically, in his July 2017 TDIU application, he claimed that his PTSD, diabetes mellitus, and high blood pressure have prevented all substantially gainful employment. The Veteran reported that he last work full-time and became too disabled to work in 2015. He also reported his only employment experience is working as a warehouse associate. He further reported that he did not graduate from high school or complete any additional vocational training. Initially, the Board notes that effective September 8, 2020, the Veteran is in receipt of a 100 percent combined schedular rating. See 38 C.F.R. § 4.25. The Board notes that the presence of a schedular 100 percent disability rating does not necessarily render the issue of TDIU moot. See Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008) (holding that 100 percent evaluation does not render a TDIU claim moot where there is a possibility that TDIU will impact entitlement to special monthly compensation (SMC) based on receipt of service connection for a disability with a 100 percent rating and another with a separate 60 percent rating). In this case, however, the Veteran does not have a single disability that is 100 percent rated, nor does he allege that any single disability rendered him unable to work. Rather, his contention is that the combined effect of his service-connected PTSD, diabetes mellitus, and high blood pressure have prevented all substantially gainful employment. Therefore, under the facts of this case, his 100 percent schedular combined disability rating, from September 8, 2020, renders his TDIU claim moot, effective from that date. Thus, the issue becomes whether his service-connected disabilities precluded him from securing or following substantially gainful employment prior to September 8, 2020. As such, the issue has been appropriately recharacterized above. In the Veteran's January 2017 VA diabetes examination, the examiner found the Veteran's diabetes mellitus is managed by a restricted diet, prescribed oral hypoglycemic agents and that he requires one insulin injection per day. However, the examiner indicated the disorder does not impact the Veteran's ability to work. During the January 2017 VA peripheral neuropathy examination, the examiner indicated the lower extremity disorders caused mild intermittent pain and numbness. She reported the disorders did not impact the Veteran's ability to work. Further, the January 2017 VA psychiatric examiner indicated the Veteran's PTSD causes occupational and social impairment with reduced reliability and productivity. He noted symptoms of avoidance, detachment, irritability, hypervigilance, anxiety, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. In addition, the Veteran's diabetes complications include bilateral peripheral neuropathies discussed above as well as diabetic nephropathy. The claim for a TDIU came before the Board in January 2020 and was remanded as it is inextricably intertwined with the increased rating claims on appeal. During the August 2020 VA PTSD examination, the examiner indicated the Veteran's PTSD causes occupational and social impairment due to mild or transient symptoms. She noted symptoms of chronic sleep impairment, disturbance of motivation and mood, difficulty in adapting to stressful circumstances, including work or a work like setting. The September 2020 VA peripheral neuropathy examiner indicated symptoms of mild intermittent pain, mild paresthesias and/or dysesthesias and mild numbness in both lower extremities. He reported the Veteran has decreased touch, position sense, vibration sense and cold sensation to his lower extremities. Further, the September 2020 VA diabetes mellitus examiner reported the Veteran's diabetes is managed by a restricted diet, prescribed oral hypoglycemic agents and required insulin, one injection per day, with no required regulation of activities. The Veteran was afforded a September 2020 VA hypertension examination in which the examiner indicated the disorder does not impact the Veteran's ability to work. Additionally, as noted above, effective September 8, 2020, the Veteran is in receipt of a 100 percent combined schedular rating. As such, the claim for a TDIU prior to September 8, 2020, is the issue on appeal. After review of the evidence, the Board finds the combined effects of the Veteran's PTSD with depression, hypertension and diabetes and its complications have prevented substantially gainful employment throughout the period on appeal. In this regard, the Veteran has met the schedular criteria with a combined disability rating of 80 percent with one disability rated over 40 percent since October 17, 2016. In addition, the Veteran's diabetes results in lower extremity symptoms and nephropathy that prevents him from performing warehouse employment. In addition, he is prevented from transitioning to employment in a sedentary occupation due to his lack of a high school diploma or relevant work experience and the severity of his psychiatric symptoms. The preponderance of the evidence shows that, prior to September 8, 2020, the Veteran was prevented him from securing and following substantially gainful employment due to the combined effects of the Veteran's PTSD with depression, hypertension and diabetes. Therefore, a TDIU is warranted throughout the period on appeal. REASONS FOR REMAND 1. Service connection for colon cancer. 2. Service connection for a digestive disorder. The Veteran contends that he has colon cancer and a digestive disorder, to include inflammatory bowel disease and ulcerative colitis, that are related to service, including in-service exposure to herbicides. The Veteran's service personnel records confirm service in Vietnam and thus, exposure to herbicides. The service connection claims were remanded by the Board in January 2020 for a VA examination to determine the etiology of the conditions. The Veteran was afforded a September 2020 VA examination in which the examiner opined the Veteran's colon cancer and digestive disorders are not etiologically related to service, to include herbicide and Agent Orange exposure. He stated there is no sufficient evidence to support a causative relationship between the Veteran's service and his diagnosed colon cancer and subsequent colon resection, as well as his fecal incontinence, inflammatory bowel disease, and ulcerative colitis. The Board finds an additional VA opinion is warranted, as the rationale provided by the September 2020 examiner was not adequate to determine the etiology of the disorders. While a negative nexus opinion was provided, the examiner did not adequately discuss the Veteran's exposure to herbicides during service with regard to a potential etiology to colon cancer and a digestive disorder. As such, VA opinions are warranted from a physician to determine the etiology of the conditions. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from a qualified physician to determine the nature and etiology of the Veteran's colon cancer. The examiner is to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's colon cancer had its onset during, or is otherwise related to, service, including the Veteran's exposure to herbicides in Vietnam. 2. Obtain a VA medical opinion from a qualified physician to determine the nature and etiology of the Veteran's digestive disorder. The examiner is to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's digestive disorder had its onset during, or is otherwise related to, service, including the Veteran's exposure to herbicides in Vietnam. DAVID JIMERFIELD Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Isaacs, Brandon 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.