Citation Nr: 21006087 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 14-15 258A DATE: February 3, 2021 ORDER Entitlement to service connection for bilateral eye disability, to include as secondary to service-connected type II diabetes mellitus, is denied. Entitlement to a 20 percent rating, but no higher, prior to September 20, 2011, for right upper extremity peripheral neuropathy, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a 40 percent rating, but no higher, from September 20, 2011, for right upper extremity peripheral neuropathy, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a 20 percent rating, but no higher, prior to September 20, 2011, for left upper extremity peripheral neuropathy, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a 30 percent rating, but no higher, from September 20, 2011, for left upper extremity peripheral neuropathy, is granted, subject to controlling regulations governing the payment of monetary awards. FINDINGS OF FACT 1. The Veteran’s bilateral eye disability did not have its onset in service, is not otherwise related to an in-service injury or disease, and is not caused or aggravated by service-connected type II diabetes mellitus. 2. During the claim period prior to September 20, 2011, the Veteran’s right and left upper extremity peripheral neuropathy were manifested by no more than mild incomplete paralysis of the median and ulnar nerves. 3. Since September 20, 2011, the Veteran’s right and left upper extremity peripheral neuropathy have been manifested by no more than moderate incomplete paralysis of the median and ulnar nerves. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral eye disability, to include as secondary to service-connected type II diabetes mellitus, are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 4.9. 2. The criteria for a 20 percent rating, but no higher, prior to September 20, 2011, for right upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8513. 3. The criteria for a 40 percent rating, but no higher, from September 20, 2011, for right upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8513. 4. The criteria for a 20 percent rating, but no higher, prior to September 20, 2011, for left upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8513. 5. The criteria for a 30 percent rating, but no higher, from September 20, 2011, for left upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8513. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1964 to January 1966, which includes service in the Republic of Vietnam. These matters initially came before the Board of Veterans’ Appeals (Board) from a September 2011 rating decision. In April 2016, the Board granted the Veteran’s application to reopen the claim of service connection for bilateral eye disability. The Board remanded the underlying claim, as well as the issues of entitlement to increased ratings for right and left upper extremity peripheral neuropathy, for further development. In October 2018 and March 2019, the agency of original jurisdiction (AOJ) awarded increased (30 percent and 20 percent) disability ratings for right and left upper extremity peripheral neuropathy, respectively, both from August 22, 2018. In February 2020, the Board again remanded these matters for further development. In November 2020, a Decision Review Officer (DRO) awarded increased (40 percent and 30 percent) disability ratings for right and left upper extremity peripheral neuropathy, respectively, both from August 22, 2018. In the April 2016 and February 2020 remands, the Board directed the AOJ to, among other things, ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records, obtain the Veteran’s outstanding VA treatment records, afford the Veteran a VA examination to assess the severity of his service-connected bilateral upper extremity peripheral neuropathy, and obtain medical opinions as to whether the Veteran’s claimed bilateral eye disability was caused or aggravated by his service-connected diabetes mellitus. Pursuant to the Board’s remand, the Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records by way of a February 2018 letter. Copies of the authorization forms (VA Forms 21-4142a and 21-4142) were included with the letter. Moreover, his outstanding VA treatment records were obtained and associated with his claims file, he was afforded a VA neurological examination in August 2018 to assess his service-connected bilateral peripheral neuropathy of the upper extremities, and medical opinions were most recently provided as to whether his claimed bilateral eye disability was caused or aggravated by his service-connected diabetes mellitus in September 2020. Therefore, the AOJ substantially complied with the Board’s pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). As a final preliminary matter, in light of the Veteran’s reported symptoms and contentions and to encompass all disorders that are reasonably raised by the record, the Board has re-characterized the claim of service connection for refractive error (claimed as eyes and vision condition) as a claim of service connection for bilateral eye disability. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim). I. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability which is proximately due to, the result of, or aggravated by service-connected disease or injury. 38 C.F.R. § 3.310(a),(b). Entitlement to service connection for bilateral eye disability, to include as secondary to service-connected type II diabetes mellitus The question for the Board is whether the Veteran has current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease or is caused or aggravated by service-connected disability. The Board finds, for the following reasons, that, while there is evidence that the Veteran has current bilateral eye disability, the claimed eye disability is not shown to have had its onset in service, to be otherwise related to a disease or injury in service, or to be caused or aggravated by service-connected diabetes mellitus. As an initial matter, the Board notes that the report of the Veteran’s January 1964 entrance examination documents that his visual acuity was measured as being 20/40 in the left eye and that he had defective vision at the time of his entrance into service. A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). The law provides that refractive error of the eyes is a developmental defect and not a disease or injury within the meaning of applicable legislation. In the absence of superimposed disease or injury, service connection is not granted for refractive error of the eyes, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. See 38 C.F.R. §§ 3.303 (c), 4.9. Developmental defects, such as refractive error, automatically rebut the presumption of soundness and therefore are considered to have pre-existed service. Id.; See also Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); Winn v. Brown, 8 Vet. App. 510, 516 (1996). There is no evidence of any pre-existing eye problems prior to service other than defective vision and the Veteran’s January 1964 entrance examination did not otherwise identify any other eye abnormalities. Therefore, the Board finds that the evidence is not clear and unmistakable that any eye abnormality other than defective vision pre-existed service and was not aggravated in service. Thus, with regard to the Veteran’s eyes, he is presumed sound at service entrance other than for defective vision. 38 U.S.C. § 1111. In this regard, the law and regulation relating to the presumption of soundness reflects that it applies to specific conditions and not more generally to a part of the anatomy. The Veteran’s medical records reflect that he has been diagnosed as having various bilateral eye disabilities. For instance, the report of a September 2020 VA eye examination shows that he experiences bilateral intraocular lens, bilateral corneal arcus, right eye ptosis, bilateral dry eye syndrome, bilateral open angle glaucoma, and left ocular hypertension. Thus, current bilateral eye disability has been demonstrated. The Veteran does not contend that his bilateral eye disability is directly related to service. In this regard, he has not reported, and the evidence does not otherwise reflect, that he has experienced a continuity of eye symptomatology in the years since service. There is no evidence of any complaints of or treatment for specific eye problems other than defective vision in the Veteran’s service treatment records and his December 1965 separation examination was normal other than for defective vision (at which time his visual acuity was measured as being 20/20 in the right eye and 20/50 in the left eye). Also, the earliest clinical evidence of eye problems following service is reflected in an October 2003 VA cardiology note, which indicates that the Veteran was treated for cataracts in December 2001. There is no evidence of any earlier eye problems following service. The absence of any evidence of eye problems for over three decades after the Veteran’s separation from active service in January 1966 is one factor weighing against a finding that his current bilateral eye disability was present in service or in the year or years immediately after service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue).” Hence, neither the clinical record nor the lay statements of record establish a continuity of symptomatology with respect to the claimed bilateral eye disability The Veteran primarily contends that his claimed bilateral eye disability is associated with his service-connected diabetes mellitus. The competent, probative opinions on whether there is any such relationship weigh against the claim. The examiner who conducted a November 2005 VA eye examination concluded that the Veteran had refractive error, blepharitis, and right eye senile cataract, but that he did not have any diabetic retinopathy. The examiner opined that the loss of vision in the right eye was caused by or a result of refractive error and senile cataract, that the loss of vision in the left eye was caused by or a result of refractive error, and that the loss of vision (including cataracts) was not caused by or a result of type II diabetes mellitus. There was no further explanation or rationale provided for this opinion. The physician who conducted a September 2018 VA eye examination opined that the Veteran’s claimed bilateral eye disability, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. The examiner reasoned that the Veteran’s entrance examination clearly and unmistakably identified a refractive error of defective visual acuity prior to service. At the time of the September 2018 examination, the Veteran’s reduction in visual acuity was due to refractive error in both eyes and right eye senile nuclear sclerosis. He also experienced bilateral small pinguecula, but this did not cause a reduction in visual acuity and was not caused by or the result of diabetes mellitus, ischemic heart disease, or refractive error. Pinguecula occurs due to actinic changes affecting the subepithelial collagen and elastoid fiber of the conjunctiva, causing degeneration to these fibers. This is very common in the tropics. The examiner further explained that the Veteran had senile nuclear sclerosis in the right eye, that this was to be expected in a 77 year old person, and that this was not caused by or the result of ischemic heart disease, diabetes mellitus, or refractive error. Studies demonstrate that 95 percent of people aged 65 years or older will present with some degree of crystalline lens opacification, producing light scattering and blurring of vision. The Veteran also had bilateral ocular hypertension which was not caused by or the result of ischemic heart disease, diabetes mellitus, or refractive error. The general population has a mean intraocular pressure of 16 mm Hg. Two standard deviations gives the normal range of 11 to 21 mm Hg. It is estimated that 7 percent of the population of those 40 years of age or older may have intraocular pressures over 21 mm Hg, without detectable glaucomatous damage on standard clinical tests. These individuals are considered to have ocular hypertension or to be glaucoma suspects. The risk factors to developing glaucoma include older age, high vertical cup to disc ratio, increased intraocular pressures, thin central corneal thickness, parapapillary changes, positive family history, and high myopia. Untreated patients with ocular hypertension have a 9.5 percent cumulative risk of developing primary open angle glaucoma after 5 years. Most patients with ocular hypertension do not require treatment, and only those with high risk are treated to delay or prevent glaucoma. Moreover, the examiner explained that the Veteran had mild ptosis of the right upper lid and that this was age-related and not caused by or the result of diabetes mellitus, ischemic heart disease, or refractive error. Ptosis is an abnormally low position of the upper lid that can be congenital or acquired. This can be classified as neurogenic (caused by innervational defect of the 3rd nerve), myogenic (caused by myopathy of the levator oculi muscle), aponeurotic (caused by defect in the levator aponeurosis; involutional is an age-related condition caused by dehiscence, disinsertion, or stretching of the levator aponeurosis, which restricts the transmission of force from normal levator muscle to the upper lid), or mechanical (caused by gravitational effect of a mass or scarring). In light of the above, the examiner concluded that the Veteran’s claimed eye disability, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. The examiner who conducted the September 2020 VA eye examination opined in the examination report that the Veteran’s claimed bilateral eye disabilities (diagnosed as open angle glaucoma, ocular hypertension, dry eye, corneal arcus, senile cataracts, and ptosis) were not likely (“less likely as not”) caused by diabetes mellitus. He reasoned that open angle glaucoma is the most common form of glaucoma, where the drainage angle formed by the cornea and iris remain open, but the trabecular meshwork is partially blocked. This causes pressure in the eye to gradually increase, and this pressure damages the optic nerve. It happens so slowly that a person might lose vision before they are even aware of a problem. A review of medical literature did not reveal any evidence to support a finding that the Veterans open-angle glaucoma was diabetes related. Moreover, the Veteran’s dry eye syndrome, corneal arcus, and bilateral intraocular lens due to senile cataract extraction were all age-related conditions. A review of medical literature revealed that nuclear sclerosis is very common in humans, that it usually develops in older people, and that these changes are part of the aging process of the eye. With respect to ptosis, medical literature revealed that adults get ptosis (called involutional ptosis) when the levator muscle stretches or separates away from their eyelid. This can be caused by aging or an eye injury. Sometimes ptosis happens as a side effect after certain eye surgery. Rarely, disease or tumors can affect the eyelid muscle, causing ptosis. The September 2020 examiner explained in a separate September 2020 opinion that the Veteran’s claimed bilateral eye disability was not likely (“less likely than not”/“less than 50 percent probability”) incurred in or caused by service and was not likely (“less likely than not”/“less than 50 percent probability”) proximately due to or the result of service-connected diabetes mellitus. The rationale for these opinions was the same that was provided in the September 2020 examination report. Lastly, the examiner explained that a baseline level of the severity of the Veteran’s claimed bilateral eye disability could not be determined because the medical evidence was not sufficient to support a determination of a baseline level of severity. Also, regardless of an established baseline, the Veteran’s claimed bilateral eye disability was not likely (not “at least as likely as not”) aggravated by service-connected disability. This opinion was based on the fact that the eye diagnoses were age-related conditions. The November 2005 opinion is of little, if any probative value, because it is not accompanied by any specific explanation or rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The September 2018 opinion is also of minimal probative value because the examiner did not provide any opinion as to whether any of the Veteran’s eye disabilities were aggravated by service-connected diabetes. Rather, the examiner opined as to whether some of the claimed eye disabilities were aggravated by service. Also, the examiner did not address all of the Veteran’s diagnosed eye disabilities. The September 2020 opinions, by contrast, are based upon an examination of the Veteran and a review of medical literature and the Veteran’s treatment records and reported history, and they are accompanied by specific rationales that are consistent with the evidence of record. Therefore, the September 2020 opinions are adequate and entitled to substantial probative weight. See Id. Additionally, lay evidence may be competent on a variety of matters concerning the nature and cause of disability. However, the dispositive question presented in this case (i.e., whether any relationship exists between the Veteran’s eye disability and his service-connected diabetes mellitus) is a question as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). An opinion as to whether there is a link between the Veteran’s claimed eye disability and his service-connected diabetes mellitus is one requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that he has such experience. His opinion on the question of nexus is therefore not competent evidence in this instance. There is no other evidence of a relationship between the Veteran’s bilateral eye disability and service or his service-connected diabetes mellitus, and he has not alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran’s claimed bilateral eye disability had its onset in service, is otherwise related to service, or is caused or aggravated by service-connected diabetes mellitus. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and service connection for bilateral eye disability, to include as secondary to service-connected type II diabetes mellitus, is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. II. Increased Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. If two ratings are potentially applicable, the higher rating 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports considering the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, 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. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Entitlement to increased ratings for right upper extremity peripheral neuropathy (rated 10 percent disabling prior to August 22, 2018 and 40 percent disabling since that date) and left upper extremity peripheral neuropathy (rated 10 percent disabling prior to August 22, 2018 and 30 percent disabling since that date) The Veteran’s left and right upper extremity peripheral neuropathy are rated under 38 C.F.R. § 4.124a, DCs 8599-8513. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of DCs 8599-8513 reflects that there is no diagnostic code specifically applicable to the Veteran’s service-connected upper extremity neuropathy, and that this disability has been rated by analogy to paralysis of all radicular groups under DC 8513. See 38 C.F.R. § 4.20 (allowing for rating of unlisted condition by analogy to closely related disease or injury). Under DC 8513, the following ratings apply: a 20 percent rating is warranted for mild incomplete paralysis of either the minor or major extremity; 30 and 40 percent ratings are warranted for moderate incomplete paralysis of the minor and major extremity, respectively; 60 and 70 percent ratings are warranted for severe incomplete paralysis of the minor and major extremity, respectively; and 80 and 90 percent ratings are warranted for complete paralysis of the minor and major extremity, respectively. 38 C.F.R. § 4.124a, DC 8513. With regard to rating neurological disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested left and right upper extremity neurological symptoms of the type and extent, frequency, and/or severity, as appropriate to warrant 20 percent ratings, but no higher, prior to September 20, 2011, and 30 percent and 40 percent ratings, respectively, since September 20, 2011. The Veteran’s claim that was interpreted by the AOJ as including a claim for an increased rating for left and right upper extremity peripheral neuropathy was received on February 11, 2011. A June 2011 VA general medical examination report indicates that the Veteran was right-hand dominant and that he experienced diminished sensation and a burning sensation in his hands. He took medication to treat his disability. Although the medication did not help much, he did not report any significant disability from his neuropathy. Examination revealed that the Veteran’s coordination, orientation, and left and right cranial nerve function were all normal and that upper extremity reflexes were all normal (2+) bilaterally. Sensation to vibration, pain/pinprick, and light touch were all decreased in the hands in a glove distribution, but position sensation was normal and there was no dysesthesias. Motor strength was normal (5/5) in the upper extremities bilaterally, muscle tone was normal, and there was no muscle atrophy. The Veteran was diagnosed as having bilateral peripheral neuropathy of the upper extremities. This disability impacted his ability to work and perform usual daily activities in that it caused lack of stamina, weakness or fatigue, and pain. The report of a VA back examination dated on September 20, 2011 and an April 2013 VA neurology consultation note indicate that deep tendon reflexes of the biceps, triceps, and brachioradialis were occasionally somewhat diminished (1+) bilaterally. Muscle strength of the upper extremities was normal (5/5) bilaterally and upper extremity sensation to pinprick, light touch, proprioception, and vibration were all normal at the proximal and distal upper extremities bilaterally. The Veteran reported during an August 2018 VA neurological examination that he was right-hand dominant and that he experienced mild intermittent pain and paresthesias/dysesthesias in the upper extremities bilaterally and moderate numbness in the upper extremities bilaterally. There was no constant pain. Examination revealed that upper extremity reflexes were absent (0) bilaterally, that sensation to light touch was decreased at the hands/fingers bilaterally, that position sense and vibration sensation were both decreased in the upper extremities bilaterally, and that there were trophic changes attributable to diabetic peripheral neuropathy (e.g., loss of body hair). Upper extremity muscle strength was normal (5/5) bilaterally, there was no muscle atrophy, and sensation to light touch was normal at the shoulder areas and inner/outer forearms bilaterally. Overall, the examiner who conducted the August 2018 examination concluded that there was mild incomplete paralysis of the median and ulnar nerves bilaterally. There were no scars related to the Veteran’s disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. A diagnosis of diabetic neuropathy was provided. This disability impacted the Veteran’s ability to work in that he experienced loss of balance, dexterity, and endurance. The above evidence reflects that during the claim period prior to September 20, 2011 the Veteran’s left and right upper extremity peripheral neuropathy were manifested by decreased sensation and a burning sensation in his hands. His upper extremity reflexes and muscle strength were normal and he reported that he did not experience any significant disability from his neuropathy. In light of the Veteran’s reported upper extremity neurological symptoms and the clinical findings of decreased sensation during the June 2011 VA examination, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the symptoms of his service-connected left and right upper extremity peripheral neuropathy more closely approximated the criteria for 20 percent ratings under DC 8513 (indicative of mild incomplete paralysis of all upper extremity radicular groups) during the entire claim period prior to September 20, 2011. However, ratings higher than 20 percent are not warranted at any time during the claim period prior to September 20, 2011. In particular, the Veteran’s upper extremity muscle strength was normal (5/5) bilaterally, upper extremity reflexes were normal (2+) bilaterally, the neurological involvement in his upper extremities was wholly sensory, and he did not report any significant disability from his neuropathy. Overall, the left and right upper extremity peripheral neuropathy were manifested by at most mild incomplete paralysis of the upper extremity radicular groups. Therefore, 20 percent ratings, but no higher, are warranted for left and right upper extremity peripheral neuropathy under DC 8513 during the entire claim period prior to September 20, 2011. See 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. § 4.7, 4.124a, DC 8513. During the claim period since September 20, 2011, the Veteran’s left and right upper extremity peripheral neuropathy have been manifested by upper extremity pain, paresthesias/dysesthesias, and numbness bilaterally. Examinations have revealed absent (0) to somewhat diminished (1+) upper extremity reflexes bilaterally and some loss of upper extremity sensation bilaterally. In light of the Veteran’s reported upper extremity neurological symptoms and the clinical findings of occasionally impaired sensation and reflexes, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the symptoms of his service-connected left and right upper extremity peripheral neuropathy have more closely approximated the criteria for 30 percent and 40 percent ratings, respectively, for paralysis of all upper extremity radicular groups (i.e., moderate incomplete paralysis) under DC 8513. It is unclear exactly when following the July 2011 VA general medical examination the Veteran began to experience more severe upper extremity neurological impairment, and the earliest that it is factually ascertainable that the Veteran’s left and right upper extremity peripheral neuropathy warranted 30 percent and 40 percent ratings, respectively, for moderate incomplete paralysis is September 20, 2011 (the date of the September 2011 VA back examination, during which examination revealed that deep tendon reflexes of the biceps, triceps, and brachioradialis were occasionally somewhat diminished (1+) bilaterally). However, ratings higher than 30 percent and 40 percent for the left and right upper extremities, respectively, are not warranted at any time during the claim period since September 20, 2011. In particular, only some upper extremity sensation has been diminished, the Veteran’s upper extremity muscle strength has been normal (5/5), there has been no muscle atrophy, and the examiner who conducted the August 2018 VA examination reported that there was at most mild incomplete paralysis of the upper extremities. Overall, the left and right upper extremity peripheral neuropathy has been manifested by at most moderate incomplete paralysis of the upper extremity radicular groups during the entire period since September 20, 2011. Therefore, 30 percent and 40 percent ratings, but no higher, are warranted for left and right upper extremity peripheral neuropathy, respectively, under DC 8513 during the entire claim period since September 20, 2011. See Id. The Board acknowledges that there is evidence of incomplete paralysis of both the median and ulnar nerves. Nevertheless, mild incomplete paralysis warrants only a 10 percent rating under both DC 8515 and DC 8516 (the diagnostic codes pertaining to paralysis of the median and ulnar nerves). Also, moderate incomplete paralysis warrants only 20 percent and 30 percent ratings for the minor and major extremity, respectively, under both DC 8515 and DC 8516. The Board is already awarding 20 percent ratings prior to September 20, 2011 and 30 and 40 percent ratings (for the left and right upper extremity, respectively) since that date under DC 8513 on the basis of the Veteran’s upper extremity neurological symptoms. Therefore, separate ratings under both DC 8513 and DCs 8515/8516 on the basis of the same upper extremity neurological symptoms would constitute prohibited pyramiding and separate ratings are not warranted. 38 C.F.R. § 4.14. As a final point, the Board notes that in conjunction with the claim for increased ratings for left and right upper extremity peripheral neuropathy, the Veteran has not raised any other related issues, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Elwood, 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.