Citation Nr: 21007365 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 14-24 984 DATE: February 9, 2021 ORDER Entitlement to service connection for hypertensive heart disease is denied. Entitlement to an initial evaluation in excess of 20 percent prior to August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, right lower extremity is denied. Entitlement to an initial evaluation in excess of 20 percent prior to August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, left lower extremity is denied. Entitlement to an increased evaluation in excess of 40 percent from August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, right lower extremity is denied. Entitlement to an increased evaluation in excess of 40 percent from August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, left lower extremity is denied. Entitlement to an initial evaluation of 30 percent, but no higher, for diabetic polyneuropathy of the femoral nerve, right lower extremity is granted. Entitlement to an initial evaluation of 30 percent, but no higher, for diabetic polyneuropathy of the femoral nerve, left lower extremity is granted. Entitlement to a certificate of eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment or automobile adaptive equipment only is denied. Entitlement to a certificate of eligibility for specially adapted housing (SAH) is denied. Entitlement to a certificate of eligibility for a special home adaptation grant is denied. REMANDED Entitlement to service connection for erectile dysfunction is remanded. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) with depressive disorder is remanded. FINDINGS OF FACT 1. The Veteran’s hypertensive heart disease did not have its onset during service, was not caused by active service, to include exposure to herbicide agents, and did not manifest to a compensable degree within one year of his separation from service. 2. Prior to August 29, 2016, the Veteran’s diabetic polyneuropathy of the sciatic nerve, right lower extremity manifested with no more than moderate incomplete paralysis of the sciatic nerve. 3. Prior to August 29, 2016, the Veteran’s diabetic polyneuropathy of the sciatic nerve, left lower extremity manifested with no more than moderate incomplete paralysis of the sciatic nerve. 4. From August 29, 2016, the Veteran’s diabetic polyneuropathy of the sciatic nerve, right lower extremity manifested with no more than moderately severe incomplete paralysis of the sciatic nerve. 5. From August 29, 2016, the Veteran’s diabetic polyneuropathy of the sciatic nerve, left lower extremity manifested with no more than moderately severe incomplete paralysis of the sciatic nerve. 6. Throughout the period on appeal, the Veteran’s diabetic polyneuropathy of the femoral nerve, right lower extremity has been manifested by severe incomplete paralysis of the femoral nerve; complete paralysis is not present. 7. Throughout the period on appeal, the Veteran’s diabetic polyneuropathy of the femoral nerve, left lower extremity has been manifested by severe incomplete paralysis of the femoral nerve; complete paralysis is not present. 8. The Veteran’s service-connected disabilities do not result in the physical loss or permanent loss of use of one or both hands or feet, permanent impairment of vision in both eyes with corrected central visual acuity of 20/200 or less in the better eye or central visual acuity of more than 20/200 with a visual field defect of a degree specified by regulation, severe burn injury, amyotrophic lateral sclerosis, or ankylosis of one or both knees or hips. 9. The Veteran’s service-connected disabilities did not result in a loss or loss of use of a lower extremity, and he was not service connected for an upper extremity disability, severe burn injury, amyotrophic lateral sclerosis, blindness, or an inhalation injury. 10. The Veteran's service-connected disabilities do not result in loss or loss of use of a lower extremity or upper extremity, ankylosis of the knee or hip, residuals of organic disease or injury, amyotrophic lateral sclerosis, residuals of an inhalation injury, full thickness or subdermal burns, severe burn injury, inhalation injury or any eye disorder. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertensive heart disease are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for an initial evaluation in excess of 20 percent prior to August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, right lower extremity are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 3. The criteria for an initial evaluation in excess of 20 percent prior to August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, left lower extremity are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 4. The criteria for an increased evaluation in excess of 40 percent from August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, right lower extremity are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 5. The criteria for an increased evaluation in excess of 40 percent from August 29, 2016, for diabetic polyneuropathy of the sciatic nerve, left lower extremity are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 6. The criteria for an initial evaluation of 30 percent, but no higher, for diabetic polyneuropathy of the femoral nerve, right lower extremity are met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.3, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8526. 7. The criteria for an initial evaluation of 30 percent, but no higher, for diabetic polyneuropathy of the femoral nerve, left lower extremity are met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.3, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8526. 8. The criteria for establishing entitlement to a certificate of eligibility for financial assistance in the purchase of one automobile or other conveyance, and automobile adaptive equipment or automobile adaptive equipment are not met. 38 U.S.C. §§ 3901, 3902, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.808. 9. The criteria for establishing entitlement to a certificate eligibility for financial assistance for specially adapted housing or special home adaptation are not met. 38 U.S.C. §§ 2101, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.809, 3.809a. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from August 1965 to August 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Jackson, Mississippi Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to increased rating for PTSD was previously before the Board in October 2018. The Board granted an increased rating of 50 percent for PTSD. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In an August 2019 Order, the Court granted a Joint Motion for Partial Remand. In a March 2020 decision, the Board remanded the issue for additional development. The matter is now before the Board for adjudication. The issues of entitlement to increased evaluations for diabetic neuropathy of the bilateral sciatic nerves and diabetic neuropathy of the bilateral femoral nerves were also remanded by the Board for additional development in its March 2020 decision. These matters are now before the Board for adjudication. During the pendency of the appeal, in a June 2020 rating decision, service connection for bilateral hearing loss and for tinnitus was granted. These actions constitute a full grant of the benefits sought, and the issues are no longer on appeal. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided in September 2011, February 2013, July 2014, and in the Fully Developed Claim form filed by the Veteran in January 2018. As noted above, the issues of entitlement to increased rating for PTSD and entitlement to increased evaluations for diabetic neuropathy of the bilateral sciatic nerves and diabetic neuropathy of the bilateral femoral nerves were remanded by the Board in March 2020 for additional development. Review of the completed development reveals that, at the very least, substantial compliance with the remand directives was obtained. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The RO associated the Veteran’s service and VA private outpatient treatment records with the claims file. All released or submitted private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding. Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. As such, VA has satisfied its duty to assist with the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101 (3), 1112(a); 38 C.F.R. §§ 3.307 (a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Hypertension and organic heart disease, each with a presumptive period of one year following separation from service, are listed conditions. Regarding service connection due to herbicide exposure, VA laws and regulations provide that if a Veteran was exposed to herbicides during service, certain listed diseases are presumptively service-connected. 38 U.S.C. § § 1116h(a)(1); 38 C.F.R. § 3.309(e). A Veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, is presumed to have been exposed to herbicide. 38 U.S.C. § § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). 38 C.F.R. § 3.309(e) lists the diseases covered by the regulation, which includes ischemic heart disease. Hypertensive heart disease is not a list condition. Competent medical evidence is 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 include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence 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 lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Hypertensive Heart Disease The Veteran asserts his hypertensive heart disease is related to his time in service, to include as due to exposure to herbicide agents. His exposure to herbicide agents has been conceded. The Veteran’ STRs are negative for heart symptoms or a diagnosis of hypertensive heart disease. The Veteran’s post service medical records show a diagnosis of hypertension in August 2011. The Veteran underwent a heart examination in January 2018. The examiner noted a diagnosis of hypertensive heart disease in 2015. The Veteran reported symptoms beginning in 2013 and stated he was diagnosed with hypertension approximately 5 years prior to the examination. He stated that his medication was controlling his blood pressure. The examiner noted that the Veteran’s heart conditions did not qualify as ischemic heart disease, and that the Veteran has not had a myocardial infarction, congestive heart failure, arrhythmia, heart valve condition, an infectious heart condition, pericardial adhesions, or any surgical or non-surgical procedures for treatment of a heart condition. The examiner noted evidence of cardiac hypertrophy on an echocardiogram performed on January 30, 2018. The examiner also noted Grade 1 Diastolic Dysfunction and mild mitral insufficiency; accordingly, a diagnosis of hypertensive heart disease was provided. In a March 2018 addendum opinion, another examiner, an internist, opined that it was less likely than not that the Veteran’s hypertensive heart disease was incurred in, or caused by, any incident of the Veteran’s active service. In support of this opinion, the March 2018 examiner noted that the medical records and service treatment records do not support incidence of cardiac problems while in service. The examiner also stated that cardiac issues and diagnostics confirmed pathology for the Veteran’s heart condition years after release from active duty. As such, the examiner concluded the Veteran’s hypertensive heart disease was less likely than not incurred in, or caused by, any incident of the Veteran’s active service. After a careful review of the record, the Board finds that the evidence does not support a determination that hypertensive heart disease is etiologically related to his active duty service. With respect to service connection on a presumptive basis, as noted above, the Veteran’s record does not show any clinical findings or diagnoses of hypertensive heart disease within one year of his separation from active duty. Accordingly, service connection for hypertension on a presumptive basis as a chronic disease manifesting to a compensable degree within one year of discharge from service is not warranted. 38 C.F.R. § 3.309(a). The Board further finds that presumptive service connection for hypertensive heart disease as a disease associated with exposure to herbicide agents, is not warranted. As noted above, hypertensive heart disease is not a disease associated with Agent Orange herbicide exposure. 38 C.F.R. § 3.309(e). Even where service connection cannot be presumed, however, service connection may still be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Unfortunately, the Board finds probative the opinion of the March 2018 VA examiner that it was less likely than not that the Veteran’s hypertensive heart disease was incurred in, or caused by, any incident of the Veteran’s active service. The examiner reviewed the record and supported his opinion by citing to the available evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board also notes that the Veteran reported during his examination that he did not suffer symptoms of hypertensive heart disease until at least 2013, approximately 40 years after the Veteran’s separation from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (explaining that the Board may consider “evidence of a prolonged period without medical complaint,” along with other factors in resolving a claim). The only evidence of record which indicates the Veteran has hypertensive heart disease due to active duty service is his own allegations. As a lay person, the Veteran’s opinion as to the etiology of hypertensive heart disease is without probative value. The determination as to its etiology is a complex medical question which requires specialized medical knowledge and testing to answer. See Jandreau, 492 F.3d at 1377. As no competent evidence of a relationship between any incident of the Veteran’s period of active service and his hypertensive heart disease is of record, the Board finds that the weight of the evidence is against the Veteran’s claim for service connection. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim for service connection for hypertensive heart disease, the doctrine is not applicable. See 38 C.F.R. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Increased Ratings Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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 importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 – 127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetic Neuropathies of the Lower Extremities The Veteran was granted service connection for diabetic polyneuropathy of the sciatic nerves of the right and left lower extremities was granted, and a 20 percent disability evaluation was assigned for each lower extremity in an August 2015 rating decision. The Veteran filed a claim for an increased evaluation for these disabilities which was received on August 29, 2016. In November 2016, the Veteran was granted a 40 percent disability evaluation for sciatic nerve diabetic polyneuropathy, right and left lower extremities, respectively effective August 29, 2016. Service connection was also granted for femoral nerve diabetic polyneuropathy, right and left lower extremities, and 20 percent disability evaluations were assigned, respectively, effective August 29, 2016. The Veteran is seeking initial ratings in excess of 20 percent for diabetic polyneuropathy of the sciatic nerve, right and left lower extremities, respectively prior to August 29, 2016; and an increased rating in excess of 40 percent for diabetic polyneuropathy of the sciatic nerve, right and left lower extremities, respectively from August 29, 2016. The Veteran is also seeking initial ratings in excess of 20 percent for diabetic polyneuropathy of the femoral nerves, right and left lower extremities, respectively. The Veteran’s bilateral lower extremity diabetic polyneuropathy, sciatic nerves, is evaluated pursuant to the criteria for diseases of the peripheral nerves, sciatic nerve. Diagnostic Code 8520. His bilateral lower extremity diabetic polyneuropathy, femoral nerves is evaluated pursuant to the criteria for diseases of the anterior crural nerve (femoral). Diagnostic Code 8526. Criteria for rating diseases of peripheral nerves are based on paralysis, neuritis, or neuralgia. Neuritis of a peripheral nerve, 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. Neuralgia of a peripheral nerve, characterized usually 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 that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve 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. Diagnostic Code 8520 provides a 10 percent evaluation for mild incomplete paralysis of the sciatic nerve of the lower extremity. A 20 percent evaluation is assigned for moderate incomplete paralysis of the sciatic nerve. A 40 percent evaluation for moderately severe incomplete paralysis of the sciatic nerve of the lower extremity. A 60 percent evaluation for severe incomplete paralysis, with marked muscular atrophy, of the sciatic nerve of the lower extremity. An 80 percent evaluation is warranted for complete paralysis of the sciatic nerve of the lower extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Complete paralysis of the sciatic nerve is indicated where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § § 4.124a, Diagnostic Code 8520. Diagnostic Code 8526 provides a 10 percent evaluation for mild incomplete paralysis of the anterior crural nerve. A 20 percent evaluation is assigned for moderate incomplete paralysis of the anterior crural nerve. A 30 percent evaluation is assigned for severe incomplete paralysis of the anterior crural nerve. A 40 percent evaluation is warranted for complete paralysis of the anterior crural nerve of the lower extremity. 38 C.F.R. § § 4.124a, Diagnostic Code 8526. Complete paralysis of the anterior crural nerve is indicated where there is paralysis of quadriceps extensor muscle. 38 C.F.R. § 4.124a, Diagnostic Code 8526. The Veteran underwent a VA peripheral neuropathy examination in July 2015. The VA examiner noted the Veteran’s diagnosis of diabetic polyneuropathy. Subjective complaints included numb sensation from the shin levels bilaterally, numbness and tingling in feet, “feels like fire ants” on prolonged standing. The Veteran reported he is able to walk with a rolling walker without difficulty. He stated that the discomfort/burning pain is most noticeable at night or when at rest after prolonged activity. He takes Gabapentin which helped but did not eliminate the symptoms in his feet. The Veteran reported he was independent in his activities of daily living. Symptoms attributable to neuropathy in the bilateral lower extremities included moderate intermittent pain and moderate numbness. Muscle strength test results were normal. Deep tendon reflexes were decreased in bilateral ankles. Light touch/monofilament test results were decreased in bilateral ankles, feet and toes. Position sense and cold sensation were decreased in both lower extremities. No muscle atrophy was present. The Veteran had trophic changes from the shin level including sparse hair distribution with skin smoot to touch. The VA examiner determined that the Veteran had moderate incomplete paralysis of the right and left sciatic nerves and normal femoral bilateral nerves. VA treatment records show diabetic neuropathy of the bilateral lower extremities as an active medical condition. The records do not reflect treatment for symptoms of diabetic neuropathy of the bilateral lower extremities. The Veteran underwent a VA contract diabetic sensory-motor peripheral neuropathy examination in October 2016. The examiner noted the Veteran’s diagnosis of diabetic peripheral neuropathy. The Veteran reported that his symptoms had worsened and now extended all the way up his left leg, with a constant feeling of pins and needles; right leg was not as severe. The examiner noted severe, constant pain in the Veteran’s right lower extremity, Symptoms included severe constant pain in the right lower extremity, severe paresthesias and/or dysesthesias in the bilateral lower extremities, and severe numbness in the bilateral lower extremities. Muscle strength test results were normal for bilateral knee extension, knee flexion and ankle plantar flexion; less than normal strength was noted in bilateral ankle dorsiflexion. Deep tendon reflexes test results were normal for bilateral knees and ankles. Light touch/monofilament testing results were decreased in the bilateral lower knees/thighs, ankles/lower legs and feet/toes. Position sense was normal in bilateral lower extremities. Cold sensation was normal in right lower extremity and decreased in left lower extremity. No muscle atrophy was present. The examiner noted trophic changes attributable to diabetic peripheral neuropathy described as loss of hair on bilateral lower extremities and smooth and shiny skin on bilateral lower extremities. The examiner determined that the Veteran experienced severe, incomplete paralysis in each sciatic nerve and severe, incomplete paralysis in each femoral nerve. VA treatment records reflect the Veteran’s bilateral lower extremity neuropathy. At a June 2017 visit, he reported that the neuropathy in his left leg was getting worse. In November 2017, he reported experiencing chronic pain in both legs, as well as swelling; tendency to favor right side as tingling and numbness in both legs. His primary care provider ordered special shoes for him; he ambulates with crutch/walker. In January 2018, the Veteran underwent another examination of his peripheral nerves. The examiner noted the Veteran’s diagnosis of bilateral lower extremity peripheral neuropathy. The Veteran reported his symptoms had worsened. Symptoms included severe constant pain in bilateral lower extremities, severe paresthesias and/or dysesthesias in the bilateral lower extremities, and stinging and burning up the legs. Muscle strength and reflex test results were normal. No muscle atrophy was present. Sensory examination revealed decreased sensation in bilateral upper anterior thighs, thighs/knees, lower legs/ankles, and feet/toes. Trophic changes of the bilateral legs were characterized by shiny, smooth skin with no hair. The examiner determined the Veteran had mild incomplete paralysis of the bilateral sciatic nerves and the bilateral anterior crural nerve. The examiner also determined the Veteran had mild incomplete paralysis of the bilateral external popliteal nerves, musculocutaneous nerves, anterior tibial nerves, internal popliteal nerves, posterior tibial nerves, internal saphenous nerves, obturator nerves, external cutaneous nerves of the thighs, and ilio-inguinal nerves. The Veteran was noted to use an assistive device, a crutch, on a regular basis. An August 2018 VA treatment note reflects the Veteran’s diabetic peripheral neuropathy was still severe; medications had not made significant differences. An August 2019 treatment note indicates peripheral neuropathy symptoms are worse; numbness and pain involving whole left leg, including upper thigh. The Veteran was seen for a neurology consult in April 2019. He reported experiencing symptoms of burning, numbness, and electrical type pain in the feet extending higher into his lower extremities. Symptoms are worse at night. Bilateral Sciatic Nerves After a careful review of the evidence of record, the Board finds that initial disability evaluations in excess of 20 percent for sciatic nerve diabetic polyneuropathy of the right and left lower extremities, respectively, prior to August 29, 2016 are not warranted. The Board finds that the evidence of record indicates that the Veteran’s sciatic nerve diabetic polyneuropathy of the right and left lower extremities manifested as moderate in severity prior to August 29, 2016. The evidence indicates that during his July 2015 VA examination, the Veteran complained of experiencing numbness and tingling in feet. The Board finds probative the opinion of the July 2015 examiner that the Veteran’s sciatic nerve diabetic polyneuropathy was moderate in severity. VA treatment records do not document treatment for symptoms of diabetic polyneuropathy of the bilateral lower extremities other than to note such in the Veteran’s active medical conditions. There is no medical evidence associated with the file which demonstrates reduced muscle strength or muscle atrophy of the bilateral lower extremities, which would potentially be indicative of moderately severe or severe polyneuropathy prior to August 29, 2016. The Board has carefully considered all the evidence and potentially applicable diagnostic codes and finds the disability pictures of the Veteran’s right and left lower extremity sciatic nerve diabetic polyneuropathies do not meet the criteria for ratings in excess of 20 percent prior to August 29, 2016. Further, the Board also finds that a disability rating in excess of 40 percent is not warranted for sciatic nerve diabetic polyneuropathy of the right and left lower extremities, respectively from August 29, 2016. The Veteran underwent VA examinations in October 2016 and in January 2018; neither of which revealed marked muscle atrophy. Specifically, the October 2016 examiner noted in his remarks that while the Veteran’s symptoms were severe, they did not result in marked muscle atrophy. Further, marked muscle atrophy was not found on subsequent examination in 2018. As such, the Board finds that the weight of the competent does not support a finding of marked muscle atrophy of the bilateral lower extremities during the appeal period. Therefore, the Board finds that the Veteran’s symptoms are more consistent with symptoms of moderate incomplete paralysis; therefore, higher ratings of 60 percent for severe incomplete paralysis of the sciatic nerves pursuant to Diagnostic Code 8520 are not warranted. The criteria for an initial evaluation of 30 percent, but no higher, for diabetic polyneuropathy of the femoral nerve, right lower extremity are met. 38 C.F.R. §§ 4.3, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8520. Bilateral Femoral Nerves The Veteran is seeking increased initial ratings in excess of 20 percent for femoral nerve, diabetic polyneuropathies of the right and left lower extremities. After a careful review of the evidence of record, the Board finds that initial disability evaluations of 30 percent for severe femoral nerve diabetic polyneuropathy of the right and left lower extremities is warranted. The Board finds that throughout the appeal period the Veteran’s femoral nerve, diabetic polyneuropathies of the right and left lower extremities more nearly approximate severe, incomplete paralysis; as such a rating of 30 percent is warranted for the left and right lower extremity. The Board finds probative the findings of the October 2016 VA examiner that reported that the Veteran demonstrated severe incomplete paralysis of the femoral nerve. The examiner stated that examination revealed decreased sensation to light touch in the knee/thigh; pain and numbness was noted. Trophic changes were also noted. While the January 2018 examiner stated that the Veteran’s condition was indicative of incomplete paralysis of the femoral nerve of mild severity, the Board notes that the January 2018 examination revealed findings otherwise consistent with the October 2016 examiner. Decreased sensation in bilateral upper anterior thighs, and knees were reported. Additionally, trophic changes of the bilateral legs were characterized by shiny, smooth skin with no hair. The January 2018 examiner also reported severe symptoms of constant pain, paresthesias, and numbness. Accordingly, the Board will resolve the benefit of the doubt in favor of the Veteran and finds that a rating of 30 percent is warranted for the left and right lower extremity due to “severe” incomplete paralysis of the femoral nerve. The medical evidence associated with the file, however, does not establish that the Veteran has experienced paralysis of the femoral nerve. Specifically, none of the medical evidence has reported paralysis quadricep extensor muscles and quadricep muscle atrophy was not reported by either examiner. As such, a rating in excess of 30 percent is not warranted for the Veteran’s right and left lower extremity femoral nerve diabetic polyneuropathies. 38 C.F.R. §§ 4.3, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code 8526. Automobile, Specially Adapted Housing and Special Home Adaptation Financial assistance may be provided to an “eligible person” in acquiring an automobile or other conveyance and adaptive equipment, or automotive adaptive equipment only. 38 U.S.C. § 3902(a)(b). Eligibility for financial assistance in the purchase of a vehicle or other conveyance and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis; or, (6) for adaptive equipment only, ankylosis of one or both knees, or one or both hips. 38 C.F.R. §§ 3.808. Specially adapted housing is available to a Veteran who is entitled to compensation for permanent and total disability due to: (1) amyotrophic lateral sclerosis rated as 100 percent disabling under 38 C.F.R. § 4.124a , Diagnostic Code 8017; (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; (3) full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; or (4) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbows. Specially adapted housing is also available to a Veteran with a permanent and total disability that precludes locomotion without the aids of braces, crutches, canes, or a wheelchair due to: (5) the loss, or loss of use, of both lower extremities; (6) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which affect the functions of balance and propulsion; or, (7) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which affect the functions of balance or propulsion. 38 U.S.C. § 2101(a); 38 C.F.R. § 3.809(a), (b), (d). If entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary home adaptations if he/she has a service-connected disability that results in blindness in both eyes with 20/200 visual acuity or less in the better eye with the use of a standard correcting lens or a limitation in fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees. Such a disability need not be permanent and total in nature. Additionally, a special home adaptation grant is available for a veteran that has a permanent and total disability which: (1) includes the anatomical loss or loss of use of both hands; (2) is due to deep partial thickness burns that have resulted in contracture(s) with limitation of motion of two or more extremities or of at least one extremity and the trunk; (3) is due to full thickness or subdermal burns that have resulted in contracture(s) of one or more extremities or the truck; or, (4) is due to residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease). 38 C.F.R. § 3.809a (b). “Loss of use” is not specifically defined under 38 C.F.R. § 3.809 or 3.809a. Regulations pertaining to special monthly compensation for loss of use of a hand or foot state that loss of use is held to exist when no effective function remains other than that which would be equally well served by an amputation with use of a suitable prosthetic appliance. The determination should be made on the basis of the actual remaining function, such as the ability balance or to propel oneself forward. See 38 C.F.R. §§ 3.350(a)(2), 4.63. The Court of Appeals for Veterans Claims has found that a “loss of use” exists when there is “deprivation of the ability to avail oneself” of that extremity, and functional impairment caused by pain, weakness, or incoordination should be taken into account when making that determination. See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). The Veteran is presently in receipt of VA service connection benefits for posttraumatic stress disorder, hearing loss, tinnitus, diabetes mellitus type II, bilateral sciatic nerve diabetic polyneuropathy, and bilateral femoral nerve diabetic polyneuropathy. These service-connected disabilities neither include nor involve visual impairment, burn injuries, scars, amyotrophic lateral sclerosis, loss or permanent loss of use of the of the extremities, hands, or feet, or residuals of an inhalational injury. The preponderance of the probative medical evidence demonstrates that the Veteran does not have loss of use of his lower extremities due to a service-connected disability. The VA diabetic neuropathy examinations and the VA peripheral neuropathy examinations note that the Veteran is able to walk and that he uses crutches. The January 2018 examiner noted that the Veteran did not experience functional impairment of an extremity such that no effective function remains, other than that which would be equally well served by and amputation with prosthesis (functions of the lower extremity include balance and propulsion). The examiner noted that the Veteran had an abnormal gait due to guarding and that he used crutches to keep pressure off his heels. While the Veteran’s peripheral neuropathy examinations and other evidence of record indicate the Veteran has reduced functioning in his bilateral lower extremities due to his service-connected sciatic and femoral diabetic polyneuropathies, they show he maintains functioning above the required level for eligibility for automobile or other conveyance and adaptive equipment, or automotive adaptive automobile, entitlement to SAH and entitlement to special home adaptation. Specifically, the record does not show prohibition of use of the lower extremities for balance, propulsion, and other such typical functions due to service-connected disability to an extent that the Veteran would be equally served by a prosthetic appliance. Because the Veteran does not have service-connected disability resulting in the loss or permanent loss of use of one or both hands or feet, ankylosis of his knees or hips, or any of the other physical disabilities listed among the relevant criteria, he does not qualify for eligibility for financial assistance in the purchase of an automobile or other conveyance and/or adaptive equipment under 38 C.F.R. § 3.808. As such, the claim must be denied. Similarly, as the Veteran does not have service-connected disability resulting in the loss, or loss of use, of both lower extremities; or the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which affect the functions of balance and propulsion he does not qualify for a specially adapted housing grant. 38 C.F.R. § 3.809. Finally, as the Veteran does not have service-connected disability related to blindness in both eyes, permanent or total loss or loss of use of both hands, a permanent and total disability resulting in loss of motion of any extremities caused by a severe burn, deep partial thickness burn, or full thickness or subdural burn, affecting the lower extremities, or the upper extremities. The Veteran has also not been found to have an inhalation injury at any time, and he is not service connected for any respiratory disorder. The provisions under 38 C.F.R. § 3.809a therefore do not apply and cannot be the basis for eligibility for a special home adaptation grant. REASONS FOR REMAND The issues of entitlement to service connection for erectile dysfunction and entitlement to an initial evaluation in excess of 50 percent for PTSD are remanded for additional development. The Veteran asserts that his erectile dysfunction is due to exposure to herbicides or is secondary to his service-connected diabetes mellitus. The Veteran underwent a VA male reproductive system examination in October 2014. The VA examiner noted the Veteran’s diagnosis of erectile dysfunction. The Veteran reported that he initially noted premature ejaculation dating back to the 1970s. Over the years, the condition has worsened, and he now has difficulty developing an erection. The Veteran stated that he used injections for such and was rarely able to ejaculate. The VA examiner determined that this condition had developed many years prior to the onset of the Veteran’s diabetes and therefore, found that it was at least as likely as not that it was unrelated to his service-connected diabetes. The Board finds that this opinion is inadequate for adjudication purposes. Despite the fact that erectile dysfunction is not a condition subject to the presumption of service connection due to exposure to herbicides, the opinion did not address the Veteran’s contention that his erectile dysfunction is due to his conceded exposure to herbicides in service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) Additionally, while the examiner determined that it was less likely than not that the Veteran’s erectile dysfunction was due to his service-connected diabetes mellitus, as his diabetes mellitus was diagnosed subsequent to onset of erectile dysfunction, the VA examiner failed to state whether or not the Veteran’s erectile dysfunction was aggravated by his service-connected diabetes mellitus. On remand, an addendum opinion as to the etiology of the Veteran’s erectile dysfunction should be obtained. The Veteran is seeking an initial rating in excess of 50 percent for his service-connected PTSD. This issue was remanded by the Court for the Board’s consideration of two medical records indicating that the Veteran had issues with sleep that impacted his functioning. The Veteran was afforded a VA PTSD examination in October 2016. The VA examiner noted that the Veteran reported experiencing horrific nightmares where he dreamt of killing or being killed. While chronic sleep impairment was noted, the Veteran’s reports of sleep issues impacting his functioning were not addressed. On remand, the Veteran should be scheduled for a new VA PTSD examination which ascertains the current level of severity and discusses the impact the Veteran’s sleep issues have on his functioning. The matters are REMANDED for the following action: 1. Return the file to the VA examiner who provided the October 2014 male reproductive system conditions examination. The file must be thoroughly reviewed by the examiner. If the examiner is not available, another appropriate medical professional may be consulted. If the reviewer determines another VA examination is necessary, one should be scheduled. The examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s currently diagnosed erectile dysfunction is caused by or related to any incident of his period of service, to include his exposure to herbicide agents. The examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s currently diagnosed erectile dysfunction was caused or aggravated by a service-connected disability, to include the Veteran’s diabetes mellitus. A complete rationale for all opinions expressed is required. 2. Schedule the Veteran for a VA PTSD examination to ascertain the current level and severity of his service-connected PTSD. The examiner is asked to specifically address how any reported nightmares, the Veteran’s documented May 2, 2014 report of experiencing difficulty driving due to his increased need for sleep medications and his documented December 19, 2014 report of sleep issues and a decline in functioning impact his overall functioning. Patrick M. Johnson Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Lunger, 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.