Citation Nr: 21009191 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 11-00 295A DATE: February 19, 2021 ORDER Entitlement to a rating in excess of 10 percent prior to August 10, 2017 for peripheral neuropathy of the upper left extremity, median nerve is denied. Entitlement to a 20 percent rating for peripheral neuropathy of the upper left extremity, median nerve, from August 10, 2017 is granted, subject to the laws and regulations governing the payment of monetary awards. Entitlement to a rating in excess of 10 percent prior to September 4, 2008 for peripheral neuropathy left lower extremity, external popliteal nerve and in excess of 20 percent from that date is denied. Entitlement to a rating in excess of 10 percent prior to August 10, 2017 for peripheral neuropathy of the upper right extremity, median nerve is denied. Entitlement to a 30 percent rating for peripheral neuropathy of the upper right extremity, median nerve, from August 10, 2017 is granted, subject to the laws and regulations governing the payment of monetary awards. Entitlement to a rating in excess 10 percent prior to September 4, 2008 for peripheral neuropathy right lower extremity, external popliteal nerve and in excess of 20 percent from that date is denied. Entitlement to a compensable rating prior to and from November 23, 2020 for peripheral neuropathy left lower extremity obturator nerve is denied. Entitlement to a compensable rating prior to and from November 23, 2020 for peripheral neuropathy right lower extremity obturator nerve is denied. Entitlement to a compensable rating prior to and from November 23, 2020 for peripheral neuropathy right lower extremity external cutaneous nerve of the thigh is denied. Entitlement to a compensable rating prior to and from November 23, 2020 for peripheral neuropathy left lower extremity external cutaneous nerve of the thigh is denied. Entitlement to a compensable rating prior to and from November 23, 2020 for peripheral neuropathy right lower extremity illio-inguinal nerve is denied. Entitlement to a compensable rating prior to and from November 23, 2020 for peripheral neuropathy left lower extremity illio-inguinal nerve is denied. FINDINGS OF FACT 1. Prior to August 10, 2017, the Veteran’s peripheral neuropathy of the median nerve is manifest by no more than mild incomplete paralysis of the minor upper left extremity. 2. From August 10, 2017, the Veteran’s peripheral neuropathy of the median nerve is manifest by moderate incomplete paralysis of the minor upper left extremity. 3. Prior to September 4, 2008, the Veteran’s peripheral neuropathy of the external popliteal nerve is manifest by no more than mild incomplete paralysis of the lower left extremity. 4. From September 4, 2008, the Veteran’s peripheral neuropathy of the external popliteal nerve is manifest by no more than moderate incomplete paralysis of the lower left extremity. 5. Prior to August 10, 2017, the Veteran’s peripheral neuropathy of the median nerve is manifest by no more than mild incomplete paralysis of the major upper right extremity. 6. From August 10, 2017, the Veteran’s peripheral neuropathy of the median nerve is manifest by moderate incomplete paralysis of the minor upper right extremity. 7. Prior to September 4, 2008, the Veteran’s peripheral neuropathy of the external popliteal nerve is manifest by no more than mild incomplete paralysis of the lower right extremity. 8. From September 4, 2008, the Veteran’s peripheral neuropathy of the external popliteal nerve is manifest by no more than moderate incomplete paralysis of the lower right extremity. 9. Prior to November 23, 2020, the Veteran’s peripheral neuropathy of the left lower extremity did not manifest in involvement of the obturator nerve. 10. From November 23, 2020 the Veteran’s peripheral neuropathy of the obturator nerve is manifest by no more than mild to moderate paralysis of the left lower extremity. 11. Prior to November 23, 2020, the Veteran’s peripheral neuropathy of the right lower extremity did not manifest in involvement of the obturator nerve. 12. From November 23, 2020 the Veteran’s peripheral neuropathy of the obturator nerve is manifest by no more than mild to moderate paralysis of the right lower extremity. 13. Prior to November 23, 2020, the Veteran’s peripheral neuropathy of the right lower extremity did not manifest in involvement of the external cutaneous nerve of the thigh. 14. From November 23, 2020 the Veteran’s peripheral neuropathy of the external cutaneous nerve of the thigh is manifest by no more than mild to moderate paralysis of the right lower extremity. 15. Prior to November 23, 2020, the Veteran’s peripheral neuropathy of the left lower extremity did not manifest in involvement of the external cutaneous nerve of the thigh. 16. From November 23, 2020 the Veteran’s peripheral neuropathy of the external cutaneous nerve of the thigh is manifest by no more than mild to moderate paralysis of the left lower extremity. 17. Prior to November 23, 2020, the Veteran’s peripheral neuropathy of the right lower extremity did not manifest in involvement of the Illio-inguinal nerve. 18. From November 23, 2020 the Veteran’s peripheral neuropathy of the Illio-inguinal nerve is manifest by no more than mild to moderate paralysis of the right lower extremity. 19. Prior to November 23, 2020, the Veteran’s peripheral neuropathy of the left lower extremity did not manifest in involvement of the Illio-inguinal nerve. 20. From November 23, 2020 the Veteran’s peripheral neuropathy of the Illio-inguinal nerve is manifest by no more than mild to moderate paralysis of the left lower extremity. CONCLUSIONS OF LAW 1. Prior to August 10, 2017, the criteria for a disability rating in excess of 10 for peripheral neuropathy of the median nerve of the minor upper left extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8515. 2. From August 10, 2017, the criteria for a 20 percent rating, bt no higher, for peripheral neuropathy of the median nerve of the minor upper left extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8515. 3. Prior to September 4, 2008, the criteria for a disability rating in excess of 10 percent peripheral neuropathy of the external popliteal nerve is manifest of the lower left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 7913-8521. 4. From September 4, 2008, the criteria for a disability rating in excess of 20 percent peripheral neuropathy of the external popliteal nerve is manifest of the lower left extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 7913-8521. 5. Prior to August 10, 2017, the criteria for a disability rating in excess of 10 for peripheral neuropathy of the median nerve of the major upper right extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8515. 6. From August 10, 2017, the criteria for a 30 percent rating, but no higher, for peripheral neuropathy of the median nerve of the major upper right extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8515. 7. Prior to September 4, 2008, the criteria for a disability rating in excess of 10 percent peripheral neuropathy of the external popliteal nerve is manifest of the lower right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 7913-8521. 8. From September 4, 2008, the criteria for a disability rating in excess of 20 percent peripheral neuropathy of the external popliteal nerve is manifest of the lower right extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 7913-8521. 9. Prior to and from November 23, 2020, the criteria for a compensable rating for peripheral neuropathy left lower extremity obturator nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8528. 10. Prior to and from November 23, 2020, the criteria for a compensable rating for peripheral neuropathy right lower extremity obturator nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8528. 11. Prior to and from November 23, 2020, the criteria for a compensable rating for peripheral neuropathy right lower extremity external cutaneous nerve of the thigh have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8529. 12. Prior to and from November 23, 2020, the criteria for a compensable rating for peripheral neuropathy left lower extremity external cutaneous nerve of the thigh have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8529. 13. Prior to and from November 23, 2020, the criteria for a compensable rating for peripheral neuropathy right lower extremity illio-inguinal nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8530. 14. Prior to and from November 23, 2020, the criteria for a compensable rating for peripheral neuropathy left lower extremity illio-inguinal nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (Code) 8530. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1962 to February 1982.    This case has a long procedural history.  The appeal was most recently before the Board in March 2020 when it was remanded for further development.  The Board finds there has been substantial compliance with the remand directives and the Board will proceed to adjudication.  Stegall v. West, 11 Vet. App. 268 (1998).  In an interim December 2020 rating decision, service connection was granted and separate noncompensable ratings assigned for peripheral neuropathy of the obturator nerve, external cutaneous nerve, and illio-inguinal nerve, effective November 23, 2020. These disabilities are part of the increased rating claims for peripheral neuropathy of the bilateral upper and lower extremities and are before the Board. Additionally, the issue of entitlement to individual unemployability due to service-connected disabilities (TDIU) prior to December 13, 2019 was remanded by the Board in March 2020. As the December 2020 rating decision granted TDIU from April 11, 2006, TDIU has been granted for the entire period on appeal and is no longer before the Board. Increased Rating The Veteran seeks higher rating for his peripheral neuropathy associated with his diabetes mellitus. He is service-connected for peripheral neuropathy of the bilateral upper and lower extremity for manifestations involving several different nerves under several separate codes. Peripheral neuropathy of the median nerves of the right and left upper extremities is each rated as 10 percent from April 11, 2006 and 30 percent from December 13, 2019 under 38 C.F.R. § 4.124a Code 8515. Peripheral neuropathy of the external popliteal nerves of the right and left lower extremities is each rated as 10 percent from November 30, 2001 and 20 percent from September 4, 2008 under Code 7913-8521. The peripheral neuropathy of the obturator nerves of the right and left lower extremities is each rated as noncompensable (0 percent) from November 23, 2020 under Code 8528. The peripheral neuropathy of the external cutaneous nerves of the thigh of the right and left lower extremities is each rated as noncompensable (0 percent) from November 23, 2020 under Code 8529. His peripheral neuropathy of the Illio-inguinal nerve of the right lower extremity is rated as noncompensable (0 percent) from November 23, 2020 under Code 8530. His peripheral neuropathy of the Illio-inguinal nerve of the left lower extremity is rated as noncompensable (0 percent) from November 23, 2020 under Code 8530. The Veteran filed his clam for a higher rating in April 2006. Disability ratings are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Codes identify the various disabilities.  38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind.  Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, 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.   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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007).   Paralysis of the median nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8515. Ratings are assigned based on the involvement of the major hand (in this case, the Veteran’s right hand) or the minor hand (left). Under these criteria, mild incomplete paralysis is rated as 10 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis is rated as 70 percent on the major side and 60 percent on the minor side. Complete paralysis of the median nerve contemplates the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscle of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. 38 C.F.R. § 4.124a, Code 8515. Paralysis of the external popliteal nerve (common peroneal) is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8521. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Severe incomplete paralysis is rated as 30 disabling. Complete paralysis is rated as 40 percent disabling. Complete paralysis of the external popliteal nerve contemplates foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes/ 38 C.F.R. § 4.124a, Code 8521. Paralysis of the obturator nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8528. Under these criteria, mild to moderate paralysis is rated as noncompensable. Moderate to complete paralysis is rated as 10 percent disabling. 38 C.F.R. § 4.124a, Code 8528. Paralysis of the external cutaneous nerve of the thigh is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8529. Under these criteria, mild to moderate paralysis is rated as noncompensable. Moderate to complete paralysis is rated as 10 percent disabling. 38 C.F.R. § 4.124a, Code 8529. Paralysis of the Ilio-inguinal nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8530. Under these criteria, mild to moderate paralysis is rated as noncompensable. Moderate to complete paralysis is rated as 10 percent disabling. A 100 percent rating is provided for a soft-tissue sarcoma of neurogenic origin. This 100 percent rating will be continued for 6 months following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. At this point, if there has been no local recurrence or metastases, the rating will be made on residuals. 38 C.F.R. § 4.124a, Code 8530. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). In an April 2006 VA treatment note, the provider noted the Veteran had decreased sensation of the lower legs and feet to light touch and monofilament testing. The provider also noted the Veteran was going to talk with his provider about beginning medication for his neuropathy. On July 2006 VA examination, the Veteran reported his neuropathy had gotten worse in the past year. His neurologic symptoms were severe pain, numbness, and tingling in both the lower extremities and numbness and tingling in the upper extremities. The examiner noted that he had severe pain in his lower extremities, especially at night tine in both the soles of his feet, mostly in the medial aspect. The pain in his lower extremities was sharp and shooting, rated as 7 to 8 out of 10. He was taking Gabapentin for the past 3 to 4 years, but he reported it was not working satisfactory. Regarding his upper extremities, the Veteran reported that when he was driving he felt numbness, especially in his right hand. His grip gets weak, but he did not have any pain in his upper extremity. There were no flare-ups for his lower extremities. Aggravating factors are standing for a long time and nighttime, lying in his bed. He also had poor balance because of neuropathy in his legs and he had to use a cane. He did not have paresthesia or dysphagia. The examiner found that his neuropathy was affecting his activities of daily living as he can no longer walk as far as he could walk. The examiner opined that the Veteran had severe peripheral neuropathy of both lower extremities and mild peripheral neuropathy of the upper extremities, but did not identify the specific nerves involved. In a July 2006 rating decision, service connection for peripheral neuropathy of the bilateral upper extremity was granted and assigned a 10 percent evaluation effective April 11, 2006 for the median nerve under DC 8515. 10 percent ratings were continued for peripheral neuropathy of the bilateral lower extremities. In a June 2007 VA treatment note, the provider noted the Veteran had no problems with his gait or balance, and no weakness. He was positive for a burning sensation, mostly in his right leg/foot. On June 2007 VA examination, the Veteran reported that since his last examination, he continued to experience numbness and burning in his feet and hands. He also reported significant diminishment in his mobility due to peripheral neuropathy because he was unable to do household chores secondary to prolonged standing resulting in severe discomfort in his feet. He reported occasional symptoms in his hands. He had been on gabapentin which he reported had helped slightly. The examiner noted his symptoms could mostly aptly be described as both paresthesias and dysesthesias. Strength and reflexes were normal in all extremities. Sensation was normal in his upper extremities. Bilateral lower extremities had mild, diminished sensation to light touch, pinprick, and monofilament testing. There was normal proprioception bilaterally. The examiner opined that the Veteran had mild peripheral neuropathy in a stocking pattern in his distal lower extremities, which remained unchanged from his last VA examination. Again, the examiner did not identify the specific nerves affected. In an August 2007 letter, the Veteran’s private provider noted he had a history of upper extremity neuropathy and his activities were restricted because of his neuropathy. On June 2008 VA examination, the Veteran reported feeling tired all the time and having significant neuropathy in the lower and upper extremities. He reported constant numbness in his hands, distal forearms, and feet. He had burning pain, which also presented in his feet most of the day. He had exacerbations, which brought his pain intensity to 9 and 10 out of 10. At its best, his pain was described as 1 to 2 out of 10. There were no alleviating factors. His flare-ups were aggravated and precipitated by prolonged sitting or walking. He had no weakness or functional loss of the upper or lower extremities. He took Neurontin and an increase dose was prescribed in January 2008. He had no other sensory abnormalities. The examiner noted the nerves involved were the distal nerves of the upper and lower extremities. Neurological examination revealed normal muscle strength bilaterally in the upper and lower extremities bilaterally. Monofilament testing showed diminished sensation midway down his left forearm and involving the entire right forearm. Both hands had diminished sensation on monofilament testing. In both lower extremities, the Veteran had diminished monofilament response bilaterally below the knee and both feet. Deep tendon reflexes were 2 out of 4 bilaterally at the biceps and knee. The examiner did not identify the specific nerves affected. In a September 2008 letter, Dr. J.E.L. reported that the Veteran had severe debilitating diabetic neuropathy. She opined that he had significant restriction in his activity due to his painful diabetic neuropathy. She noted that he had a remarkably abnormal neurologic examination with loss of 10-gram fiber test and loss of vibratory sensation. He also had loss of flexion at his ankles when he walked and had very poor walking with instability and poor balance. She noted his imbalance is mainly from moderate problems with flexion of his feet and disruption of normal neurologic condition. In a September 2008 letter, Dr. F.V. reported that the Veteran had progressive peripheral neuropathy with constant pain in his feet and decreased sensitivity of his lower extremities. His gait was unsteady and a walking cane was recommended to prevent him from sustaining a fall. The provider noted that his neuropathy affected his routine activities of daily living because he had difficulty walking. In a statement received in December 2010, the Veteran reported that his neuropathy in both hands caused his middle gingers to lock when he tried to close his hand, which he could only close to about 3/4ths of the way. He reported that he could not grip bottles or jars to open them. His hands tingled and burned most of the time, and at times he had very little feeling in his lower arms and hands. He also reported that his pain was sometimes so severe that he dropped things because he could not feel them in his hands. In a May 2012 private disability benefits questionnaire (DBQ), the Veteran’s private provider opined that the Veteran was unable to work given his significant debilitating painful diabetic neuropathy. The specific nerves affected was not identified. In a June 2013 letter, the Veteran’s provider, Dr. J.E.L., reported that the Veteran had debilitating diabetic neuropathy with absence of sensation in his toes, loss of flexion in his ankle and as a consequence had poor ambulation. On June 2015 VA examination, the examiner noted his endocrinologist limited his activities due to his peripheral neuropathy. He had mild intermittent pain of the bilateral upper extremities and moderate intermittent pain of the bilateral lower extremities. He had mild paresthesias of the bilateral upper extremities, and moderate paresthesias of the bilateral lower extremities. He also had mild numbness of his bilateral upper extremities and moderate numbness of the bilateral lower extremities. On neurologic examination the Veteran had normal strength bilateral for his elbow flexion, elbow extension, wrist flexion, wrist extension, grip, pinch (thumb to index finger), knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion. He had decreased reflexes in his biceps, triceps, brachioradialis, knee, and ankle. For monofilament testing, his shoulder area and inner/outer forearm were normal bilaterally; and he had decreased sensation bilaterally for hand/fingers, knee/thigh, ankle/lower leg, and foot/toes. His position sense was normal bilaterally for both upper and lower extremities. He had decreased vibration sensation for his bilaterally upper and lower extremities. He did not have muscle atrophy or trophic changes. The examiner found the Veteran had normal radial nerve bilaterally, normal medial nerve bilaterally, normal ulnar nerve bilaterally, normal sciatic nerve bilaterally, and normal femoral nerve bilaterally. The examiner noted the Veteran also had glove distribution (just the finger up to the metatarsal region) and stocking distribution (just below the knee). The examiner opined that the Veteran had mild incomplete paralysis of the right and left upper extremities and moderate incomplete paralysis of the right and left lower extremity. The ultimate opinion did not identify specific nerves affected; however, the examiner noted on the report itself that there was evidence of peripheral neuropathy affecting the radial, medial, ulnar, sciatic and femoral nerves of the bilateral extremities. In an August 2017 DBQ filled out by his private provider, the Veteran was noted to have debilitating diabetic neuropathy with severe pain with low vibrating sensation in his feet and diminished sensation in his knees. On physical examination, the Veteran had decreased strength and vibration in his hands, worse than on his last examination. Muscle wasting and thenar wasting noted. Deep tendon reflexes were abnormal, on tuning fork, severe decrease on the right and left and monofilament were abnormal on the right and left. He also used a cane for ambulation and difficulty picking up his foot. A 10g fiber was only felt about his ankle, and vibration was diminished even at knee. The examiner did not identify the specific nerves affected. At an August 2017 hearing, the Veteran testified that most of his toes were numb, he did not have feeling in them, and he had balance problems. He described having increase in burning of his feet for the past few years. He testified he had shooting pain in both his hands and feet. He used a cane to help him walk, but he only walked around his house. Regarding his upper extremities, he testified that he had to sleep with a pillow propped up to put his left arm laying on that pillow and his right arm on his side, and he could only sleep on his right side or his back. He described that he would also have to wake up at night due to pain and have to shake out his hands. He testified this would last 10 minutes or longer. He testified that his numbness in his hands, especially in his fingers, made him lose grip on objects, and he was unable to unscrew a tight lid off a jar. He also testified that the numbness impacted his ability to write. On June 2018 VA examination, the Veteran had no pain in his upper extremities, and mild intermittent pain in his bilateral lower extremities. He had mild paresthesias of the bilateral upper extremities, and moderate paresthesias of the bilateral lower extremities. He also had no numbness of his bilateral upper extremities and moderate numbness of the bilateral lower extremities. On neurologic examination the Veteran had normal strength bilateral for his elbow flexion, elbow extension, wrist flexion, wrist extension, grip, pinch (thumb to index finger), knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion. He had decreased reflexes only in ankle. For monofilament testing, his shoulder area, inner/outer, forearm hand/fingers, knee/thigh, ankle/lower leg, were normal bilaterally; and he had decreased sensation bilaterally for his foot/toes. He had decrease vibration sensation for his bilateral lower extremities. There was no atrophy or trophic changes. The examiner found the Veteran had normal radial nerve bilaterally, normal medial nerve bilaterally, and normal ulnar nerve bilaterally. The examiner found the Veteran had mild incomplete paralysis of his sciatic nerve. The examination itself identified the affected nerves as the bilateral radial median, ulnar and sciatic nerves. On December 2020 VA examination, the VA examiner only specifically addressed the severity of the Veteran’s service-connected radiculopathy, but the examiner addressed the severity of the Veteran’s median nerve, which is before the Board. The examiner characterized the severity as moderate incomplete paralysis of the median nerve. In a January 2020 rating decision the AOJ increased the ratings for the right median nerve to 30 percent and for the left median nerve to 20 percent, both effective December 13, 2019, the date of the examination. On November 2020 VA examination, the Veteran reported feeling constant numbness and burning from his forefoot distally. He reported having flare-ups each night when he gets off his feet that lasts from as long as he gets off hs feet until he is unable to go to sleep. He reported that these flare-ups are painful. He was unable to walk further than 100 yards or stand for prolonged period of 3 to 4 minutes. The examiner noted no specific nerve pattern was followed. He reported numbness and shooting pains in hands that starts in in the tips of his fingers and shoot up his hands. He described that it’s a sharp pain and had progress to the point where he feels like his nerves are exposed. The examiner noted he was treated with Lyrica twice daily and had been on Gabapentin. He also needed help with buttoning shirts, getting dressed, and sometimes standing up from a sitting position. The Veteran had constant mild pain in his bilateral upper and lower extremities, and severe intermittent pain in his bilateral upper and lower extremities. He also had severe paresthesias and numbness of the bilateral upper and lower extremities. On muscle strength examination the Veteran had strength rated as 4 out 5 bilaterally for his elbow flexion, elbow extension, wrist flexion, wrist extension, grip, pinch (thumb to index finger), knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion. There was no muscle atrophy. He had decreased reflexes bilaterally in his biceps, triceps, brachioradiales, knee, and ankles. His shoulder was normal bilaterally to light touch, but his inner/outer forearm, hand/finger, upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes were all decreased to light touch sensation. The Veteran had tropic changes of dry skin, no hair on his lower extremities, and no swelling. The Veteran ambulated with a slow gait, wide stance, and he waked with a cane. The examiner noted that the Veteran’s gait was due to his inability to feel the ground when he walks due to his neuropathy in his feet. Phalen’s sign and Tinel’s sign were positive bilaterally. The examiner found the Veteran had moderate incomplete paralysis of the radial nerve, median nerve, ulnar nerve, musculocutaneous nerve, circumflex nerve, long thoracic nerve, upper radicular group, middle radicular group, lower radicular group, sciatic nerve, external popliteal nerve, musculocutaneous nerve, anterior tibial nerve, internal popliteal nerve, posterior tibial nerve, anterior crural nerve, internal saphenous nerve, obturator nerve, external cutaneous nerve of the thigh, and Illio-inguinal nerve. The examiner opined that there was no functional impairment of an extremity that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The examiner opined that the Veteran’s peripheral neuropathy impacted his ability to work because he could not feel to manipulate devices like his hearing aid or when he holds his coffee mug for a few minutes, he had to use a cane to help his balance because he could not feel the front of his feet. He also needed to use a cane to help his balance. He also had problems with his fine motor skills. He used a cane to walk short distances and a wheelchair for long distances. In a December 2020 rating decision, service connection for peripheral neuropathy of the bilateral lower extremity effecting the external cutaneous nerve, Illio-inguinal nerve, and obturator nerve were granted and each assigned a noncompensable (0 percent) rating, all effective November 23, 2020. Median Nerve Based on a review of the record, the Board finds that entitlement to ratings higher than 10 percent are not warranted prior August 10, 2017. However, from August 10, 2017, a 30 percent rating, but no higher, for the right and a 20 percent rating, but no higher, for the left median nerve, respectively, is warranted. For the period to prior to August 10, 2017, this period, the Veteran’s neuropathy was manifested by symptoms affecting both upper extremities including numbness and burning in his hands, diminished sensation, and decreased reflexes. Both the July 2006 and June 2015 VA examiners characterized these symptoms as mild in severity. The Veteran reported having problems with his grip and closing his hand in December 2010, however, he was found to have normal strength in both upper extremities, including on June 2015 VA examination. Thus, the Board finds that the criteria for higher 30 percent and 20 percent ratings for moderate incomplete paralysis of the right and left upper extremity, respectively, are not more closely approximated for the period prior to August 10, 2017. The Board finds that the criteria for higher 30 percent and 20 percent ratings for moderate incomplete paralysis of the right and left upper extremity, respectively, have been met beginning August 10, 2017, the date of the private DBQ. While the Veteran had reported having problems with his grip in both hands, decreased strength was not noted until the August 2017 DBQ, on which his private provider found he had decreased strength and vibration in his hands, which was worse than on his last examination in June 2015. Additionally, the Veteran testified in August 2017 that the numbness in his hands and fingers made him lose grip on objects, he could only sleep in certain positions, and he would have to wake up at know to shake out his hands. Accordingly, the Board finds that the Veteran’s symptoms more nearly approximate moderate incomplete paralysis for his bilateral upper extremities from August 2010, 2017. Therefore, a 30 percent rating is warranted for his major right upper extremity and a 20 percent rating is warranted for his upper left extremity. See Code 8515. Higher ratings are not warranted for the period from August 10, 2017 as the record does not reflect that the Veteran’s peripheral neuropathy nearly approximated severe incomplete paralysis at any point during this period. Throughout this period, the Veteran’s neuropathy was manifested by symptoms affecting both upper extremities including numbness and burning in his hands, diminished sensation, decreased reflexes, and decreased strength, and severe intermittent pain. The November 2020 VA examiner characterized these symptoms as moderate in severity. Thus, the Board finds that the criteria for a higher ratings for severe incomplete paralysis for either upper extremity are not more closely approximated for the period from August 10, 2017. External popliteal nerve (common peroneal) Based on a review of the record, the Board finds that ratings higher than 10 percent prior to September 4, 2008 for both the Veteran’s peripheral neuropathy of the right and left lower extremity external popliteal nerve and in excess of 20 percent from that date are not warranted. For the period prior to September 4, 2008, ratings higher than 10 percent are not warranted. Throughout this period, the symptoms affecting the right and left lower extremities included decreased sensation, numbness, paresthesias, dysesthesias, and sharp shooting pain. While the July 2006 VA examiner characterized his symptoms as severe, the June 2007 VA examiner characterized them as mild, and throughout this period strength and reflexes were normal on examination. Thus, the Board finds that the criteria for a higher 20 percent rating for moderate incomplete paralysis are not more closely approximated for the period prior to September 4, 2008. For the period from September 4, 2008, ratings higher than 20 percent are not warranted. Throughout this period, the Veteran’s symptoms affecting his right and left lower extremities included constant pain, severe intermittent pain, numbness, decreased sensation, decrease reflexes, and difficulty walking due to his neuropathy for which he used a cane. Additionally, the June 2015, and November 2020 VA examiners characterized such symptoms as moderate in severity. At no point during this period did the Veteran have muscle strength rated as less than 4 out of 5, or were reflexes or sensation to light touch absent. Thus, the Board finds that the criteria for a higher 30 percent rating for severe incomplete paralysis are not more closely approximated for the period from September 4, 2008. Obturator nerve Based on a review of the record, the Board concludes that a compensable rating is not warranted for the period prior to or from November 23, 2020 for the peripheral neuropathy of the right and left lower extremity obturator nerves. For the period prior to November 23, 2020, the record reflects decreased sensation of the thigh and the obturator nerve involves the medial thigh; however, at no point during this period does the competent evidence of record reflect that the neuropathy of either lower extremity affected the obturator nerve. For the period from November 23, 2020, compensable ratings are not warranted. Throughout this period, the Veteran’s symptoms affecting his right and left lower extremities included constant mild pain, severe intermittent pain, decreased sensation to light touch of the upper anterior thigh and thigh/knee areas, and he walked with a slow gait. The November 2020 VA examiner characterized these symptoms as moderate in severity. Thus, the Board finds that the criteria for a compensable percent rating for severe incomplete paralysis are not more closely approximated for the period from November 23, 2020. External cutaneous nerve of the thigh Based on a review of the record, the Board concludes that a compensable rating is not warranted for the period prior to or from November 23, 2020 for the right and left lower extremity neuropathy affecting the bilateral external cutaneous nerves of the thigh. For the period prior to November 23, 2020, while the record during this period reflects decreased sensation of the thigh and the external cutaneous nerve involves the medial thigh, at no point during this period does the competent evidence of record reflect that the neuropathy affected the obturator nerve. For the period from November 23, 2020, compensable ratings are not warranted. Throughout this period, the Veteran’s symptoms affecting his right and left lower extremities included constant mild pain, severe intermittent pain, decreased sensation to light touch of the upper anterior thigh and thigh/knee areas, and he walked with a slow gait. The November 2020 VA examiner characterized these symptoms as moderate in severity. Thus, the Board finds that the criteria for a compensable percent rating for severe incomplete paralysis are not more closely approximated for the period from November 23, 2020. Illio-inguinal nerve Based on a review of the record, the Board concludes that a compensable rating is not warranted for the period prior to or from November 23, 2020 for the peripheral neuropathy of the right and left Illio-inguinal nerves. For the period prior to November 23, 2020, the record reflects decreased sensation of the thigh and the Illio-inguinal nerve involves the medial thigh; however, at no point during this period does the competent evidence of record reflect that the peripheral neuropathy affected either obturator nerve. For the period from November 23, 2020, compensable ratings are not warranted. Throughout this period, the Veteran’s symptoms affecting his right and left lower extremities included constant mild pain, severe intermittent pain, decreased sensation to light touch of the upper anterior thigh and thigh/knee areas, and he walked with a slow gait. The November 2020 VA examiner characterized these symptoms as moderate in severity. Thus, the Board finds that the criteria for a compensable percent rating for severe incomplete paralysis are not more closely approximated for the period from November 23, 2020. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. The Board acknowledges that the Veteran’s peripheral neuropathy of his bilateral upper and lower extremities significantly limited his activities of daily living throughout the period on appeal. While not contemplated by the rating criteria for the involved nerves, it is contemplated through the award of TDIU throughout the entire period on appeal. In deciding the claims, the Board has also considered the Veteran’s lay statements that his peripheral neuropathy of the right and left lower extremity symptoms were worse than currently evaluated. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which his disabilities are evaluated. As such, the Board finds these records to be more probative than the Veteran’s subjective complaints of increased symptomatology. The Board has considered the doctrine of reasonable doubt but has determined that it is inapplicable, other than to the extent of allowing an increase in the ratings to 30 percent and 20 percent ratings for peripheral neuropathy of the right and left upper extremities, median nerve because otherwise the preponderance of the evidence is against higher ratings. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7, 4.71a, 4.124a. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Eric Struening 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.