Citation Nr: 21009414 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 17-21 369 DATE: February 22, 2021 ORDER Entitlement to a 20 percent rating, but no higher, for a right lower extremity sciatic neuropathy from February 19, 2013 to July 7, 2019 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a separate 10 percent rating, but no higher, for a right lower extremity femoral neuropathy since May 30, 2014 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 20 percent disabling since July 8, 2019 for a right lower extremity sciatic neuropathy is denied. Entitlement to a 20 percent rating, but no higher, for a left lower extremity sciatic neuropathy from February 19, 2013 to July 7, 2019 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a separate 10 percent rating, but no higher, for a left lower extremity femoral neuropathy since May 30, 2014 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 20 percent disabling since July 8, 2019 for a left lower extremity sciatic neuropathy is denied. Entitlement to an initial rating in excess of 10 percent for a right upper extremity peripheral neuropathy prior to July 8, 2019 is denied. Entitlement to a rating in excess of 40 percent for a right upper extremity peripheral neuropathy since July 8, 2019 is denied. Entitlement to an initial rating in excess of 10 percent for a left upper extremity peripheral neuropathy prior to July 8, 2019 is denied. Entitlement to a rating in excess of 30 percent for a left upper extremity peripheral neuropathy since July 8, 2019 is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to July 8, 2019 is denied. Entitlement to a TDIU since July 8, 2019 is granted, subject to the laws and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder is remanded. Entitlement to special monthly compensation (SMC) based on a need for aid and attendance of another person is remanded. FINDINGS OF FACT 1. From February 19, 2013 to July 7, 2019, the Veteran’s right lower extremity sciatic neuropathy was manifested by moderate incomplete paralysis of the sciatic nerve, but not moderately severe incomplete paralysis. 2. Since May 30, 2014, the Veteran’s right lower extremity peripheral neuropathy was manifested by mild incomplete paralysis of the femoral nerve, but not moderate incomplete paralysis. 3. Since July 8, 2019 the Veteran’s right lower extremity sciatic neuropathy was not manifested by moderately severe incomplete paralysis of the sciatic nerve. 4. From February 19, 2013 to July 7, 2019, the Veteran’s left lower extremity sciatic neuropathy was manifested by moderate incomplete paralysis of the sciatic nerve, but not moderately severe incomplete paralysis. 5. Since May 30, 2014, the Veteran’s left lower extremity peripheral neuropathy was manifested by mild incomplete paralysis of the femoral nerve, but not moderate incomplete paralysis. 6. Since July 8, 2019 the Veteran’s left lower extremity sciatic neuropathy was not manifested by moderately severe incomplete paralysis of the sciatic nerve. 7. Prior to July 8, 2019 the Veteran’s right upper extremity peripheral neuropathy was not manifested by a moderate nerve impairment. 8. Since July 8, 2019 the Veteran’s right upper extremity peripheral neuropathy was not manifested by a severe nerve impairment. 9. Prior to July 8, 2019 the Veteran’s left upper extremity peripheral neuropathy was not manifested by a moderate nerve impairment. 10. Since July 8, 2019 the Veteran’s left upper extremity peripheral neuropathy was not manifested by a severe nerve impairment. 11. Prior to July 8, 2019, the Veteran’s right lower extremity sciatic neuropathy, right lower extremity femoral neuropathy, left lower extremity sciatic neuropathy, left lower extremity femoral neuropathy, right upper extremity peripheral neuropathy and left upper extremity peripheral neuropathy did not preclude him from securing or following substantially gainful employment. 12. Since July 8, 2019, the Veteran’s right lower extremity sciatic neuropathy, right lower extremity femoral neuropathy, left lower extremity sciatic neuropathy, left lower extremity femoral neuropathy, right upper extremity peripheral neuropathy and left upper extremity peripheral neuropathy precluded him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 20 percent rating, but no higher, for a right lower extremity sciatic neuropathy from February 19, 2013 to July 7, 2019 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.7, 4.124a, Diagnostic Criteria (DC) 8520. 2. The criteria for entitlement to a separate 10 percent rating, but no higher, for a right lower extremity femoral neuropathy, since May 30, 2014 have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DC 8526. 3. The criteria for entitlement to a rating in excess of 20 percent for a right lower extremity sciatic neuropathy since July 8, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DC 8520. 4. The criteria for entitlement to a 20 percent rating, but no higher, for a left lower extremity sciatic neuropathy from February 19, 2013 to July 7, 2019 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.7, 4.124a, DC 8520. 5. The criteria for entitlement to a separate 10 percent rating, but no higher, for a left lower extremity femoral neuropathy, since May 30, 2014 have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DC 8526. 6. The criteria for entitlement to a rating in excess of 20 percent a left lower extremity sciatic neuropathy since July 8, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DC 8520. 7. The criteria for entitlement to a rating in excess of 10 percent for a right upper extremity peripheral neuropathy prior to July 8, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DC 8515. 8. The criteria for entitlement to a rating in excess of 40 percent for a right upper extremity peripheral neuropathy since July 8, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DCs 8512-8516. 9. The criteria for entitlement to a rating in excess of 10 percent for a left upper extremity peripheral neuropathy prior to July 8, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DC 8515. 10. The criteria for entitlement to a rating in excess of 30 percent for a left upper extremity peripheral neuropathy since July 8, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, DCs 8512-8516. 11. The criteria for assignment of a TDIU prior to July 8, 2019 were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.15, 4.16. 12. The criteria for assignment of a TDIU since July 8, 2019 were met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1967 to April 1969. These matters are before the Board of Veterans’ Appeals (Board) on appeal of a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2018 the Board remanded the appeals for further development. The issues have now been returned to the Board. Entitlement to 20 percent ratings for bilateral lower extremity sciatic neuropathies from February 19, 2013 to July 7, 2019 are granted; entitlement to separate 10 percent ratings for bilateral lower extremity femoral neuropathies since May 30, 2014 are granted; entitlement to ratings in excess of 20 percent disabling since July 8, 2019 for bilateral lower extremity sciatic neuropathies are denied; entitlement to ratings in excess of 10 percent for bilateral upper extremity peripheral neuropathies prior to July 8, 2019 are denied; entitlement to a rating in excess of 40 percent for a right upper extremity peripheral neuropathy since July 8, 2019 is denied; and entitlement to a rating in excess of 30 percent for a left upper extremity peripheral neuropathy since July 8, 2019 is denied. The Veteran contends that his bilateral upper and lower extremity peripheral neuropathies are more severely disabling than represented by the 10 percent ratings assigned for right and upper extremity peripheral neuropathy prior to July 8, 2019, and 40 percent and 30 percent ratings assigned for the right and left upper extremities thereafter respectively, the 10 percent ratings assigned for right and left lower extremity peripheral neuropathies prior to July 8, 2019 and 20 percent ratings assigned thereafter. Prior to July 8, 2019, the Veteran’s left and right upper extremity peripheral neuropathies were rated under DC 8515 based on paralysis of the median nerve. Starting July 8, 2019, the left and right upper extremity peripheral neuropathies were rated under DC 8513 based on paralysis of all radicular groups. Throughout the appeal period, the Veteran’s bilateral lower extremity peripheral neuropathies have been rated under DC 8520 based on paralysis of the sciatic nerve. Under DC 8512, incomplete paralysis of the lower radicular group is rated as 20 percent disabling when it is mild. When incomplete paralysis of all radicular groups is moderate, a 30 percent rating is assigned for the minor extremity and a 40 percent rating is assigned for the major extremity. When incomplete paralysis of the median nerve is severe, a 40 percent rating is assigned for the minor extremity and a 50 percent rating is assigned for the major extremity. 38 C.F.R. § 4.124a. Under DC 8513, incomplete paralysis of all radicular groups is rated as 20 percent disabling when it is mild. When incomplete paralysis of all radicular groups is moderate, a 30 percent rating is assigned for the minor extremity and a 40 percent rating is assigned for the major extremity. When incomplete paralysis of the median nerve is severe, a 60 percent rating is assigned for the minor extremity and a 70 percent rating is assigned for the major extremity. 38 C.F.R. § 4.124a. Under DC 8514 incomplete paralysis of the musculospiral (radial) nerve is rated as 20 percent disabling when it is mild. When incomplete paralysis of the median nerve is moderate, a 20 percent rating is assigned for the minor extremity and a 30 percent rating is assigned for the major extremity. When it is severe, a 40 percent rating is assigned for the minor extremity and a 50 percent rating is assigned for the major extremity. Id. Under DC 8515 incomplete paralysis of the median nerve is rated as 10 percent disabling when it is mild. When incomplete paralysis of the median nerve is moderate, a 20 percent rating is assigned for the minor extremity and a 30 percent rating is assigned for the major extremity. When incomplete paralysis of the median nerve is severe, a 40 percent rating is assigned for the minor extremity and a 50 percent rating is assigned for the major extremity. Id. Under DC 8516 incomplete paralysis of the ulnar nerve is rated as 10 percent disabling when it is mild. When incomplete paralysis of the ulnar nerve is moderate, a 20 percent rating is assigned for the minor extremity and a 30 percent rating is assigned for the major extremity. When it is severe, a 30 percent rating is assigned for the minor extremity and a 40 percent rating is assigned for the major extremity. Id. Under DC 8520 incomplete paralysis of the sciatic nerve is rated as 10 percent disabling when it is mild, 20 percent disabling when it is moderate, and 40 percent disabling when it is moderately severe. Id. Under DC 8526 incomplete paralysis of the anterior crural (femoral) nerve is rated as 10 percent disabling when it is mild, 20 percent disabling when it is moderate, and 30 percent disabling when it is severe. Id. The words “mild,” “moderate,” and “severe” as used in the various DCs are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on 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. 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 of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). A February 19, 2013 VA treatment record noted the Veteran’s leg pain was controlled by medication. However, the Veteran had reduced leg strength due to sciatic nerve paralysis and walked with a cane to prevent falls. An October 2013 VA treatment record noted worsening leg pain and discomfort and that it was more difficult to walk. At a May 2014 VA examination, the Veteran’s bilateral upper extremities were manifested by mild intermittent pain, mild paresthesias and/or dysesthesias and mild numbness. His lower extremities were manifested by moderate intermittent pain, moderate paresthesias and/or dysesthesias and moderate numbness. The Veteran was noted to have occasional leg cramps, mostly nocturnal. Strength testing was normal in all extremities and deep tendon reflexes were decreased in the right bicep, right triceps, right brachioradialis, and bilateral knees. Sensation to light touch was decreased in the bilateral hands and fingers, bilateral ankle/lower leg, and absent in the feet and toes bilaterally. Position sense was decreased in both lower extremities and vibration sense was absent in the lower extremities. There was no muscle atrophy, though the Veteran had trophic changes described as “shiny pretibials and loss of body hair.” The overall severity of the upper extremity neuropathies was described as mild incomplete paralysis of the median nerve bilaterally. The overall severity of the lower extremity neuropathies was described as mild incomplete paralysis of the sciatic and femoral nerves bilaterally. The functional impact of the neuropathies was described as “significantly lost mobility and stamina.” At a July 2019 VA examination, the Veteran’s bilateral upper and lower extremities were manifested by mild intermittent pain, mild paresthesias and/or dysesthesias and severe numbness. Strength testing was less than normal for grip, pinch, ankle plantar flexion and ankle dorsiflexion bilaterally. Deep tendon reflexes were absent in the triceps and ankles bilaterally. Sensation to light touch was absent in the hands, fingers, feet and toes bilaterally. Position sense was absent in all extremities and vibration sense was absent in the left upper and left lower extremities and decreased in the right upper and right lower extremities. There was no muscle atrophy, but the Veteran had trophic changes described as “smooth, shiny skin on feet without hair bilaterally.” The overall severity of the upper extremity neuropathies was described as moderate incomplete paralysis of the radial, median and ulnar nerves bilaterally. The overall severity of the lower extremity neuropathies was described as moderate incomplete paralysis of the sciatic nerve bilaterally. The functional impact of the neuropathies was described as difficulty performing strength maneuvers with either hand and either foot, difficulty balancing, climbing and walking on uneven surfaces, difficulty feeling and manipulating objects, and difficulty judging temperature with hands and feet. The examiner noted that the Veteran had difficulty performing activities of daily living and walking and used a walker due to lower extremity symptoms. Effective from February 19, 2013 through July 7, 2019, 20 percent ratings for the bilateral lower extremity peripheral neuropathies based on sciatic nerve impairment is granted. In this regard, while the May 2014 VA examiner described the overall impairment due to bilateral lower extremity sciatic nerve impairment as only “mild” the examination revealed moderate lower extremity intermittent pain, paresthesias and/or dysesthesias and numbness, as well as decreased position sense and absent vibration sense in the lower extremities. Significantly, the Veteran had trophic changes described as “shiny pretibials and loss of body hair.” These symptoms resulted in “significant lost mobility and stamina.” Significantly, the February 19, 2013 VA treatment record first revealed loss of lower extremity strength with use of a cane to walk due to sciatic nerve impairment, representing more than merely sensory findings. This evidence is at least in equipoise as to whether a moderate sciatic nerve impairment was demonstrated from February 19, 2013 to July 7, 2019. As moderate sciatic nerve symptoms were factually ascertainable starting February 19, 2013, an increased rating is warranted effective that date. See 38 C.F.R. § 3.400 (o)(2). For the period since February 19, 2013 a rating in excess of 20 percent for the bilateral lower extremity peripheral neuropathies is not warranted. In this regard, the May 2014 examination revealed no more than moderate lower extremity symptoms. Lower extremity strength testing was normal and there was no muscle atrophy. While ankle reflexes were decreased, they were not absent. On VA examination in July 2019, while severe lower extremity numbness was noted, other lower extremity symptoms were no more than mild. While ankle reflexes were absent, ankle plantar and dorsiflexion strength was only “less than normal.” While foot/toe sensation to light touch, positional sense, and vibration sense in the left lower extremity were absent, these findings are sensory in nature. The overall severity of the sciatic nerve symptoms since February 19, 2013 are contemplated by a finding of moderate overall impairment, and the evidence preponderates against finding a moderately severe impairment of the sciatic nerves. Effective from May 30, 2014, separate 10 percent ratings for bilateral lower extremity neuropathies based on mild incomplete paralysis of the femoral nerves is warranted. In this regard, the May 30, 2014 VA examination revealed mild incomplete paralysis of the femoral nerves bilaterally. As discussed above, the Board finds that the Veteran’s sciatic nerve symptoms were of moderate severity, but the evidence demonstrates that the femoral nerve impairment was less severe. Notably, while a sciatic nerve impairment relates to impairment of the foot and muscles below the knee, the femoral nerve pertains to the quadriceps extensor muscles, i.e. muscles above the knee. See 38 C.F.R. § 4.124a, DCs 8520, 8526. The May 2014 VA examination revealed full knee strength, normal knee reflexes, and normal sensation to light touch at the knee. Trophic changes noted were located at the “pretibial region,” of the lower legs. The VA examiner characterized the femoral nerve impairment as only “mild.” On VA examination in July 2019, no femoral nerve impairment was noted. Knee strength, reflexes and sensation to light touch remained normal, and trophic changes were noted only with respect to the Veteran’s feet. This evidence preponderates against a rating in excess of 10 percent for bilateral lower extremity femoral nerve impairment since May 30, 2014. With regard to the upper extremities, ratings in excess of 10 percent prior to July 8, 2019, and in excess of 40 percent for the right upper extremity and 30 percent for the left upper extremity since July 8, 2019 are not warranted. In this regard, the May 2014 VA examiner found only a mild impairment of the median nerves bilaterally. Bilateral upper extremity symptoms were no more than mild bilaterally. While right bicep and triceps reflexes were decreased, upper extremity strength was normal. While sensation to light touch in the hand and fingers was decreased it was not absent, and position and vibration sense in the upper extremities was normal. There was no muscle atrophy or tropic changes related to the upper extremities. This evidence preponderates against finding more than a mild impairment of the median nerves prior to July 8, 2019. On VA examination in July 2019, the examiner reported moderate impairments of the bilateral radial, medial and ulnar nerves. While the Veteran had severe upper extremity numbness, his remaining symptoms were no more than mild. Upper extremity strength was normal except for grip and pinch which were only “less than normal strength.” While he had no reflexes in the triceps, his biceps and brachioradialis reflexes were normal. While sensation to light touch was absent in the hand and fingers, position sense was absent to the upper extremities, and vibration sensation was absent to the left upper extremity, these are sensory findings. There were no upper extremity trophic changes or muscle atrophy. The Board has considered the July 2019 examiner’s reports of difficulty performing maneuvers with either hand, difficulty gripping, pulling, pinching, handling objects and performing fine motor activities and difficulty feeling and manipulating objects, as well as difficulty judging temperature with his hands. However, based on the severity of symptoms reported by the examiner, the overall impairment of the upper extremity nerves was no more than moderate. This evidence preponderates against finding a severe nerve impairment since July 8, 2019 under any applicable DC, to include 8512, 8513, 8514, 8515, or 8516. 38 C.F.R. § 4.124a. Therefore, ratings in excess of 40 percent for the major extremity and 30 percent for the minor extremity are not warranted. The Board has considered whether separate ratings may be assigned for the separate impairments of the radial, medial and ulnar nerves. However, the DCs 8510, 8511, 8512, and 8513 contemplate various levels of paralysis of the entire upper radicular group (shoulder and elbow movements), middle radicular group (adduction, abduction and rotation of arm, flexion of elbow and extension of wrist), lower radicular group (all intrinsic muscles of hand, and some or all of flexors of wrist and finger) and all radicular groups, respectively. The Veteran’s currently assigned rating since July 8, 2019 contemplates “all radicular groups” including the upper extremity functions contemplated by impairments of the radial medial and ulnar nerves. Based on the availability of a combined rating under these diagnostic codes, separate ratings for individual upper extremity nerve impairments are not appropriate in this case.  38 C.F.R. § 4.124a. Based on the foregoing, 20 percent ratings, but no higher for bilateral lower extremity sciatic neuropathies are granted from February 19, 2013 to July 7, 2019. Separate 10 percent ratings, but no higher are granted for bilateral lower extremity femoral neuropathies since May 30, 2014. The evidence preponderates against finding that ratings in excess of 10 percent are warranted for bilateral upper extremity neuropathies prior to July 8, 2019, or in excess of 40 percent for the major extremity and 30 percent for the minor extremity thereafter. Entitlement to a TDIU prior to July 8, 2019 is denied; entitlement to a TDIU since July 8, 2019 is granted. A TDIU is authorized for any disability or combination of disabilities where the schedular rating is less than total, and the claimant is unable to secure and maintain substantially gainful employment because of the severity of service-connected disabilities. If there is only one such disability, it must be rated as at least 60 percent disabling. If two or more disabilities, at least one must be rated as at least 40 percent disabling, with sufficient additional service-connected disability to bring the combined rating to 70 percent. 38 C.F.R. §§ 4.15, 4.16(a). For the above purpose, VA will consider disabilities resulting from common etiology, a single accident, or affecting a single body system as one disability. 38 C.F.R. § 4.16(a). For a TDIU, the critical question is whether the veteran’s service-connected disabilities alone are sufficient to cause unemployability, absent consideration of any nonservice-connected condition. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Other factors that may receive consideration include his employment history, level of education and vocational attainment. See 38 C.F.R. § 4.16; see also Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). The issue of entitlement to a TDIU presently before the Board is raised in connection with the claims for increased ratings for bilateral upper and lower extremity peripheral neuropathies. When a request for a TDIU is made during the pendency of a claim, whether expressly raised by a veteran or reasonably raised by the record, it is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of the initial adjudication of the claim. Rice v. Shinseki, 22 Vet. App. 447, 453-454 (2009). As such, the issue before the Board is limited to the narrow question of whether the Veteran has been rendered unemployable during the period on appeal due to his service-connected bilateral upper and lower extremity neuropathies alone. From February 19, 2013 to September 12, 2013, the Veteran was service connected for diabetes mellitus rated 20 percent disabling, right lower extremity sciatic neuropathy rated 20 percent disabling, and left lower extremity peripheral neuropathy rated 20 percent disabling. From September 13, 2013, to May 29, 2014 the Veteran was service connected for diabetes mellitus rated 20 percent disabling, right lower extremity sciatic neuropathy rated 20 percent disabling, left lower extremity peripheral neuropathy rated 20 percent disabling, right upper extremity peripheral neuropathy rated 10 percent disabling, and left upper extremity peripheral neuropathy rated 10 percent disabling. From May 30, 2014 to July 7, 2019 the Veteran was service connected for diabetes mellitus rated 20 percent disabling, right lower extremity sciatic neuropathy rated 20 percent disabling, left lower extremity peripheral neuropathy rated 20 percent disabling, right lower extremity femoral neuropathy rated 10 percent disabling, left lower extremity femoral neuropathy rated 10 percent disabling, right upper extremity peripheral neuropathy rated 10 percent disabling, and left upper extremity peripheral neuropathy rated 10 percent disabling. Since July 8, 2019 the Veteran was service connected for right upper extremity peripheral neuropathy rated 40 percent disabling, left upper extremity peripheral neuropathy rated 30 percent disabling, diabetes mellitus rated 20 percent disabling, right lower extremity sciatic neuropathy rated 20 percent disabling, left lower extremity peripheral neuropathy rated 20 percent disabling, right lower extremity femoral neuropathy rated 10 percent disabling, and left lower extremity femoral neuropathy rated 10 percent disabling. After application of the relevant bilateral factors, the Veteran’s combined rating was 50 percent from February 19, 2013 to September 12, 2013, 60 percent from September 13, 2013 to May 29, 2014, 70 percent from May 30, 2014 to July 7, 2019, and 90 percent since July 8, 2019. As diabetes mellitus and peripheral neuropathies of the upper and lower extremities have the same etiology, they can be combined for TDIU purposes. Thus, the appellant meets the schedular requirements for a TDIU from September 13, 2013. 38 C.F.R. § 4.16. On VA examination in May 2014, the functional impairment due to upper and lower extremity peripheral neuropathy was described as “significantly lost mobility and stamina.” In his June 2019 application for TDIU the Veteran reported being totally disabled due to his diabetic neuropathy. He reported working from 1969 to 2002 as a transportation supervisor. From 2003 to 2007 he reported self-employment as a handyman. The Veteran noted two years of college education. On VA examination on July 8, 2019, functional impairment due to upper and lower extremity peripheral neuropathy was described as “difficulty performing strength maneuvers with either hand and either foot … difficulty balancing, climbing, and walking on uneven surfaces … difficulty gripping, pulling, pinching, handling objects and performing fine motor activities … difficulty feeling and manipulating objects” and “difficulty judging temperature with his hands and feet.” In a second application for TDIU, the Veteran noted that he completed his education in accounting in 1971. In September 2020, a request for employment information in connection with claim for disability completed by the Veteran’s previous employer reported that the Veteran had stopped working in December 2002 due to “back and emotional disability.” In this case, the evidence preponderates against finding that the Veteran was precluded from all substantially gainful employment solely due to his service-connected upper and lower extremity peripheral neuropathy. In this regard, while the May 2014 VA examiner noted “significantly lost mobility and stamina” the evidence does not indicate that the peripheral neuropathy symptoms alone would preclude all substantially gainful employment. For example, the record indicates extensive experience in a supervisory capacity, and the evidence does not indicate that the Veteran would be precluded from performing supervisory work consistent with his occupational experience due to a loss of mobility and stamina alone. On the contrary, the evidence of record, to include the September 2020 request for employment information, suggests that the Veteran’s unemployability prior to July 8, 2019 was partly attributable to his non-service connected psychiatric disorder. The evidence preponderates against finding that the Veteran’s upper and lower extremity peripheral neuropathies alone precluded all forms of substantially gainful employment prior to July 8, 2019. Since July 8, 2019 the evidence of record is in equipoise as to whether the Veteran’s peripheral neuropathy precluded all forms of substantially gainful employment consistent with his education and occupational experience. On VA examination on July 8, 2019, the examiner described functional impairment causing “difficulty performing strength maneuvers with either hand and either foot … difficulty balancing, climbing, and walking on uneven surfaces … difficulty gripping, pulling, pinching, handling objects and performing fine motor activities … difficulty feeling and manipulating objects” and “difficulty judging temperature with his hands and feet.” The Board finds it particularly significant that the Veteran’s peripheral neuropathy caused difficulty “gripping … handling object and performing fine motor activities” and “manipulating objects.” While the examiner did not specifically state that these limitations would preclude all forms of gainful employment, these limitations suggest that the Veteran may be unable to complete tasks such as writing, typing, or handling even light objects. This evidence indicates the Veteran would have difficulty even with occupations requiring little physical activity. In combination with the Veteran’s long absence from the labor force, having last worked in any capacity in 2007, the Board finds the evidence in equipoise as to whether his peripheral neuropathies alone would preclude all forms of substantially gainful employment consistent with his occupational history. As the evidence is in equipoise, entitlement to a TDIU since July 8, 2019 is granted. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (“By requiring only an ‘approximate balance of positive and negative evidence’ the Nation, ‘in recognition of our debt to our veterans,’ has ‘taken upon itself the risk of error’ in awarding... benefits.”). REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives. In its July 2018 remand, the Board directed that a VA examination be obtained regarding the etiology of the Veteran’s acquired psychiatric disorder. The examiner was to specifically address whether a current acquired psychiatric disorder was related to active-duty service or caused or aggravated by the service-connected peripheral neuropathies. The examiner was also directed to specifically discuss the Veteran’s lay reports of frequent trouble sleeping, frequent or terrifying nightmares, depression or excessive worry, loss of memory or amnesia, and nervous trouble of any sort during his separation examination, as well as his lay reports in his April 2017 VA Form 9 that he experienced bullying and rejection in-service. The examiner diagnosed major depressive disorder but opined against a relationship between that disorder and service in the August 2019 examination report and an August 2020 addendum. The examiner did not address the Veteran’s lay reports of frequent trouble sleeping, frequent or terrifying nightmares, depression or excessive worry, loss of memory or amnesia, and nervous trouble of any sort during his separation examination as directed by the July 2018 Board remand. Additionally, the examiner opined that major depressive disorder was not caused or aggravated by the Veteran’s peripheral neuropathy. The only clear rationale provided in support of that conclusion was that the Veteran first sought psychiatric care almost 40 years after service. It is not clear how that evidence is relevant to the question of whether major depressive disorder was caused or aggravated by the peripheral neuropathy. Additionally, the examiner did not provide separate findings and rationales with respect to the independent questions of causation and aggravation. See Atencio v. O’Rourke, 30 Vet. App. 74 (2018) (holding that causation and aggravation are independent concepts and should have separate findings and rationales). Given that the Board’s July 2018 instructions were not fulfilled, and the August 2019 and August 2020 opinions are otherwise inadequate, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to SMC based on a need for aid and attendance is remanded. The record raises a claim for entitlement to special monthly compensation based on the need for the aid and attendance of another person. At the July 2019 VA examination, the Veteran reported difficulty dressing, feeding himself and using the toilet due to peripheral neuropathy. As the claim for entitlement to increased ratings for peripheral neuropathy is before the Board, the Board also has jurisdiction over the issue of entitlement to SMC based on the need for aid and attendance due to peripheral neuropathy. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). However, this issue has not been considered by the AOJ in the first instance. Additionally, the July 2019 VA examiner did not specifically address whether the Veteran, in fact, required aid and attendance due to his service-connected peripheral neuropathy. Remand is required to obtain a medical examination addressing this question, and for initial consideration of the issue by the AOJ. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the etiology of major depressive disorder. The examiner should answer the following questions: a) Is major depressive disorder at least as likely as not related to an in-service injury, event or disease to include the April 2017 report of bullying and rejection in-service? The examiner must explicitly discuss the Veteran’s reports of frequent trouble sleeping, frequent or terrifying nightmares, depression or excessive worry, loss of memory or amnesia, and nervous trouble of any sort during his separation examination. b) Is major depressive disorder at least as likely as not proximately caused by bilateral upper and lower extremity peripheral neuropathies? c) Is major depressive disorder at least as likely as not aggravated beyond its natural progression by bilateral upper and lower extremity peripheral neuropathies? 2. Schedule the Veteran for an aid and attendance examination to assess the Veteran’s functional impairment due to service-connected disability. The examiner must state whether, due to service-connected disability, the Veteran requires the regular aid and attendance of another person, to include whether the Veteran is unable to dress or undress himself, unable to keep himself ordinarily clean and presentable, needs frequent adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without such aid, is unable to feed himself or attend to the wants of nature, or experiences incapacity which requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Paul J. Bametzreider 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.