Citation Nr: 21013788 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 15-46 401 DATE: March 10, 2021 ORDER Service connection for right hand disability, including upper right extremity radial nerve disability, claimed as disfigurement of right middle finger and right hand condition, to include as secondary to service-connected right upper extremity peripheral neuropathy, is granted, subject to the law and regulations governing the payment of monetary benefits. A compensable initial rating prior to April 9, 2018 and in excess of 20 percent from April 9, 2018 for bilateral hearing loss is denied. A rating in excess of 20 percent for diabetes mellitus, type 2 is denied. A rating in excess of 20 percent prior to December 23, 2019 and in excess of 40 percent from December 23, 2019 for left lower extremity peripheral artery disease is denied. A rating in excess of 20 percent prior to December 23, 2019 and in excess of 40 percent from December 23, 2019 for right lower extremity peripheral artery disease is denied. A rating in excess of 80 percent for diabetic nephropathy with hypertension is denied. FINDINGS OF FACT 1. The Veteran’s upper right extremity radial nerve disability began during active service, and/or is due to or aggravated by his service-connected right upper extremity diabetic peripheral neuropathy. 2. Prior to April 9, 2018, the Veteran’s bilateral hearing loss has been manifested by hearing acuity of no worse than Level III in the right ear and no worse than Level III in the left ear. 3. From April 9, 2018, the Veteran’s bilateral hearing has been manifested by hearing acuity of no worse than Level IV in the right ear and no worse than Level VI in the left ear. 4. The preponderance of the evidence is against finding that the Veteran has had a regulation of activities due to his diabetes mellitus. 5. Prior to December 23, 2019, the preponderance of the evidence is against a finding that the Veteran’s left lower extremity peripheral artery disease was manifested by arteriosclerosis obliterans with claudication on walking between 25 and 100 yards on a level grade at two miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less. 6. From December 23, 2019, the preponderance of the evidence is against a finding that the Veteran’s left lower extremity peripheral artery disease was manifested by arteriosclerosis obliterans with claudication on walking less than 25 yards on a level grade at two miles per hour, and; either persistent coldness of the extremity or ankle/brachial index of 0.5 or less. 7. Prior to December 23, 2019, the preponderance of the evidence is against a finding that the Veteran’s right lower extremity peripheral artery disease was manifested by arteriosclerosis obliterans with claudication on walking between 25 and 100 yards on a level grade at two miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less. 8. From December 23, 2019, the preponderance of the evidence is against a finding that the Veteran’s right lower extremity peripheral artery disease was manifested by arteriosclerosis obliterans with claudication on walking less than 25 yards on a level grade at two miles per hour, and; either persistent coldness of the extremity or ankle/brachial index of 0.5 or less. 9. The preponderance of the evidence indicates that the Veteran’s diabetic nephropathy with hypertension was not manifested by renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80 mg percent; or, creatinine more than 8 mg percent; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. CONCLUSIONS OF LAW 1. The criteria for service connection for upper right extremity radial nerve disability, to include as secondary to service-connected diabetic right upper extremity peripheral neuropathy, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for a compensable initial rating prior to April 9, 2018 and in excess of 20 percent from April 9, 2018 for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, diagnostic code 6100. 3. The criteria for an increased rating in excess of 20 percent for diabetes mellitus, type 2 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.119, diagnostic code 7913. 4. The criteria for an increased rating for left lower extremity peripheral artery disease in excess of 20 percent prior to December 23, 2019 and in excess of 40 percent from December 23, 2019 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.104, diagnostic code 7114. 5. The criteria for an increased rating for right lower extremity peripheral artery disease in excess of 20 percent prior to December 23, 2019 and in excess of 40 percent from December 23, 2019 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, diagnostic code 7114. 6. The criteria for an increased rating in excess of 80 percent for diabetic nephropathy with hypertension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 5.115b, diagnostic code 7541. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1965 to September 1968 and from August 1970 to October 1973. These matters come before the Board of Veterans’ Appeals (Board) on appeal from July 2011 (diabetes mellitus, type 2, left and right lower extremity peripheral artery disease, and TDIU) and June 2013 (bilateral hearing loss, right hand, diabetic nephropathy with hypertension) rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO) of the Agency of Original Jurisdiction (AOJ). In May 2019, the Board, in pertinent part, remanded the appeals for entitlement to service connection for a right hand disability and for increased ratings for bilateral ear hearing loss, diabetes mellitus, type II, left and right lower extremity peripheral artery disease and diabetic nephropathy with hypertension. The Board finds that there has been substantial compliance with the Board’s remand directives with regard to the appeals for increased ratings for bilateral hearing loss, diabetes mellitus, type 2, left and right lower extremity peripheral artery disease and diabetic nephropathy with hypertension, but not with the Board’s remand directives with regard to the entitlement to service connection for right hand disability, which must be remanded, as discussed in further detail below. See Stegall v. West, 22 Vet. App. 269 (1998). In a June 2020 rating decision, the AOJ granted entitlement to service connection for left and right great hammertoes, claimed by the Veteran as bilateral foot conditions in September 2011. As this represents a total grant of the benefits sought on appeal with respect to the issues of left and right foot disabilities, they are no longer before the Board. See Grantham v. Brown, 114 F. 3d 1156, 1159 (Fed. Cir. 1997). In the June 2020 rating decision, the AOJ granted entitlement to a TDIU, effective July 23, 2010, the date the Veteran met the schedular criteria for a TDIU. This is also the effective date for TDIU that the Veteran, through his attorney requested. See Appellant’s brief, dated and received in March 2019. The RO also granted an increased rating of 20 percent for bilateral hearing loss, effective April 9, 2018 and an increased rating of 40 percent for left and right lower extremity peripheral artery disease, effective December 23, 2019. As these actions regarding bilateral hearing loss and left and right lower extremity peripheral artery disease do not represent full grants of the benefits sought, the Veteran’s appeals of these matters are not abrogated, remain in appellate status and have been characterized as shown above. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran requested a Board hearing in the December 2015 Appeal to Board of Veterans’ Appeals, VA Form 9. In a December 2018 letter, the Veteran was notified that a Board hearing was scheduled for January 14, 2019. In a letter dated and received in December 2018, the Veteran, through his attorney, requested to waive the Board hearing scheduled for January 14, 2019. Further, he requested that his Board hearing be cancelled and not rescheduled. The Veteran’s Board hearing request is thus deemed withdrawn. 38 C.F.R. § 20.704 (e). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. 1. Entitlement to service connection for right hand disability, including radial nerve disability, to include as secondary to service-connected right upper extremity diabetic peripheral neuropathy, is granted. The Veteran asserts that he injured his hand in-service. Specifically, the Veteran states that in-service, he was a motor-pool mechanic and that a he experienced a crushing injury to his right hand. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is shown to be proximately due to, the result of, or chronically aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. In May 2009, the Veteran initial claimed entitlement to service connection for disfigurement of right middle finger which the RO denied in a July 2010 rating decision. In September 2011, the Veteran submitted a claim of entitlement to service connection for “right hand condition.” The RO interpreted this as a claim to reopen the previously denied claim for right middle finger impairment, and in a June 2013 rating decision, the RO found that new and material evidence had not been received to reopen the claim. In May 2019, the Board recharacterized the issue as entitlement to service connection for a right-hand disability and found that new and material evidence was not required to address the claim. The Board then remanded the appeal in order to obtain an examination to determine whether the Veteran had a right hand or right finger disabilities which were related to his service, and/or which were caused or aggravated by his service-connected diabetes mellitus, type 2 and/or right upper extremity peripheral neuropathy. The Board finds that the Veteran has a current right upper extremity radial nerve disability that is related to an in-service injury, and/or is secondary to his service-connected right upper extremity diabetic peripheral neuropathy. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran had a VA examination in September 2019. The examiner reported that the Veteran had a right upper extremity radial nerve injury. During service, on March 20, 1973, the Veteran was seen for complaints of an injury to his right hand carbuncle, second digit and was referred to surgery. Thus, the question before the Board is whether the current right finger disability is related to service. The September 2019 VA examiner opined that the Veteran’s right upper extremity radial nerve, which supplies the part of the middle finger which runs down to the wrist, was injured in the in-service motor pool accident. Additionally, the examiner opined that the Veteran’s right radial nerve injury may be secondary to his service-connected right upper extremity diabetic peripheral neuropathy. As rationale, the examiner stated that free radical-mediated oxidative stress is implicated in the pathogenesis of diabetic neuropathy by inducing neurovascular defects that result in endoneural hypoxia and subsequent nerve dysfunction, and that diabetic neuropathic pain is a common complication of diabetes and the most common form of neuropathic pain. Accordingly, the Board finds that service connection for the Veteran’s right upper extremity radial nerve disability, to include as secondary to his service connected right upper extremity diabetic neuropathy, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.310. 2. A compensable initial rating for bilateral hearing loss prior to April 9, 2018 in excess of 20 percent from April 9, 2018 is denied. The Veteran’s claim for a compensable initial rating for bilateral hearing loss stems from the June 2013 rating decision which granted service connection for bilateral hearing loss, effective July 5, 2011. Thus, the relevant period on appeal for entitlement to an initial compensable rating for bilateral hearing loss is from July 5, 2011, the effective date of service connection. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. Lendenman v. Principi, 3 Vet. App. 345 (1992). The rating schedule establishes auditory hearing acuity levels based on average puretone thresholds and speech discrimination. The rating of a hearing loss is a two-step process, and it is based on examination results that include a controlled speech discrimination test (Maryland CNC) and an audiometric test of pure tone decibel thresholds at 1000, 2000, 3000, and 4000 Hertz (Hz), with the average pure tone threshold obtained by dividing these thresholds by four. Once these test results are obtained, a Roman numeral designation of hearing impairment is ascertained based on a combination of the percent of speech discrimination and the pure tone threshold average, pursuant to Table VI (the first step). After a Roman numeral designation of auditory acuity level for each ear is determined under Table VI, Table VII is used to determine the percentage evaluation for bilateral hearing loss by combining the Roman numeral designations of auditory acuity level for the hearing impairment of each ear (the second step). In addition, there is an alternative method of rating hearing loss, which is applied only in the instances of exceptional hearing loss, which is not applicable to the Veteran’s bilateral ear hearing loss claims. 38 C.F.R. § 4.85. Prior to April 9, 2018 Turning to the medical evidence of record, the Veteran submitted a private audiological evaluation report dated May 2011, received in August 2011, and a private audiological evaluation report dated July 2012, received in May 2013; however, the examination reports do not reflect that speech recognition testing was conducted in accordance with Maryland CNC testing, which is necessary per VA regulations to determine the degree of hearing loss for VA purposes. Thus, the Board affords the evaluations no probative value regarding the determination of the degree of the Veteran’s hearing loss for VA purposes, but will consider the Veteran’s statements regarding the functional effects of any bilateral hearing loss. The Veteran had a VA audiological examination in May 2013. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 25 35 40 LEFT 15 20 25 65 65 The puretone threshold average of for the right ear was 29. The puretone threshold average for the left ear was 44. Speech audiometry under Maryland CNC testing shows speech recognition ability of 82 percent in the right ear and 76 percent in the left ear. The examiner diagnosed bilateral ear sensorineural hearing loss. Applying the foregoing medical evidence to the rating criteria, the Veteran’s right ear is assigned a Level III and the left ear is assigned a Level III designation under Table VI. These categories correspond with a noncompensable disability rating under Table VII. The Veteran’s hearing loss disability did not meet the criteria for an exceptional pattern of hearing loss in either ear. see 38 C.F.R. §§ 4.85, 4.86. The Board has considered the functional effects of the Veteran’s bilateral ear hearing loss. At the May 2013 VA examination, the Veteran reported difficulty hearing some high-frequency speech, especially with background noise, difficulty hearing the television, telephone conversations and with understanding women, children and people with heavy accents/dialects. At the Veteran’s May 2011 private audiological examination, the Veteran reported that he has trouble hearing in background noise, in church, listening to children, and hearing the television at a normal level. At the Veteran’s July 2012 private audiological examination, the Veteran reported that he has trouble understanding conversation when there is background noise, hearing in church, listening to children and hearing the television when it is at normal volume. The Veteran has not asserted that he has additional functional impairment of the bilateral ears that is not considered in the current schedular rating criteria. The provisions of 38 C.F.R. §§ 4.85 and 4.86 contemplate, and thus compensate for, the functional effects of hearing loss, namely difficulty understanding speech and the inability to hear sounds in various contexts. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The situations noted by the Veteran amount to decreased hearing and difficulty understanding speech in an everyday environment and are not exceptional or unusual for someone with bilateral hearing loss. The Board has considered the Veteran’s contention that his bilateral hearing loss disability warrants a compensable rating during this period. The Veteran is competent to report the symptoms of his bilateral ear hearing loss disability. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran has not been shown to have medical training or skills, and is thus not competent to determine the severity of his bilateral hearing loss symptoms. Thus, the Board finds the May 2013 VA examination report to be the most probative evidence of record regarding the degree of the Veteran’s bilateral ear hearing loss disability for VA purposes prior to April 9, 2019. From April 9, 2018 The Veteran had a VA audiological examination in September 2019. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 40 40 65 75 LEFT 45 50 55 75 90 The puretone threshold average of for the right ear was 55. The puretone threshold average for the left ear was 68. Speech audiometry under Maryland CNC testing shows speech recognition ability of 76 percent in the right ear and 68 percent in the left ear. The examiner diagnosed bilateral sensorineural hearing loss. Applying the foregoing medical evidence to the rating criteria, the Veteran’s right ear is assigned a Level IV and the left ear is assigned a Level VI designation under Table VI. These categories correspond with a 20 percent disability rating under Table VII. The Veteran’s bilateral hearing loss disability did not meet the criteria for an exceptional pattern of hearing loss in either ear. see 38 C.F.R. §§ 4.85, 4.86. The Board has considered the functional effects of the Veteran’s bilateral ear hearing loss from April 9, 2018. At the September 2019 VA examination, the Veteran reported that he is using hearing aids, and sometimes he must ask people to repeat themselves and he has difficulty understanding what people are saying when he is in a crowd. The Veteran has not asserted that he has additional functional impairment of the bilateral ears that is not considered in the current schedular rating criteria. Once again, the provisions of 38 C.F.R. §§ 4.85 and 4.86 contemplate, and thus compensate for, the functional effects of hearing loss, namely difficulty understanding speech and the inability to hear sounds in various contexts. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The situations noted by the Veteran amount to decreased hearing and difficulty understanding speech in an everyday environment and are not exceptional or unusual for someone with bilateral hearing loss. The Board has considered the Veteran’s contention that his bilateral hearing loss disability warrants a higher rating during this period. The Veteran is competent to report the symptoms of his bilateral hearing loss disability. See Jandreau. However, the Veteran has not been shown to have medical training or skills, and is thus not competent to determine the severity of his bilateral hearing loss symptoms. Thus, the Board finds the September 2019 VA examination report to be the most probative evidence of record regarding the degree of the Veteran’s bilateral ear hearing loss disability for VA purposes from April 9, 2018. In making this determination, the Board considered the application of staged ratings during the period prior to April 9, 2018 and from April 9, 2018, but found no distinctive period(s) where the Veteran’s service-connected bilateral hearing loss met or nearly approximated the criteria for a higher rating than that assigned. Accordingly, as the preponderance of the evidence is against a compensable rating for bilateral hearing loss disability prior to April 9, 2018 or from April 9, 2018, the benefit of the doubt rule is not applicable, and the appeals are denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 3. Entitlement to an increased rating in excess of 20 percent for diabetes mellitus, type 2 The Veteran contends that he is entitled to an increased rating for his service-connected diabetes mellitus, type 2. Although he has submitted medical records and buddy statements from family and friends, the Veteran has not submitted any argument as to why he is entitled to an increased rating for diabetes mellitus type 2. The Veteran’s increased rating claim was received on August 31, 2010. Therefore, the relevant rating period is from August 31, 2009, one year prior to receipt of the claim, through the present, if increased disability is demonstrated during the one year prior to receipt of the claim. see 38 C.F.R. § 3.400 (o) (2). Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’ favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The question in this appeal is whether the Veteran’s diabetes mellitus type 2 required one or more daily injections of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. This criterion requires medical evidence. Camacho v. Nicholson, 21 Vet. App. 360, 364-65 (2007). The Veteran submitted records from the Northeast Georgia Diagnostic Clinic from June 2011. The records show that the Veteran sought follow-up treatment for diabetes hyperlipemia and obesity. The pertinent assessment was uncontrolled type 2 diabetes, complicated by neuropathy. The recommendation, in pertinent part, were to start treatment with Levemir, an oral hypoglycemic agent. The record shows that the doctor emphasized to the Veteran the importance of healthy eating habits and regular physical activity for weight loss and maintenance and also cardiovascular health. He was advised to stop all sweet tea, regular soda, ice cream and to avoid fried foods. The record does not reflect that the Veteran was prescribed a regulation of activities, defined as an avoidance of strenuous occupational and recreational activities. The Veteran had a VA examination for in November 2011. The Veteran reported being diagnosed with diabetes mellitus, type 2 in 2005. The Veteran reported that he had been prescribed oral medication, insulin and a restricted diet. Specifically, he was prescribed Glipizide, taken 2 times per day and insulin, brand name Levemir, taken 1 time per day. The Veteran was prescribed insulin, namely Novolog Mix 70/30 once per day. The VA examiner did not find medical evidence that the Veteran had regulation of activities, namely medical evidence of a requirement to avoid strenuous occupational and recreational activities. The Veteran had a VA examination for diabetes mellitus, type 2 in April 2015. The examiner reported that the Veteran’s diabetes mellitus, type 2 was managed by prescribed oral hypoglycemic agent(s), one injection of insulin per day and that the Veteran did not require regulation of activities as part of medical management of the disease. Pursuant to the May 2019 Board remand instructions, the Veteran was provided with a VA examination for diabetes mellitus, type 2 in September 2019. The examiner reported that the treatment for the disease was prescribed oral hypoglycemic agent, insulin more than 1 injection per day, and a restricted diet. The examiner reported that the Veteran was required to regulate his activities as part of medical management of diabetes mellitus, however this was based on the Veteran’s report that he exercises on the tread mill for 30 minutes daily. The Board reiterates that regulation of activities is defined as avoidance of strenuous occupational and recreational activities, which requires medical evidence. See Camacho. The evidence that the Veteran exercises on the treadmill for 30 minutes per day supports a finding that the Veteran is not required to regulate his activities as part of medical management of the disease to include avoidance of strenuous occupational and recreational activities. The Board has reviewed the buddy statements from the Veteran’s family and friends, received in October 2015. B.R. stated that the Veteran’s diabetes mellitus is “bad,” and that even with medicine, it is very hard to control. K.W. Others noted that the Veteran takes medicine and insulin shots for his diabetes mellitus, type 2. The Board has reviewed the Veteran’s VA and private treatment records which show prescribed oral medication, insulin and a restricted diet. The buddy statements and VA and private treatment records do not contain medical evidence of regulation of activities, defined as avoidance of strenuous occupational and recreational activities, which must be shown in order to increase the Veteran’s rating. The Board finds that the Veteran’s diabetes mellitus type 2 required only restricted diet and one or more daily injection of insulin during the period on appeal. A review of the Veteran’s VA and private treatment records shows that he was prescribed glipizide and/or metformin and daily insulin injection and follows a restricted diet for treatment of his diabetes mellitus, type 2. Thus, the medical evidence of record is against a finding that regulation of activities was required during the period on appeal and thus, an increased rating in excess of 20 percent for diabetes mellitus, type 2 is denied. The evidence shows that the Veteran has complications of diabetes mellitus, type 2, namely left and right lower extremity peripheral artery disease and diabetic nephropathy with hypertension, which are also on appeal herein. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). 4. Entitlement to an increased rating in excess of 20 percent prior to December 23, 2019 for peripheral artery disease of the left lower extremity 5. Entitlement to an increased rating in excess of 40 percent from December 23, 2019 for peripheral artery disease of the right lower extremity The Veteran contends that his left and right lower extremity peripheral artery disease is more severe than reflected by the currently assigned 20 ratings prior to December 23, 2019 and 40 percent ratings assigned from December 23, 2019. The Veteran states that he has bad arteries in his legs causing them to swell, making it difficult for him to do anything. See written correspondence dated and received in September 2010. The Veteran’s left and right lower extremity peripheral arterial disease is currently rated under 38 C.F.R. § 4.104, diagnostic code 7114, pertaining to arteriosclerosis obliterans, as 20 percent disabling prior to December 23, 2019 and 40 percent disabling from December 23, 2019. The Veteran’s increased rating claim was received on August 31, 2010. Therefore, the relevant rating period is from August 31, 2009, one year prior to receipt of the claim, through the present, if increased disability is demonstrated during the one year prior to receipt of the claim. see 38 C.F.R. § 3.400 (o) (2). Under Diagnostic Code 7114, a 20 percent rating, which is the minimum compensable rating available under this code, is assigned for arteriosclerosis obliterans with claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less. A 40 percent rating is assigned for arteriosclerosis obliterans with claudication on walking between 25 and 100 yards on a level grade at two miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less. A 60 percent rating is assigned for arteriosclerosis obliterans with claudication on walking less than 25 yards on a level grade at two miles per hour, and; either persistent coldness of the extremity or ankle/brachial index of 0.5 or less. A 100 percent rating is assigned for arteriosclerosis obliterans with ischemic limb pain at rest, and; either deep ischemic ulcers or ankle/brachial index of 0.4 or less. 38 C.F.R. § 4.104, Diagnostic Code 7114. Notes following Diagnostic Code 7114 provide that the ankle/brachial index is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure. The normal index is 1.0 or greater. 38 C.F.R. § 4.104, Diagnostic Code 7114, Note (1). Residuals of aortic or large arterial bypass surgery or arterial graft are evaluated as arteriosclerosis obliterans. 38 C.F.R. § 4.104, Diagnostic Code 7114, Note (2). The ratings are for involvement of a single extremity; if more than one extremity is affected, each extremity is evaluated separately and combined (under 38 C.F.R. § 4.25), using the bilateral factor (38 C.F.R. § 4.26), if applicable. 38 C.F.R. § 4.10, Diagnostic Code 7114, Note (3). Prior to December 23, 2019 The Veteran had a general VA examination in July 2009. The Veteran described progressive loss of strength in legs and claudication after walking 25 yards on grand level at 2 miles per hour. The examiner found that the Veteran had abnormal pulses of the left and right lower extremities. The Veteran had a general VA examination in October 2010. The Veteran described progressive loss of bilateral leg strength. The examiner noted that the Veteran stated he had symptoms of claudication after walking 1 yard on level ground at 2 miles per day. Physical examination showed that the Veteran’s right lower extremity peripheral artery disease was quiescent. The Veteran’s left lower extremity showed only ankle/brachial index of 0.97. The examiner found that there was no functional impairment due to the Veteran’s left and right lower extremity peripheral artery disease. The Veteran had a VA contract examination in November 2011. The examiner noted that the Veteran’s extremities examination did not reveal, in pertinent part, persistent coldness or trophic changes. Neurological examination of the lower extremities showed motor function within normal limits. The Veteran had a VA examination for artery and vein conditions in April 2015. The Veteran stated that his right and left lower extremity peripheral artery disease cause burning, swelling and shooting pain. The Veteran had right ankle/brachial index of 1.02 and left ankle/brachial index of 1.40. There were no other significant diagnostic test findings and/or results. The examiner described the functional impact of the Veteran’s bilateral lower extremity vascular condition as the Veteran has difficulty walking long distances. The Veteran had a VA examination for diabetes mellitus in April 2015. The examiner found that examination of the lower extremities was all normal, other than the neurological examination which showed decreased sensory sensation. From December 23, 2019 The Veteran had a VA examination for artery and vein conditions in December 2019. The Veteran stated, in pertinent part, that he had a cold sensation in his lower feet. Upon examination, the examiner noted that the Veteran had left and right lower extremity claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour and right ankle brachial index of 1.07 and left ankle brachial index of 0.99. The examiner found bilateral lower extremity persistent coldness. The examiner further found that there were no trophic changes in either the left or right lower extremity. Regarding functional impact, the examiner stated that the Veteran has pain and that his inability to do prolonged walking, standing and/or running can interfere with his ability to perform occupational tasks. The Board finds that prior to December 23, 2019, the Veteran’s left and right lower extremity peripheral artery disease was manifested by no more than claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less. These findings are consistent with the 20 percent rating assigned for each lower extremity prior to December 23, 2019. Higher ratings are not warranted during this time period for either lower extremity because trophic changes, persistent coldness of the extremity or ankle, deep ischemic limb pain at rest, or deep ischemic ulcers were not present; and an ankle/brachial index of 0.7 or less was not demonstrated. As a result, an increased rating in excess of 20 percent is not warranted for left and/or right lower extremity peripheral artery disease prior to December 23, 2019. From December 23, 2019, the Veteran’s left and right lower extremity peripheral artery disease has been manifested at worst by claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour and persistent coldness of the bilateral extremities. The Veteran did not exhibit trophic changes or ankle/brachial index of 0.7 or less in either the left or right extremity, which would meet the requirements for a 40 percent rating. However, the RO determined that the findings were consistent with a 40 percent rating for each lower extremity due to claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour and persistent coldness of the lower extremities shown on this examination. The Board will not disturb this favorable ruling. A 60 percent rating is not warranted for either lower extremity because the evidence of record does not show that the Veteran has claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; either persistent coldness of the extremity or ankle;/brachial index of 0.5 or less. Similarly, a 100 percent rating is not warranted for either lower extremity because the evidence of record shows the Veteran has not had ischemic limb pain at rest and either deep ischemic ulcers, or ankle/brachial index of 0.4 or less of either extremity. Based on the foregoing, an initial rating in excess of 40 percent is not warranted for peripheral arterial disease of either lower extremity from December 23, 2019. The Board has also considered whether further staged ratings under Hart, supra, are appropriate for the Veteran's service connected peripheral artery disease of the left and right lower extremities; however, the Board finds that his symptomatology referable to such disability has been stable throughout each period on appeal. The Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Board has reviewed the buddy statements from the Veteran’s friends and family regarding, in pertinent part, the Veteran’s bilateral lower extremity peripheral artery disease, which were received in October 2015. K.W. stated that the Veteran’s legs always hurt, he is not able to stand and he falls when he stands up if not assisted, as his legs won’t hold him up. A letter with an indecipherable signature states that the Veteran never knows when his legs will “give out,” that he falls to the floor and some days he can hardly walk. C.P. stated that the Veteran limps on both legs and is very slow due to leg pain. B.R. stated that the Veteran cannot balance himself, falls on the floor, and is has a very limited ability to walk, due to severe pain. K W.-T. stated that she has seen the Veteran having pain and discomfort in his feet and has daily conversations with the Veteran about how painful his feet are. She has seen him have difficulty walking without stumbling or losing his balance. She has had to keep him from falling on many occasions, and when he walks, stands or spends time on hard surfaces or uneven ground his feet and legs hurt so badly that he cannot walk at all. There are periods where he doesn’t have the strength or pain resistance to stand or walk. In August 2010, the Veteran reported that he could not work because of the swelling of his leg and other service-connected disabilities. In assessing the severity of peripheral artery disease of the left and right lower extremities, the Board has considered these competent lay assertions from the Veteran and his friends and family regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings involve medical findings that are within the province and purview of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the Veteran and his friends’ and family’s statements are not considered more persuasive than the objective medical findings which, as indicated above, do not support higher ratings pursuant to the applicable rating criteria during the appellate periods. While the Veteran and his friends and family are competent to report symptoms, as this is personal knowledge as it comes to their senses, they are not competent to identify a specific level of disability of the Veteran’s bilateral lower extremity peripheral artery disease according to the appropriate diagnostic code. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Thus, the preponderance of the evidence is against the assignment of increased ratings in excess of 20 percent for left and right lower extremity peripheral artery disease prior to December 23, 2019 and in excess of 40 percent from December 23, 2019. The benefit of the doubt doctrine is not for application and the appeals are denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to an increased rating in excess of 80 percent for diabetic nephropathy with hypertension The Veteran seeks entitlement to an increased rating for his diabetic nephropathy with hypertension rating. He has not stated why he believes he is entitled to an increased rating; however, he has submitted medical evidence and buddy statements from family and friends which are relevant to his appeal. The Veteran’s increased rating claim was received on July 6, 2011. Therefore, the relevant rating period is from July 6, 2010, one year prior to receipt of the claim through the present, if increased disability is demonstrated during the one year prior to receipt of the claim. See 38 C.F.R. § 3.400 (o) (2). The Veteran’s chronic kidney disease with hypertension is rated 80 percent disabling under 38 C.F.R. § 4.115b, diagnostic code 7541, as renal dysfunction due to diabetes. Diagnostic code 7541 provides that such disability should be evaluated based on the criteria pertinent to renal dysfunction. 38 C.F.R. § 4.115a. Only the predominant area, in this case, renal dysfunction, shall be considered for rating purposes. Id. If chronic renal disease has progressed to the point where regular dialysis is required, any coexisting hypertension or heart disease will be separately rated. 38 C.F.R. § 4.115a. In the Veteran’s case, his renal disease does not require dialysis. Diagnostic Code 7541 provides that such disability should be evaluated based on the criteria pertinent to renal dysfunction. 38 C.F.R. § 4.115a. Under the rating criteria for renal dysfunction, an 80 percent rating requires persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80 mg percent; or, creatinine 4 to 8 mg percent; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A maximum 100 percent evaluation is assigned for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80 mg percent; or, creatinine more than 8 mg percent; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Albuminuria refers to the presence of albumin, a protein, in the urine. Dorland’s Illustrated Medical Dictionary 45 (32nd ed. 2012). Albuminuria is also known as proteinuria and is the presence of an excess of serum proteins in the urine. Booton v. Brown, 8 Vet. App. 368, 369 (1995). VA treatment and private treatment records during the appeal period do not reflect that the Veteran required regular dialysis or was precluded from more than sedentary activity from persistent edema and albuminuria, or BUN more than 80 mg.; or, creatinine more than 8 mg. or markedly decreased function of the kidney or other organ systems, especially cardiovascular. On VA examination in October 2010, the Veteran showed normal range microalbuminuria. His diastolic blood pressure was 90, though it was noted to usually be 60-70. The Veteran's BUN was 16 mg/dL in December 2007. In addition, the examiner noted that the Veteran's BUN was 33 mg/dL in August 2007 and 30 mg/dL in June 2007. The Veteran's creatinine was 1.4 mg/dL in December 2007; 1.8 in August 2007; and 1.7 in June 2007. Although the Veteran had long-standing hypertension, there was no evidence of microalbuminuria. There was also no edema. The Veteran had a general VA examination in October 2010. The Veteran had a diagnosis of diabetic nephropathy. The Veteran reported that he was not on dialysis and, in pertinent part, that he had leg swelling and limitation of exertion. Upon examination, the Veteran did not have edema. The Veteran’s EKG was normal. The Veteran had a normal Complete blood count (CBC). The examination report does not show albuminuria, or BUN or creatinine level results. The Veteran submitted a private examination dated November 2011. The Veteran’s BUN level was 16 mg./dL and his creatinine level was 1.27 mg/dL. The Veteran had a VA examination for kidney conditions in January 2013. The examiner noted the Veteran’s diagnosis of diabetic nephropathy. The examiner noted that the Veteran did not require dialysis, did not have proteinuria (albuminuria) or edema due to renal dysfunction. The Veteran’s BUN level was 18 mg., his creatinine level was 1.36 mg/dL. The examiner did not find that the Veteran was precluded from more than sedentary activity due to persistent edema caused by renal dysfunction or had markedly decreased function of the kidney or other organ systems, especially cardiovascular. Pursuant to the May 2019 Board remand, the Veteran had a VA examination for kidney conditions in December 2019. The examiner noted the Veteran’s diagnosis of diabetic nephropathy in 2008 and a diagnosis of stage 3 kidney disease in 2019. The examiner noted that the Veteran did not require dialysis. The examiner noted that the Veteran had some edema and constant proteinuria (albuminuria) due to renal dysfunction, but no limitation of exertion due to renal dysfunction. The Veteran’s BUN level was 20 mg. and his creatinine level was 1.58 mg/dL. The examiner found that the Veteran had hypertension and/or heart disease due to renal dysfunction, however, the examiner did not find that Veteran had markedly decreased function of the kidney or other organ systems, especially cardiovascular, and the evidence of record pertaining to the Veteran’s heart disease does not show markedly decreased cardiovascular function. The Veteran underwent a cardiac stress test in October 2012 and the examiner found mild evidence of left ventricular wall motion and left ventricular ejection fraction. The Veteran is separately service connected for coronary artery disease, rated as 10 percent disabling, as due to left ventricular ejection, as well as the need for continuous medication. Thus, the record does not show that the Veteran met the criteria for a 100 percent rating for diabetic nephropathy with hypertension at any time during the period on appeal. During that time, the Veteran was not on dialysis, he was not precluded from more than sedentary activity by persistent edema and albuminuria; or BUN more than 80 mg.; or, creatinine more than 8 mg.; or markedly decreased function of the kidney or other organ systems, especially cardiovascular. As for the potential for a separate compensable rating for hypertension, DC 7541 (the diagnostic code used to rate the Veteran’s diabetic nephropathy with hypertension) specifically contemplates nephritis and its relationship to hypertension. As such, awarding the Veteran a separate rating for hypertension would result in impermissible pyramiding and is therefore inappropriate. 38 C.F.R. § 4.14; see also Esteban. The Board has considered assigning staged ratings. However, at no time during the rating period in question has the disability warranted a higher schedular rating than that 80 percent rating assigned. Hart, 21 Vet. App. 505. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert, 1 Vet. App. 49. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Susan Leary, Associate 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.