Citation Nr: 21021889 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 14-11 480 DATE: April 14, 2021 ORDER Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and depression, is denied. Entitlement to a rating higher than 20 percent for diabetes mellitus is denied. Entitlement to a 10 percent rating, but not higher, as of March 29, 2018, but not earlier, for right lower extremity peripheral neuropathy with external popliteal nerve involvement is granted. Entitlement to a 10 percent rating, but not higher, as of March 29, 2018, but not earlier, for left lower extremity peripheral neuropathy with external popliteal nerve is granted. Entitlement a 10 percent rating, but not higher, as of March 29, 2018, but not earlier, for right lower extremity peripheral neuropathy with posterior tibial nerve involvement is granted. Entitlement to a 10 percent rating, but not higher, as of March 29, 2018, but not earlier, for left lower extremity peripheral neuropathy with posterior tibial nerve involvement is granted. Entitlement to a rating higher than 10 percent, prior to December 10, 2019, for right lower extremity peripheral neuropathy with sciatic nerve involvement is denied. Entitlement to a rating higher than 10 percent, prior to December 10, 2019, for left lower extremity peripheral neuropathy with sciatic nerve involvement is denied. Entitlement to a rating higher than 20 percent from December 10, 2019, to October 29, 2020, for right lower extremity peripheral neuropathy with sciatic nerve involvement is denied. Entitlement to a rating higher than 20 percent from December 10, 2019, to October 29, 2020, for left lower extremity peripheral neuropathy with sciatic nerve involvement is denied. Entitlement to a rating higher than 20 percent as of December 10, 2019, for right lower extremity peripheral neuropathy with femoral nerve involvement is denied. Entitlement to a rating higher than 20 percent as of December 10, 2019, for left lower extremity peripheral neuropathy with femoral nerve involvement is denied. Entitlement to a rating higher than 40 percent as of October 29, 2020, for right lower extremity peripheral neuropathy with sciatic nerve involvement is denied. Entitlement to a rating higher than 40 percent as of October 29, 2020, for left lower extremity peripheral neuropathy with sciatic nerve involvement is denied. Entitlement to a rating higher than 60 percent for diabetic nephropathy Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to a rating higher than 10 percent for bilateral glaucoma, diabetic retinopathy, and cataracts is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had a diagnosis of a psychiatric disability at any time during or approximate to the pendency of the claim. 2. Throughout the period of appeal, the Veteran’s diabetes mellitus requires insulin and a restricted diet, but not regulation of activities. 3. Prior to December 10, 2019, the Veteran’s bilateral lower extremity peripheral neuropathy symptomatology has more nearly has approximated mild incomplete paralysis of the external popliteal nerve and posterior tibial nerve. 4. From December 10, 2019, to October 29, 2020, the Veteran’s bilateral lower extremity peripheral neuropathy symptomatology has more nearly has approximated moderate incomplete paralysis of the sciatic nerve. 5. As of December 10, 2019, the Veteran’s bilateral lower extremity peripheral neuropathy symptomatology has more nearly has approximated moderate incomplete paralysis of the femoral nerve. 6. As of October 29, 2020, the Veteran’s bilateral lower extremity peripheral neuropathy symptomatology has more nearly has approximated moderately severe incomplete paralysis of the sciatic nerve. 7. Throughout the appeal period, the Veteran’s diabetic nephropathy has not been productive of persistent edema and albuminuria with BUN 40 to 80 mg%; or creatinine 4 to 8 mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. 8. The evidence is at least in equipoise regarding whether the service-connected disabilities alone preclude the Veteran from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating higher than 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.10, 4.119, Diagnostic Code 7913. 3. Prior to December 10, 2019, the criteria for a rating higher than 10 percent, but not higher, for right lower extremity peripheral neuropathy with external popliteal nerve involvement were met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8521. 4. Prior to December 10, 2019, the criteria for a rating higher than 10 percent, but not higher, for left lower extremity peripheral neuropathy with external popliteal nerve involvement were met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8521. 5. Prior to December 10, 2019, the criteria for a rating higher than 10 percent, but not higher, for right lower extremity peripheral neuropathy with posterior tibial nerve involvement were met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8525. 6. Prior to December 10, 2019, the criteria for a rating higher than 10 percent, but not higher, for left lower extremity peripheral neuropathy with posterior tibial nerve involvement were met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8525. 7. From December 10, 2019, to October 29, 2020, the criteria for a rating higher than 20 percent for right lower extremity peripheral neuropathy with sciatic nerve involvement were not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8520. 8. From December 10, 2019, to October 29, 2020, the criteria for a rating higher than 20 percent for left lower extremity peripheral neuropathy with sciatic nerve involvement were not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8520. 9. As of December 10, 2019, the criteria for an initial rating higher than 20 percent for right lower extremity peripheral neuropathy with femoral nerve involvement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8526. 10. As of December 10, 2019, the criteria for an initial rating higher than 20 percent for left lower extremity peripheral neuropathy with femoral nerve involvement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8526. 11. As of October 29, 2020, the criteria for a rating higher than 40 percent for right lower extremity peripheral neuropathy with sciatic nerve involvement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8520. 12. As of October 29, 2020, the criteria for a rating higher than 40 percent for left lower extremity peripheral neuropathy with sciatic nerve involvement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8520. 13. The criteria for a rating in excess of 60 percent for diabetic nephropathy are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.115, 4.115; Diagnostic Code 7541. 14. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1969 to February 1971. In February 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. In April 2018 and August 2020, the Board remanded the case for further development. 1. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and depression The Veteran contends that he has PTSD that began during service in Vietnam. The service medical records do not show reports of a psychiatric disability. The December 1968 entrance examination and February 1971 separation examination do not indicate a psychiatric disability. The post-service medical records show complaints for difficulty sleeping. At a June 2011 VA examination, the examiner opined there was insufficient symptomatology to warrant a diagnosis for PTSD. The examiner did not find evidence of any psychiatric disorder on examination. While the Veteran reported some symptoms, the frequency, severity, and duration were not significant. In a February 2012 statement, Dr. R.D. stated the Veteran had severe PTSD, and he was unable to hold down a job of any kind. It was his professional opinion that the Veteran was disabled. No reasoning was provided. In a March 2017 statement, Dr. R.D. stated that he did not have an expertise in diagnosis or treatment of PTSD. However, that doctor recorded the diagnosis and symptoms that the Veteran reported regarding combat experiences, and the diagnosis that the Veteran believed was related to those experiences. The doctor stated that resources from VA would be needed to confirm the diagnosis. At a December 2019 VA examination, the examiner opined the Veteran did not meet the criteria for PTSD, and did not have a mental disorder that conformed with the DSM-5 criteria. The Veteran was not currently receiving any mental health treatment. He had difficulty sleeping and woke up throughout the night with hot flashes. He reported nightmares about Vietnam. The Board finds that the evidence of record does not provide a medical basis for finding that the Veteran is currently diagnosed with a psychiatric disability. The Veteran states that he experiences nightmares about Vietnam and has depression. However, the evidence does not show any currently diagnosed disability or medical findings of disability that would constitute a disability for which service connection could be established. The June 2011 and December 2019 VA examiners found that the evidence did not support a diagnosis of a psychiatric disability. While the Board is aware that a condition which causes functional impairment may be service-connected in the absence of a medical diagnosis, the Board finds that functional impairment resulting in impairment of earning capacity is not shown by the evidence of record. While the record shows evidence of complaints of difficulty sleeping at times, the record does not show any diagnosed disability of a psychiatric disability. Under applicable regulations, the term disability means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Notably, none of the competent evidence of record demonstrates that the Veteran is currently diagnosed with a psychiatric disability, or that the Veteran has been diagnosed with a psychiatric disability during or approximate to the appeal period. The Board notes symptoms can constitute a current disability under 38 U.S.C. § 1110, if they result in functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Here, the treatment record does not show, and the Veteran has not established, that any psychiatric disability results in a functional impairment which limited his earning capacity. Consequently, the Board finds that the Veteran has not experienced a current disability for VA purposes. The presence of a chronic disability at any time during or contemporary to the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because there was no actual disability diagnosed at any time since the claim was filed or contemporary to the filing of the claim, and there remains no current evidence of the claimed disability, no valid claim for service connection exists. The Board notes that statements from Dr. R.D. in February 2012 and March 2017 that noted a diagnosis of PTSD. However, in the latter statement, that doctor stated that he did not have expertise in diagnosis or treatment of PTSD, and that he was recording the diagnosis reported by the Veteran and that VA resources would be needed to confirm that diagnosis. That doctor’s letterhead states that the physician is a doctor specializing in internal medicine. Therefore, the Board finds that those statements are of less probative value than the VA examinations which were conducted by psychologists in December 2019 and June 2011 because those examiners are specialists in diagnosing psychiatric disorders. The Board acknowledges the statements of the Veteran regarding the onset of a psychiatric disability, and finds the Veteran competent to report symptoms, such as panic attacks, anxiety and sadness, as that requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994); Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, the issue in this case is outside the realm of common knowledge of a lay person, as a nexus is not obvious merely through observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds the VA examination opinions to be the most probative and persuasive evidence of record. The VA examiners have medical training, and reviewed all the available medical records, including the Veteran’s statements about the onset of a psychiatric disability, and in-service symptomatology. The evidence of record and supporting medical opinions suggest that the Veteran’s in-service symptoms and post-service complaints of difficulty sleeping, anxiety, and sadness were temporary episodes. The Board finds that the preponderance of the evidence supports a finding that a psychiatric diagnosis is not warranted and that a psychiatric disability is not present. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for a psychiatric disability, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. That does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). 2. Entitlement to a rating higher than 20 percent for diabetes mellitus Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted when the diabetes requires 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 the diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational 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 rated. Compensable complications of diabetes are to be separately rated unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. The definition of regulation of activities in the rating criteria for diabetes mellitus is the avoidance of strenuous occupational and recreational activities, and applies to the regulation of activities criterion for a 40 percent rating under Diagnostic Code 7913. Camacho v. Nicholson, 21 Vet. App. 360 (2007). Moreover, because of the successive nature of the rating criteria, such that the rating for each higher disability rating includes the criteria of each lower disability rating, each of the three criteria listed in the 40 percent rating must be met in order to warrant a 40 percent rating. Tatum v. Shinseki, 23 Vet. App. 152 (2009). In addition, a 40 percent rating under Diagnostic Code 7913 requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho v. Nicholson, 21 Vet. App. 360 (2007). At a March 2011 VA examination, the examination report specified that the Veteran’s diabetes treatment did not require regulation of activities. The Veteran visited his diabetic care provider less than two times per month for episodes of ketoacidosis and/or hypoglycemia. No hospitalizations were required for episodes of ketoacidosis or hypoglycemic reactions over the prior 12 months. At a December 2019 VA examination, the examiner noted that the Veteran’s diabetes mellitus was managed by prescribed oral hypoglycemic agents, and prescribed insulin with more than one injection per day. The examination report specified that the Veteran’s diabetes treatment did not require regulation of activities. The Veteran visited his diabetic care provider less than two times per month for episodes of ketoacidosis and/or hypoglycemia. No hospitalizations were required for episodes of ketoacidosis or hypoglycemic reactions over the prior 12 months. There was no progressive unintentional weight loss or loss of strength attributable to diabetes mellitus. The Veteran had complications of diabetic peripheral neuropathy, diabetic nephropathy, and diabetic retinopathy. No other pertinent physical findings, complications, conditions, signs, or symptoms were found. The examiner opined that the Veteran’s diabetic nephropathy interfered with prolonged walking or standing. Based on a careful review of all of the evidence, the Board finds that the Veteran’s diabetes mellitus does not warrant a 40 percent rating. The Veteran requires insulin and a restricted diet, but the preponderance of the evidence is against a finding that he requires regulation of activities due to diabetes. Although the Veteran takes numerous medications, the rating criteria do not provide for higher ratings based on the number of medications. Rather, the rating criteria require that the Veteran’s activity have restrictions as a result of diabetes to consider a higher rating. Here, the evidence does not demonstrate that the Veteran’s diabetes mellitus has reached that level of severity. The VA examiners have specifically opined that the Veteran’s diabetes mellitus did not require regulation of activities as part of the medical management of his diabetes. Therefore, the Board is without any discretion and must find that the Veteran’s diabetes mellitus is no more than 20 percent disabling. The Veteran has not provided evidence of any further unaddressed complications related to diabetes mellitus, beyond those already considered. Separate ratings have been assigned for diabetic retinopathy, glaucoma, cataracts, diabetic nephropathy, and peripheral neuropathy of the upper and lower extremities. The Board finds that there are no further unaddressed complications of diabetes that require a further separate rating. The Board finds that the preponderance of the evidence is against the claim for any other increased or separate rating and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to increased ratings for bilateral lower extremity peripheral neuropathy The Board notes that the Veteran’s bilateral lower extremity peripheral neuropathy was considered to have sciatic nerve involvement prior to December 10, 2019. A March 2019 VA examination report indicates the sciatic nerve was normal, but there was mild incomplete paralysis of the external popliteal nerve and posterior tibial nerve. Therefore, the Board has updated the Diagnostic Codes for the period prior to December 10, 2019, to separate the ratings for each lower extremity between Diagnostic Code 8521, for the popliteal nerve, and Diagnostic Code 8526, for the posterior tibial nerve. The Board finds that the evidence does not support a rating higher than 10 percent prior to December 10, 2019, for sciatic nerve involvement prior to December 10, 2019. Paralysis of the sciatic nerve is rated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under those criteria, mild incomplete paralysis is rated 10 percent. Moderate incomplete paralysis is rated 20 percent. Moderately severe incomplete paralysis is rated 40 percent. Severe incomplete paralysis, with marked muscular atrophy is rated 60 percent. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated 80 percent. 38 C.F.R. § 4.124a. Paralysis of the popliteal nerve (common peroneal) nerve is rated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8521. Under those criteria, mild incomplete paralysis is rated 10 percent. Moderate incomplete paralysis is rated 20 percent. Severe incomplete paralysis is rated as 30 percent. Complete paralysis of the nerve, rated 40 percent, involves foot drop and a slight drop of all the first phalanges of all the toes; an inability to dorsiflex the foot, lost foot abduction, and other factors. 38 C.F.R. § 4.124a. Paralysis of the posterior tibial nerve is rated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8525. Under those criteria, mild or moderate incomplete paralysis is rated 10 percent. Severe incomplete paralysis is rated 20 percent. Complete paralysis of all muscles of the sole of foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; plantar flexion is impaired is rated 30 percent. 38 C.F.R. § 4.124a. Paralysis of the anterior crural nerve (femoral) rated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8526. Under those criteria, mild incomplete paralysis is rated 10 percent. Moderate incomplete paralysis is rated 20 percent. Severe incomplete paralysis is rated 30 percent. Complete paralysis of the nerve, rated a 40 percent, involves paralysis of quadriceps extensor muscles. 38 C.F.R. § 4.124a. The words mild, moderate, moderately severe, 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. 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 rating for conditions that are wholly sensory, as opposed to a minimum rating for conditions that are more than wholly sensory. Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. 38 C.F.R. § 4.123. At a March 2011 VA examination, strength testing was normal. Sensory testing was normal until the mid-calf area. The vibratory sensation testing was also normal. The examiner concluded the bilateral lower extremity peripheral neuropathy was mild. At a March 2018 VA examination, the Veteran reported tingling and some numbness both feet. He also experienced more weakness on the left side than the right. There was bilateral mild intermittent pain, paresthesias and/dysesthesias, and numbness. There was no constant pain. Muscle strength testing was normal in the knee and ankle, with active movement against some resistance in the left knee extension. Reflex testing showed normal reflexes in the knees and hypoactive reflexes in the ankle. Light touch was normal in the knees and thigh, and right lower leg and there was decreased light touch in the right lower leg and ankle, and both feet and toes. Vibratory testing was decreased in both feet and ankles. The examiner concluded there was mild incomplete paralysis of the external popliteal nerve and posterior tibial nerve. At a December 2019 VA examination, the Veteran reported constant numbness and pain in the feet and legs, which made walking difficulty. There was bilateral moderate paresthesias and dysesthesias, and severe constant pain and numbness. There was no intermittent pain. Strength testing was normal. The Veteran demonstrated decreased deep tendon reflexes in the knees and ankles. Light touch was normal in the knees and thighs, and there was decreased light touch at the ankles, lower legs, feet, and toes. Position sense testing was normal. There were also decreased sensations bilaterally vibrations sensation, and cold sensation testing. The feet had trophic changes. The examiner concluded there was moderate incomplete paralysis of the sciatic and femoral nerves. In an October 2020 VA examination, the Veteran experienced bilateral severe constant pain, paresthesias, dysesthesias, and numbness. There was no intermittent pain. Strength testing showed less than normal strength bilaterally on knee extension and flexion, and ankle plantar flexion and dorsiflexion. The Veteran demonstrated decreased deep tendon reflexes in the knees and ankles, and decreased light touch in the knees, thighs, ankles, lower legs, feet, and toes. There were also decreased sensations bilaterally with position sense, vibrations sensation, and cold sensation testing. The examination did not find muscle atrophy or trophic changes. The examiner concluded there was moderately severe incomplete paralysis of the sciatic nerve and moderate incomplete paralysis of the femoral nerve. In reviewing the record, the Board finds that the Veteran’s bilateral lower extremity peripheral neuropathy disability has not more nearly approximated a rating higher than 10 percent for external popliteal nerve and posterior tibial nerve involvement at any time prior to December 10, 2019; a rating higher than 10 percent prior to December 10, 2019, for sciatic nerve involvement; higher than 20 percent for sciatic nerve involvement from December 10, 2019, to October 29, 2020; higher than 20 percent for femoral nerve involvement as of December 10, 2019; and higher than 40 percent for sciatic nerve involvement as of October 29, 2020. Prior to December 10, 2019, as of the date of a March 29, 2018, VA examination, the Board finds that a separate 10 percent rating, but not higher, for each lower extremity due to mild incomplete paralysis of the popliteal nerve and posterior tibial nerve is warranted. The March 2018 VA examination showed bilateral mild intermittent pain, paresthesias, dysesthesias, and numbness. However, there was no constant pain. In addition, strength testing was normal. Thus, the Board finds that the level of impairment is most analogous to mild incomplete paralysis, which warrants a 10 percent rating for each lower extremity with external popliteal nerve and posterior tibial nerve involvement. Prior to December 10, 2019, the Board finds that a rating higher than 10 percent was not warranted for right or left lower extremity sciatic peripheral neuropathy as the evidence does not show more than mild incomplete paralysis. No more than sensory involvement was shown prior to December 10, 2019. From December 10, 2019, to October 29, 2020, the Board finds a rating higher than 20 percent for each lower extremity due to sciatic nerve involvement is not warranted. The December 2019 VA examination showed bilateral moderate paresthesias, dysesthesias, and severe constant pain and numbness. There was no intermittent pain. Strength testing was normal. The Veteran experienced decreased reflexes and sensations. The Board finds that the level of impairment is most analogous to moderate incomplete paralysis. As moderately severe incomplete paralysis of the sciatic nerve is not shown, higher ratings are is not warranted. As of December 10, 2019, the Board finds a rating higher than 20 percent for each lower extremity due to femoral nerve involvement is not warranted. The December 2019 VA examination showed there was moderate incomplete paralysis of the femoral nerves, which equates to a 20 percent rating for each lower extremity. As severe incomplete paralysis is not shown, higher ratings are not warranted. As of October 29, 2020, the Board finds a rating higher than 40 percent for each lower extremity due to sciatic nerve involvement is not warranted. The October 2020 examination showed severe constant pain, paresthesias, dysesthesias, and numbness. However, there was no intermittent pain. The Veteran experienced decreased reflexes, light touch, and sensations bilaterally. The Board finds that the level of impairment is most analogous to moderately severe incomplete paralysis. As severe incomplete paralysis of the sciatic nerve is not shown, higher ratings are not warranted. Accordingly, the Board finds that the bilateral lower extremity peripheral neuropathy does not warrant ratings higher than 10 percent for external popliteal nerve and posterior tibial nerve involvement at any time prior to December 10, 2019; higher than 10 percent for sciatic nerve involvement prior to December 10, 2019; higher than 20 percent for sciatic nerve involvement from December 10, 2019, to October 29, 2020; higher than 20 percent for femoral nerve involvement as of December 10, 2019; and higher than 40 percent sciatic nerve involvement as of October 29, 2020. A rating higher than 40 percent is not warranted during the appeal period. The Board finds that the preponderance of the evidence is against the assignment of any higher ratings. 4. Entitlement to a rating higher than 60 percent for diabetic nephropathy Diagnostic Code 7541 indicates that renal involvement in diabetes should be rated as renal dysfunction under 38 C.F.R. § 4.115a. A 60 percent rating is warranted where there is constant albuminuria with some edema, or definite decrease in kidney function, or hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is warranted where there is persistent edema and albuminuria with BUN 40 to 80 mg%, or creatinine 4 to 8 mg%, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted where the condition requires regular dialysis, or if it precludes more than sedentary activity from one of the following: persistent edema and albuminuria, or BUN more than 80 mg%, creatinine more than 8mg%, or markedly decreased function of kidney or other organ systems, especially cardiovascular. VA and private medical records show chronic kidney disease, stage 3, throughout the appeal period. The evidence has not shown the Veteran’s kidney disability manifested with greater severity than demonstrated on examination. At a March 2011 VA examination, the Veteran denied any renal dysfunction. The diagnostic testing showed creatinine was 1.6, and eGFR was 44. At the December 2019 VA examination, the Veteran did not report any symptoms. Although the Veteran had renal dysfunction, he did not have any signs or symptoms of renal dysfunction. Recent diagnostic testing showed BUN was 14, creatinine was 1.86, and eGFR was 43. The examination did not indicate any proteinuria. In reviewing the record, the Board finds that a rating higher than 60 percent is not warranted. The Board acknowledges that the severity of the Veteran’s kidney symptoms appeared to have somewhat fluctuated throughout the appeal period. However, he experienced chronic kidney disease, stage 3, which indicates definite decrease in kidney function throughout the appeal period. The evidence does not indicate persistent edema or albuminuria. Rather, the evidence indicated decreased kidney function with BUN below 40 mg% and creatinine below 4 mg%. In addition, VA treatment records do not support diastolic pressure predominately at 120. The Veteran does not meet the criteria for an 80 percent rating as the evidence does not show persistent edema and albuminuria with BUN 40 to 80 mg%, or creatinine 4 to 8 mg%, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Therefore, a rating higher than 60 percent is not warranted. Accordingly, the Board finds that the Veteran’s nephropathy does not warrant a rating higher than 60 percent during the appeal period. A rating higher than 60 percent is not warranted during the. The Board finds that the preponderance of the evidence is against the assignment of any higher rating. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides a rating of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. If the schedular rating is less than total, a total disability rating can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated 60 percent or higher; or two or more service-connected disabilities, with one disability rated 40 percent or higher and a combined rating of 70 percent or higher. The existence or degree of nonservice-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran’s service-connected disabilities make him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). The Veteran has service-connected ratings of 60 percent for diabetic nephropathy, 40 percent for peripheral neuropathy with sciatic nerve involvement in each lower extremity, 20 percent for diabetes mellitus, 20 percent for peripheral neuropathy with femoral nerve involvement in each lower extremity, 20 percent for peripheral neuropathy with radial nerve involvement in each upper extremity; 10 percent for peripheral neuropathy with median nerve involvement in each upper extremity; 10 percent for peripheral neuropathy with ulnar nerve involvement in each upper extremity; and 10 percent for glaucoma with diabetic retinopathy and cataracts. The combined service-connected disability rating is 100 percent. As the Veteran has a combined rating of at least 70 percent, the service-connected disabilities meet the percentage requirements for consideration of the assignment of TDIU. 38 C.F.R. § 4.16(a). The question that remains is whether the service-connected disabilities preclude the Veteran from obtaining or retaining substantially gainful employment. The central inquiry is whether the service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). On a VA Form 21-8940 submitted in April 2011, the Veteran indicated that he last worked full-time in December 2010, when he had worked in production in a mill. He held several positions, including as a crane operator. He completed two years of college. In a March 2017 statement, Dr. R.D. stated complications from diabetes and chronic kidney disease limited the Veteran’s ability to maintain employment. Dr. R.D. highlighted the bilateral upper and lower extremity peripheral neuropathy. At the December 2019 VA examination, the examiner opined the diabetic nephropathy made prolonged walking or standing difficulty. In addition, the Veteran had difficulty using his hands, especially with hand strength. In an October 2020 VA examination, the examiner found the bilateral upper and lower extremities peripheral neuropathy would impact the Veteran’s ability to work. He had to take frequent breaks when working as a crane operator because bilateral weak hand grips. At times, he would have someone else drive the crane if his hands were too weak. In addition, he had difficulty climbing into the crane due to bilateral lower extremity weakness and neuropathy. At the February 2017 Board hearing, the Veteran testified that he had last worked in December 2010. He stated that he did not believe he could perform a 40 hour work week due to lack of strength and the inability to stand or stand for prolonged periods of time. In addition, he could walk for one block and carry 20 pounds. When he was working, his hands and legs would swell and hurt constantly. Based on all the evidence of record of the Veteran’s various service-connected disabilities of diabetic nephropathy, bilateral upper and lower extremity peripheral neuropathy, diabetes, and glaucoma with diabetic retinopathy and cataracts, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran is precluded from securing or following gainful employment due to the combined effects of the service-connected disabilities. The Board acknowledges the opinions of the VA examiners who opined that the Veteran’s disabilities would not preclude sedentary work. However, those opinions appear to have simply considered the bilateral upper and lower extremity peripheral neuropathy singly and in isolation without consideration of all of the service-connected disabilities, to specifically include the service-connected diabetic nephropathy, diabetes, and glaucoma with diabetic retinopathy and cataracts. Taken as a whole, the evidence suggests that the service-connected diabetic nephropathy, bilateral upper and lower extremity peripheral neuropathy, diabetes, and glaucoma with diabetic retinopathy and cataracts restrict the Veteran to sedentary work, while the service-connected diabetic nephropathy, and bilateral upper and lower extremity peripheral neuropathy severely hampers the ability to work at a sedentary job. The Board further notes that the Veteran’s occupational as a crane operator requires physical labor, and the Veteran does not have education that is readily applicable to a sedentary occupation based on the ordinary meaning of the term. Withers v. Wilkie, 30 Vet. App. 139 (2018). Taken as a whole, the evidence is at least in equipoise regarding whether the Veteran would be able to function in any occupational setting due to her service-connected disabilities, as demonstrated by the evidence. Accordingly, the Board resolves reasonable doubt in favor of the Veteran and finds that entitlement to TDIU is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107. REASONS FOR REMAND 1. Entitlement to a rating higher than 10 percent for bilateral glaucoma, diabetic retinopathy, and cataracts is remanded. A review of the record indicates that there are outstanding VA records, to specifically include the eye records were stored in the VistA Imaging system. Specifically, the VA records show that the ophthalmology notes and testing were uploaded to VistA on the following dates: October 31, 2011, December 5, 2011, July 7, 2012, July 20, 2012, June 6, 2016, July 31, 2017, October 2, 2018. However, the record does not contain those notes. In addition, the VistA records obtained show there are outstanding eye charts that have also not been associated with the record. Accordingly, the Board finds the record incomplete and those records should be associated with the claims file. (Continued on the next page)   The matters are REMANDED for the following action: Obtain the Veteran’s VA treatment records from September 2020 to the present. All records related to the Veteran’s eyes which have been stored in VistA Imaging since 2011 must be obtained, to specifically include all eye charts and visual field testing results uploaded to VistA on the following dates: October 31, 2011, December 5, 2011, July 7, 2012, July 20, 2012, June 6, 2016, July 31, 2017, October 2, 2018. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Kass, 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.