Citation Nr: 21028924 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-34 341 DATE: May 12, 2021 ORDER Prior to May 23, 2019, a rating in excess of 20 percent for right and left upper extremity peripheral neuropathy is denied. From May 23, 2019 onwards, a 40 percent rating for right upper extremity and a 30 percent rating for left upper extremity peripheral neuropathy is granted. A rating in excess of 20 percent for right and left lower extremity peripheral neuropathy of the sciatic nerve is denied. A rating in excess of 10 percent prior to May 23, 2019 and in excess of 20 percent from that date onwards for right and left lower extremity peripheral neuropathy of the femoral nerve is denied. Prior to February 28, 2019, a rating in excess of 30 percent for PTSD is denied. From February 28, 2019 onwards, a 70 percent rating for PTSD is granted. Service connection for autonomic neuropathy is denied. FINDINGS OF FACT 1. Prior to May 23, 2019, the Veteran's bilateral upper extremities peripheral neuropathy symptoms more closely approximated mild incomplete paralysis. 2. From May 23, 2019, these symptoms more closely approximated moderate incomplete paralysis. 3. The Veteran's bilateral lower extremities peripheral neuropathy symptoms more closely approximate moderate incomplete paralysis. 4. Prior to May 23, 2019, objective testing revealed symptoms more closely approximating mild incomplete paralysis of the femoral nerve. 5. From May 23, 2019, the evidence reflects symptoms more closely approximating moderate incomplete paralysis of the femoral nerve. 6. Prior to February 28, 2019, the evidence documents PTSD symptoms which more closely approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). 7. From February 28, 2019, the evidence is in relative equipoise as to whether PTSD has caused severe deficiencies in most areas of functioning; however, the preponderance of the evidence is against a finding of total occupational and social impairment. 8. The preponderance of the evidence weighs against finding that the Veteran has autonomic neuropathy that is causally related to his service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for right upper extremity peripheral neuropathy have not been met prior to May 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DCs 8614, 8514. 2. The criteria for a rating in excess of 20 percent for left upper extremity peripheral neuropathy have not been met prior to May 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DC 8614, 8514. 3. The criteria for a 40 percent rating for right upper extremity peripheral neuropathy has been met from May 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DC 8513. 4. The criteria for a 30 percent rating for left upper extremity peripheral neuropathy has been met from May 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DC 8513. 5. The criteria for a rating in excess of 20 percent for right lower extremity peripheral neuropathy (common peroneal nerve) have not been met prior to May 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DCs 8521, 8621. 6. The criteria for a rating in excess of 20 percent for left lower extremity peripheral neuropathy (common peroneal nerve) have not been met prior to May 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DCs 8521, 8621. 9. The criteria for a rating in excess of 10 percent for right lower extremity peripheral neuropathy (femoral nerve) prior to May 23, 2019, and in excess of 20 percent from that date onwards, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DC 8526. 10. The criteria for a rating in excess of 10 percent for left lower extremity peripheral neuropathy (femoral nerve) prior to May 23, 2019, and in excess of 20 percent from that date onwards, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.123, 4.124a, DC 8526. 11. The criteria for a rating in excess of 30 percent for PTSD have not been met prior to February 28, 2019. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. 12. The criteria for a 70 percent rating for PTSD have been met from February 28, 2019 onwards. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. 13. The criteria for service connection for autonomic neuropathy have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310, (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These matters come before the Board of Veterans' Appeals (Board) on appeal of February 2012, October 2014, and May 2016 rating decisions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2014 and May 2016 rating decisions. These matters were previously remanded by the Board in January 2019 for further development. The Board finds that there has been substantial compliance with those remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall). INCREASED RATINGS 1. Bilateral upper extremities peripheral neuropathy 2. Bilateral lower extremities peripheral neuropathy Legal Criteria 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). 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 deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Rating Criteria for Peripheral Neuropathy The evidence reflects that the Veteran is right hand dominant. Accordingly, his left upper extremity is his minor extremity, and his right upper extremity is his major (dominant) extremity. Under 38 C.F.R. § 4.124a , DCs 8514 (paralysis), 8614 (neuritis), and 8714 (neuralgia) neurologic impairment of the musculospiral (radial) nerve of the minor (non-dominant) upper extremity when incomplete and mild warrants a 20 percent rating; when moderate a 20 percent rating is warranted; when severe a 40 percent rating is warranted; and when complete with drop of the hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity, a 60 percent rating is warranted. A note to the schedular criteria for rating peripheral nerve disabilities states that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent consider radicular group ratings. 38 C.F.R. § 4.124A. DC 8513 provides the rating criteria for paralysis of all the upper extremity radicular groups, and therefore, neuritis and neuralgia of all the radicular groups. 38 C.F.R. § 4.124a. Under DC 8513, mild incomplete paralysis of the affected nerves is rated 20 percent disabling for either extremity, moderate incomplete paralysis of the affected nerves is rated 40 percent disabling for the major extremity and 30 percent disabling for the minor extremity, severe incomplete paralysis of the affected nerves is rated 70 percent disabling for the major extremity and 60 percent disabling for the minor extremity, and complete paralysis of the affected nerves is rated 90 percent disabling for the major extremity and 80 percent disabling for the minor extremity. Id. DC 8621 provides for a rating for neuritis of the external popliteal (common peroneal) nerve. The rating criteria for neurological impairment of the external popliteal nerve is listed under DC 8521. For diseases of the peripheral nerves, disability ratings are based on whether there is complete or incomplete paralysis of the particular nerve. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. See 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. Under DC 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis; a 40 percent rating is assigned for moderately severe incomplete paralysis; and a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy. An 80 percent rating is assigned for complete paralysis of the sciatic nerve, where the foot dangles and drops, and there is no active movement possible of muscles below the knee, flexion of knee weakened, or (very rarely), lost. 38 C.F.R. § 4.124A, DC 8520. DC 8521 provides for a 40 percent rating for complete paralysis of the external popliteal nerve (common peroneal) where there is foot drop and slight drop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; and anesthesia covers the entire dorsum of foot and toes. 38 C.F.R. § 4.124a. A 30 percent evaluation is warranted for severe incomplete paralysis. Id. A 20 percent evaluation is assigned where there is moderate incomplete paralysis, and a 10 percent evaluation is warranted for mild incomplete paralysis. Id. The words "mild," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a, DC 8510-8730. Factual Background A November 2009 Preventative Medicine Note indicates complaints of constant right leg pain that the Veteran subjectively reported as 8/10 in pain severity. A February 2012 VAMC treatment note documents worsening pain in the lower extremities which elicited an increase in prescribed medication by the Veteran's primary care physician. On August 2013 VA Nerve Conditions Examination, the Veteran's bilateral upper extremity peripheral neuropathy (BUE PN) was characterized by mild intermittent pain, mild paresthesias and/or dysesthesias, normal muscle strength testing, normal reflexes, and normal sensation testing. Mild incomplete paralysis of the radial and medial nerves was indicated. The Veteran's bilateral lower extremities peripheral neuropathy (BLE PN) was characterized by mild paresthesias and/or dysesthesias. Reflex and muscle strength testing were normal, there was evidence of decreased sensation for light touch in the foot/toes (L5). Trophic changes of hair stopping at the mid tibia was documented. Mild incomplete paralysis of the common peroneal and tibial nerves was indicated. The Veteran was afforded a VA Nerve Conditions Examination in February 2019. The Veteran's BUE PN was characterized by the following: mild intermittent pain, mild paresthesias and/or dysesthesias, mild numbness, normal muscle strength testing, normal reflexes, decreased sensation for light touch in the hand/fingers (C6-8), and mild incomplete paralysis of the radial nerve. The Veteran's BLE PN was characterized by the following: moderate intermittent pain, mild paresthesias and/or dysesthesias, mild numbness, normal muscle strength testing, normal reflexes, decreased sensation for light touch in the foot/toes (L5), and mild incomplete paralysis of the sciatic and femoral nerves. The Veteran again underwent a Peripheral Neuropathy VA examination in May 2019. The course of his disability was described as progressively worsening symptoms with increased frequency and intensity of burning in the upper and lower extremities. The Veteran's BUE PN was characterized by the following: moderate constant pain, severe intermittent pain, moderate paresthesias and/or dysesthesias, moderate numbness, normal muscle strength testing and normal sensory testing. Moderate incomplete paralysis of the radial, medial, and ulnar nerves was indicated. The functional impact of these symptoms was noted to be difficulty gripping, grasping and an inability to write or type due to pain, numbness and tingling in the hands. The Veteran's BLE PN was characterized by the following: moderate constant pain, severe intermittent pain, moderate paresthesias and/or dysesthesias and moderate numbness. Strength testing of the lower extremities showed reduced strength (described as a 4/5) on knee extension, knee flexion, ankle plantar flexion and ankle dorsiflexion. Light touch/monofilament testing showed decreased sensation in the ankle/lower leg and foot/toes. Vibration sensation testing revealed decreased sensation. Trophic changes of sparse hair on the BLE was indicated. The examiner noted moderate incomplete paralysis of the sciatic and femoral nerves. These symptoms were noted to cause the Veteran to be unable to walk, stand or sit for prolonged periods. An October 2019 VAMC outpatient pain screen documents lower extremity pain related to a crush injury subjectively reported as a 7/10 that is aching and sharp. The pain was noted to be primarily concentrated in the left foot and impact standing/walking. A June 2020 progress note from Kelsey-Seybold Clinic reflects normal motor and sensory examination in all four extremities. An August 2020 neurological progress note was positive for tingling, numbness and paresthesias but was negative for weakness. Analysis Upper Extremities Throughout the period on appeal, the Veteran's peripheral neuropathy of the right and left upper extremity have each been assigned a 20 percent rating under DC 8614 for neuritis of the radial nerve (criteria for which is found under DC 8514). Based on the foregoing lay and medical evidence, the Board finds that ratings in excess of 20 percent prior to May 23, 2019 are not warranted. Critically, the August 2013 and February 2019 VA examination reports document, at the most severe, symptoms of mild incomplete paralysis of the affected nerves, mild intermittent pain, and mild paresthesias/dysesthesias. Diagnostic testing during this period also revealed normal muscle strength testing, normal reflexes, and decreased sensation for light touch in the hand/fingers (C6-8). The February 2019 VA examiner ultimately described the severity of the Veteran's bilateral upper extremity peripheral neuropathy as "mild" in severity. These findings are entitled to significant probative weight because they were formulated following a thorough examination of the Veteran. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the examiner's characterization of the level of impairment is not binding on the Board, in this case the characterizations are consistent with the above evidence of record showing mostly normal and mild findings. Mild incomplete paralysis of the radial nerve corresponds to the 20 percent ratings assigned during this period on appeal. DCs 8614, 8514. Therefore, ratings in excess of 20 percent prior to May 23, 2019 are not warranted. The Board further finds that a 40 percent rating for right upper extremity (dominant) peripheral neuropathy and a 30 percent rating for left upper extremity (non-dominant) peripheral neuropathy is warranted under DC 8513 for moderate incomplete paralysis of all radicular groups from May 23, 2019 onwards. The May 2019 VA examination revealed moderate incomplete paralysis of the radial, median, and ulnar nerves. Accordingly, the Board finds that DC 8513 more appropriately encapsulates the Veteran's disability as the evidence shows the involvement of multiple nerves that overlap in symptomatology. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). This examination also documented moderate constant pain, severe intermittent pain, moderate paresthesias and/or dysesthesias, moderate numbness, normal muscle strength testing and normal sensory testing. The functional impact of these symptoms was noted to be difficulty gripping, grasping and an inability to write or type due to pain, numbness and tingling in the hands. The Board has considered this functional impact and intermittent pain described as "severe" in severity. However, the preponderance of the objective diagnostic testing during this period characterized the Veteran's symptoms as predominately "moderate" in severity. Therefore, a still higher rating is not warranted under DC 8513 for symptoms more closely approximating "severe" incomplete paralysis of all radicular groups. Finally, the Board finds that assigning separate ratings under DCs 8514, 8515, and 8516 for the Veteran's upper extremity from May 23, 2019 onwards would constitute impermissible pyramiding as the Veteran's injuries to the radial, median, and ulnar nerves all contribute to the same and overlapping functional impairment of the upper extremities consisting of pain, paresthesias, numbness, and sensory loss. The Board notes that VA regulations prohibit evaluation of the same disability or the same or overlapping symptomatology under different DCs (which is called "pyramiding"). 38 C.F.R. § 4.14. Esteban v. Brown, 6 Vet. App. 259 (1994). Analysis Lower Extremities Throughout the period on appeal, the Veteran's right and left lower extremity have each been assigned a 20 percent rating under DC 8621 for neuritis of the common peroneal nerve (criteria for which is found under DC 8521). Additionally, each lower extremity has been assigned a 10 percent rating under DC 8526 (femoral nerve) prior to May 23, 2019 and a 20 percent rating from that date onwards. Initially, the Board finds that ratings in excess of 20 percent are not warranted prior to May 23, 2019. During the August 2013 and February 2019 VA examinations, the Veteran's BLE PN symptoms were characterized, at their most severe, by moderate intermittent pain, mild paresthesias and/or dysesthesias, mild numbness, normal muscle strength testing, normal reflexes, decreased sensation for light touch in the foot/toes (L5), and mild incomplete paralysis of the common peroneal, tibial and sciatic nerves. Trophic changes of hair growth ceasing at the mid tibia were also documented. These findings are entitled to significant probative weight because they were formulated following a thorough examination of the Veteran. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the examiner's characterization of the level of impairment is not binding on the Board, in this case, the characterizations are consistent with the above evidence of record showing mostly normal results following reflex, muscle strength, and sensation testing, in addition to manifestations of symptoms mostly described as "mild" or "moderate" in severity. Therefore, the preponderance of the evidence does not show symptoms more closely approximating severe incomplete paralysis of the common peroneal nerve such that ratings in excess of 20 percent prior to May 23, 2019 are warranted. DCs 8621, 8521. Notably, the May 2019 VA examination documented moderate incomplete paralysis of the sciatic and femoral nerves. The preponderance of evidence is against characterizing the Veteran's symptoms as causing moderately severe incomplete paralysis of the sciatic nerve such that higher 40 percent ratings are warranted. DC 8526. The Board has considered whether a separate rating is warranted under DC 8524 (tibial nerve). Again, assigning a separate rating would constitute impermissible pyramiding as impairment of the tibial, common peroneal and sciatic nerve during this period all contributed to the same and overlapping functional impairment of the lower extremities consisting of pain, paresthesias, numbness, sensory loss, and trophic changes. The Board notes that VA regulations prohibit evaluation of the same disability or the same or overlapping symptomatology under different DCs (which is called "pyramiding"). 38 C.F.R. § 4.14. Esteban v. Brown, 6 Vet. App. 259 (1994). Regarding the Veteran's separate 10 percent ratings under DC 8526 (femoral nerve) prior to May 23, 2019 and 20 percent ratings thereafter, the Board finds that higher ratings are not warranted. Prior to May 23, 2019, objective testing revealed mild incomplete paralysis of the femoral nerve at the most severe, which corresponds to the assigned 10 percent rating during this period. See February 2019 VA examination report. Moreover, the May 2019 VA examination report reflects an increase in severity to moderate incomplete paralysis of the femoral nerve, which corresponds to the assigned 20 percent rating from the date of this examination (May 23, 2019) onwards. This assigned rating also accounts for the documented moderate decrease in muscle strength rated as a 4/5 on knee extension testing during the May 2019 VA examination which is consistent with paralytic changes in the quadriceps extensor muscles. The preponderance of evidence is against characterizing the Veteran's symptoms as causing severe incomplete paralysis of the femoral nerve such that higher 30 percent ratings are warranted. DC 8526. 3. An increased rating for PTSD Legal Criteria PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent evaluation is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Factual Background & Analysis During the appeal period, the Veteran's service-connected PTSD has been assigned a 30 percent rating prior to February 28, 2019, a 50 percent rating from February 28, 2019 to May 23, 2019, and a 70 percent rating thereafter. On October 2010 VA psychological examination the Veteran was noted to have been diagnosed with PTSD in 2005. The Veteran stated that he visits with a few friends and attends church functions. The Veteran described symptoms of nightmares about death, sleep disturbance, anger issues, and exaggerated startle response. The severity of the symptoms was noted to be mild. The above symptoms were noted to be constant, continuous, or ongoing. The Veteran stated that the symptoms affect total daily functioning which results in anger on the job and lack of productivity. The Veteran reported that he has had trouble sleeping for 30 years. He sleeps only four hours per night and he further stated that he has a history of violent behavior. The Veteran communicated that he is in his fourth marriage which has lasted 21 years. He described the marriage as very good and he has a good relationship with all five of his children. The Veteran reported general low motivation and disinterest since the onset of his PTSD. At the time of the examination the Veteran was unemployed, and he stated that in his opinion his unemployment was not primarily because of his PTSD. The mental status examination documents normal orientation, appearance, hygiene, and behavior. His affect and mood were noted to show anxiety with occasional crying episodes and depressed mood. His anxiety was characterized as moderate to constant; his depressed mood occurs daily and is moderate. The Veteran showed signs of suspiciousness such as questioning people's motives and looking over his shoulder. Thought processes were noted to be appropriate. The examiner indicated that the Veteran could understand directions and does not have slowness of thought or confusion. Judgment and abstract thinking were normal. Memory was noted to be impaired to mild degree, he forgets names, directions, and recent events. Suicidal and homicidal ideation were not present. The examiner remarked "The best description of the [Veteran's] current psychiatric impairment is: psychiatric symptoms cause occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the person is functioning satisfactorily with routine behavior, self-care and normal conversation." On February 2019 VA psychological examination, the Veteran reported that he stopped working in 2015 when he was 68 years old and applied for social security benefits. He last worked in shipping and receiving in a warehouse environment as a supervisor. He worked in that capacity for almost 9 years. He stated, "It became terrible. I was having anger outbursts and I got written up." He stated, "Even though I'm not working I try to stay busy." Mental status examination documented moderately anxious and irritable mood. The examiner remarked that the Veteran still suffers from symptoms such as nightmares, irritability, hyperarousal, avoidance behaviors and social isolation. The examiner specifically stated that the Veteran's PTSD symptoms cause him to be unable to function in a competitive work environment due to irritability and low frustration tolerance. The Veteran's PTSD was characterized by the following symptoms that are relevant for VA rating purposes: depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting. On May 2019 VA psychological examination the Veteran presented as "nervous and tired." The Veteran reported thoughts of feeling as though he would be "better off dead." He denied a plan or intent to harm himself. He communicated that he feels a lack of purpose since he stopped working but he has his family as a support system. Additional symptoms relevant for VA rating purposes of flattened affect and suicidal ideation were associated with the Veteran's PTSD. Additional symptoms of anxiety with loud noises and in crowded areas were noted. He has difficulty falling asleep and when he awakes from nightmares, he is unable to fall back asleep. Based on the evidence of record prior February 28, 2019, the Board finds that the Veteran's PTSD did not produce occupational and social impairment with reduced reliability and productivity warranting a higher 50 percent rating. In so finding, the Board acknowledges that during this period the Veteran was noted to have some symptoms that are similar in nature to those contemplated by the higher rating criteria such as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. Critically, however, these symptoms are not shown to be of the same frequency, duration, or severity as those deemed consistent with a 50 percent rating (e.g., flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking)). Moreover, the Veteran reported during the October 2010 VA examination that he has some social interaction with friends and through his church. He reported a healthy marriage and strong relationships with his five children. He also denied significant occupational impairment stemming from his PTSD symptoms. Accordingly, the Board finds that the preponderance of the evidence weighs against finding that the Veteran's PTSD produced occupational and social impairment with reduced reliability and productivity warranting a 50 percent rating prior to February 28, 2019. Deciding all reasonable doubt in the Veteran's favor, the Board finds the evidence is in relative equipoise as to whether the Veteran's service-connected PTSD has caused deficiencies in most areas of functions from February 28, 2019 thereafter. Specifically, the Veteran's documented symptoms in the February 2019 VA psychological examination report were noted to cause significant deficiencies and impairment to his mood (irritability, anger, depression, chronic sleep impairment, anxiety, mood swings/outbursts), social functioning, (noted to struggle with social isolation), and work (was noted to be unable to function in a competitive work environment due to outbursts and irritability). Consequently, and giving the Veteran the benefit of the doubt, the criteria for a higher 70 percent rating for a service-connected psychiatric disability have been met from February 28, 2019 thereafter. As the Board is granting a higher 70 percent rating from February 28, 2019 onwards, what remains for consideration is whether a still higher 100 percent rating is warranted. The Board concedes that the Veteran's PTSD causes severe and serious impairment. However, the evidence does not demonstrate that his overall disability picture is characterized by total social and occupational impairment warranting a higher 100 percent rating. As discussed, the Veteran has maintained some social interaction and has strong relationships with his wife and children. Moreover, the VA psychological examination reports of record during this period document mostly normal judgment, appearance, thinking and orientation to time and place. Consequently, the Board finds the preponderance of the evidence is against finding that the PTSD causes symptoms and deficiencies approximating the total occupational and social impairment contemplated by a higher 100 percent rating and, to that extent, the appeal must be denied. 4. Service connection for autonomic neuropathy (secondary to service-connected diabetes) Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the disease or injury in service and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. 38 U.S.C. § 5107 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Finally, service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Factual Background & Analysis The Veteran contends that he has autonomic neuropathy because of his service-connected diabetes. On February 2019 VA examination the examiner determined after an examination of the Veteran that there was no evidence present to warrant a diagnosis for autonomic neuropathy. (Continued on the next page) In an accompanying medical opinion, the examiner explained that autonomic neuropathy is a group of conditions caused by damage to your nerves. It can lead to many different symptoms, like dizziness, night sweats, and constipation. They noted that the Veteran's records are consistent with diabetic and sciatic radiculopathy but not an autonomic nerve condition. Proof of a current disability is a threshold requirement for any service connection claim. In the absence of competent evidence documenting a separate diagnosis for autonomic neuropathy, service connection cannot be granted on secondary basis. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107 (b). Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kyle McKone 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.