Citation Nr: 21030176 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-25 510 DATE: May 18, 2021 ORDER A rating higher than 20 percent for service-connected diabetes mellitus with impotency and nephropathy is denied. A rating higher than 20 percent for service-connected right lower extremity peripheral neuropathy is denied. A rating higher than 20 percent for service-connected left lower extremity peripheral neuropathy is denied. A total disability based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran's diabetes mellitus with impotency does not require regulation of activities, has not resulted in a penile deformity, and does not manifest albumin constant or recurring with hyaline and granular casts or red blood cells, edema, or compensable hypertension. 2. The Veteran's right lower extremity peripheral neuropathy has not resulted in moderately severe incomplete paralysis. 3. The Veteran's left lower extremity peripheral neuropathy has not resulted in moderately severe incomplete paralysis. 4. The Veteran's service-connected disabilities, which combined have only a 50 percent rating, have not rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 20 percent for service-connected diabetes mellitus with impotency and nephropathy have not been met. 38 U.S.C. §§ 1114, 1155, 5107, 7104; 38 C.F.R. §§ 3.102, 3.350, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.104 Diagnostic Code 7101, 4.115A, 4.115B Diagnostic Codes 7522 and 7541, 4.119 Diagnostic Code 7913, 20.105. 2. The criteria for a rating higher than 20 percent for service-connected right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124a, 4.124a Diagnostic Code 8520. 3. The criteria for a rating higher than 20 percent for service-connected left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124a, 4.124a Diagnostic Code 8520. 4. The criteria for a TDIU have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19, 4.25, 4.26. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to May 1971. This matter is on appeal from an August 2014 rating decision which denied a rating higher than 20 percent for his service-connected diabetes mellitus and ratings higher than 10 percent for his service-connected right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy. In September 2019, the Veteran testified regarding it at a hearing before the undersigned Board of Veterans' Appeals (Board) Veterans Law Judge. The Board determined that a TDIU was part and parcel to the Veteran's higher rating claim in August 2020. Rice v. Shinseki, 22 Vet. App. 447, 454-455 (2009). This matter then was remanded for additional development. As a result of this additional development, a February 2021 rating decision increased the ratings for the Veteran's service-connected right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy to 20 percent for the entire period on appeal. This constitutes only a partial grant for these issues, so they remain part of this matter. AB v. Brown, 6 Vet. App. 35, 38 (1993). Finally, the Veteran's contention that he is entitled to special monthly compensation (SMC) for loss of use of a creative organ because his pancreas does not produce glucose at all is acknowledged. That he may file a claim in that regard if he chooses was noted in August 2020 and is reiterated at this time. Higher Ratings Ratings represent as far as practicably can be determined the average impairment in earning capacity due to a disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A rating is assigned under the Rating Schedule by comparing the extent to which a disability impairs the ability to function under the ordinary conditions of daily life, as demonstrated by symptoms, with the criteria for that disability. Id.; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The disability's history and all other relevant evidence is to be considered. 38 C.F.R. §§ 4.1, 4.6. Examinations are to be interpreted and, if necessary, reconciled. 38 C.F.R. § 4.2. When two ratings may be applicable, the higher is assigned only if the criteria for it are more nearly approximated. 38 C.F.R. § 4.7. Any reasonable doubt on this or any other point is resolved in the claimant's favor. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Different ratings may be assigned for different periods. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When a disability worsened thus must be determined. The period under consideration begins one year prior to the claim. 38 U.S.C. § 5110(b)(3); 38 C.F.R. § 3.400(o)(2). Diabetes Mellitus 38 C.F.R. § 4.119 addresses endocrine disorders. Diagnostic Code 7913 thereunder concerns diabetes mellitus. It establishes a 20 percent rating when a restricted diet and insulin or an oral hypoglycemic agent are required. A 40 percent rating is assigned when a restricted diet, insulin, and regulation of activities are required. When a restricted diet, insulin, and regulation of activities are required but there are 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 rated separately, a 60 percent rating is merited. Effective December 10, 2017, the requirement for insulin was amended for the 20 through 60 percent ratings to a requirement for one or more daily injection of insulin. 82 Fed. Reg. 50802 (Nov. 2, 2017). The maximum 100 percent rating is reserved for when more than one daily injection of insulin, a restricted diet, and regulation of activities are required but there are 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 rated separately. Compensable complications are to be rated separately unless used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process. Note (1). Regulation of activities is defined in parenthesis in the 100 percent rating criteria and means avoidance of strenuous occupational and recreational activities. This avoidance must be due to a medical need, and therefore medical evidence is required to establish that the definition is met. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). Currently, the Veteran's service-connected diabetes mellitus is rated 20 percent under Diagnostic Code 7913 based on his use of insulin and a restricted diet. He contends that a higher rating should be assigned because his disability has gotten worse. He emphasizes in this regard that his rating has remained the same despite his progression from pills to insulin shots and finally to an insulin pump to manage his disability. The Veteran reports that his pump restricts his ability to travel due to fear that it will malfunction. For example, he testified at his hearing that he got sand in it while vacationing at the beach and had to drive back home to get it checked. He finally requests reconsideration of the criteria for assigning a 40 percent rating. The Board is bound by applicable law and regulation. 38 U.S.C. § 7104; 38 C.F.R. § 20.105. It follows that reconsideration of the criteria for assigning a 40 percent rating cannot occur in this decision. A December 2000 VA treatment record and a September 2001 private treatment record confirm that the Veteran required daily insulin. Subsequent VA treatment records document his transition to using an insulin pump. However, the method of insulin delivery is irrelevant. Whether the next highest rating of 40 percent is warranted indeed hinges on regulation of activities. The Board finds that this rating is not warranted because there is no indication of a medical need for the Veteran to avoid strenuous occupational and recreational activities. While August 2013 and September 2014 VA treatment records respectively reference the Veteran's extensive walking on the job and plan to be more active generally the following week, on neither occasion did his diabetic care provider advise him to limit or stop doing what he was doing. A June 2015 letter from one of his VA diabetic care providers further indicates that up to 30 minutes of exercise per day was recommended to him. A July 2018 VA treatment record similarly instructed the Veteran to exercise 30 minutes three times per week to control his blood pressure. Although this is a different disability, his diabetic status was noted in the same record. The instruction to exercise was provided notwithstanding his diabetes, in other words. None of the aforementioned included the proviso that the Veteran avoid strenuous activity. Finally, June 2014 and January 2021 VA medical examinations both specifically found that he did not require regulation of activities to manage his diabetes mellitus. He has not reported ever being told by a diabetic care provider to avoid strenuous occupational and/or recreational activities. His hearing testimony that he cannot engage in physical activity as he desires is acknowledged. Yet he largely attributed his limitations in this regard to his peripheral neuropathy of the lower extremities (the ratings for these service-connected disabilities account for any impairment in functioning they cause). Even if he had instead attributed them to his diabetes mellitus, being less physically active than he would like simply is not the same as needing to avoid strenuous activity. In sum, the preponderance of the evidence shows that the criteria for a 40 percent rating have not been met. When rating criteria are successive, each higher rating includes the criteria of each lower rating such that if one criterion is not met at any one level, the assigned rating is at the level that does not require that missing criterion. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). The rating criteria for diabetes mellitus are successive. Camacho, 21 Vet. App. at 366. Since the Veteran does not require regulation of activities, one criterion for a 40 percent rating, it is unnecessary to proceed with consideration of an even higher rating. They indeed require this missing criterion along with additional criteria. A rating higher than 20 percent, in conclusion, is denied for the entire period on appeal. The June 2014 VA medical examination found that impotency (erectile dysfunction), nephropathy, and peripheral neuropathy were the only complications of the Veteran's diabetes mellitus. The January 2021 examination curiously found that there were no complications, but then later acknowledge peripheral neuropathy as a complication. Since this no complications finding is at odds with the rest of the evidence, it is not probative. A September 2001 private treatment record finally references retinopathy. However, subsequent evidence does not. VA treatment records dated in December 2013 and July 2019 (referencing an October 2018 eye assessment) indeed specifically did not find retinopathy. Many others documenting assessments of the Veteran's eyes are silent with respect to this complication, which strongly suggests he did not have it. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). The Veteran's peripheral neuropathy of the lower extremities already is rated separately from his diabetes mellitus. These disabilities are addressed below. Impotency, as a noncompensable complication, currently is considered part of his diabetic process. 38 C.F.R. § 4.115B addresses genitourinary disorders. Diagnostic Code 7522 thereunder establishes a 20 percent rating for penis deformity with loss of erectile power. SMC also is to be considered. In seeking a separate 20 percent rating for his impotency, the Veteran has not explained why he believes such a rating is merited. The Board finds that a compensable rating separate from his diabetes mellitus is not warranted for his impotency because there is no indication of a penis deformity. At the June 2014 VA medical examination, his penis was not assessed. Though he later did not recall declining such an assessment, this was per the Veteran's request. He related having normal anatomy with no penile deformity or abnormality at that time of his examination in any event. No penis deformity is mentioned by him at any other time either. His VA treatment records further do not include findings of any such deformity. A separate compensable rating for impotency, in conclusion, is denied for the entire period on appeal. SMC is payable for anatomical loss or loss of use of one or more creative organs. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). A February 2003 rating decision granted SMC based on loss of use of a creative organ effective January 23, 2003. It was explained that his diabetes mellitus has rendered him impotent. The Veteran already is in receipt of SMC on account of his impotency, in other words. Turning to nephropathy, Diagnostic Code 7541 under 38 C.F.R. § 4.115B addresses renal involvement in diabetes mellitus. It calls for rating as renal dysfunction under 38 C.F.R. § 4.115A (genitourinary system dysfunctions). Renal dysfunction assigns a noncompensable rating for albumin and casts with history of acute nephritis or for noncompensable hypertension. A 30 percent rating requires albumin constant or recurring with hyaline and granular casts or red blood cells, transient or slight edema, or hypertension at least 10 percent disabling. A 60 percent rating is merited for constant albuminuria with some edema, definite decrease in kidney function, or hypertension at least 40 percent disabling. An 80 percent rating is for persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80 mg percent, creatinine 4 to 8 mg percent, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. The maximum 100 percent rating is reserved for when regular dialysis is required or when more than sedentary activity is precluded from one of the following: persistent edema and albuminuria, BUN more than 80 mg percent, creatinine more than 8 mg percent, or markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.104 concerns cardiovascular disorders. Diagnostic Code 7101 thereunder is for hypertensive vascular disease (hypertension and isolated systolic hypertension). It assigns a 10 percent rating when diastolic pressure is predominantly 100 or more or systolic pressure is predominantly 160 or more. A 10 percent rating also is the minimum rating for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. When diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more, a 20 percent rating is assigned. A 40 percent rating requires that diastolic pressure is predominantly 120 or more. The maximum rating of 60 percent is reserved for when diastolic pressure is predominantly 130 or more. Hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Note (1). The Veteran has not sought a separate 30 percent rating for his nephropathy. Instead, he seems to accept that it should remain noncompensable. He indeed testified at his hearing that his kidneys, though monitored, thus far have not caused any complications. The Board finds that a compensable rating separate from his diabetes mellitus is not warranted for his nephropathy because there is no indication that any of the criteria for a 30 percent rating are met. VA treatment records reflect that the Veteran takes medication to protect his kidneys. Although they document albumin outside the identified reference range in February 2016 and microalbumin outside the identified reference range in October 2020, these as well as BUN and creatinine much more often were not noted in any way to be abnormal. Neither hyaline and granular casts nor red blood cells further was ever mentioned. At a June 2014 VA medical examination, the Veteran had 1+ protein in his urine. He was noted to have recurring proteinuria (albuminuria). Yet once again neither hyaline and granular casts nor red blood cells was mentioned. This examination next did not mention any edema, whether transient or slight or otherwise. VA treatment records also do not include any findings of any edema. On the contrary, some specifically did not find edema. Regarding hypertension, the June 2014 VA medical examination did not find that the Veteran's is due to renal dysfunction. Yet VA treatment records reveal a diagnosis made in or around September 2001, years after his diabetes mellitus diagnosis, when he was first noted to take medication to control his blood pressure. They also reveal that he continues to take medication for this purpose. Only a few blood pressure measurements prior to September 2001 are available in VA and private treatment records. None included a diastolic pressure of 100 or more. A history where such predominates thus did not exist. During the period on appeal, VA treatment records show that the Veteran's blood pressure has been measured frequently. His diastolic pressure never has been 100 or more. His systolic pressure further was 160 or more only once, when he was at peak stress during a June 2017 cardiology stress test. Such pressures thus are not predominant. Peripheral Neuropathy of the Right and Left Lower Extremities 38 C.F.R. § 4.124a addresses neurological disabilities. The Veteran's service-connected peripheral neuropathy of the right lower extremity and of the left lower extremity are rated pursuant to Diagnostic Code 8520 thereunder. Diagnostic Code 8520 is for paralysis of the sciatic nerve. It assigns a 20 percent rating for moderate incomplete paralysis. Moderately severe incomplete paralysis merits a 40 percent rating, while a 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. Incomplete paralysis indicates a degree of lost or impaired function substantially less than that for complete paralysis. 38 C.F.R. § 4.124a, opening paragraph for diseases of the peripheral nerves. The maximum rating of 80 percent is reserved for complete paralysis. Complete paralysis exists when the foot dangles and drops, no active movement is possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. Moderate, moderately severe, and severe are not defined. However, the rating is limited to the mild or at most the moderate degree when involvement is wholly sensory. Id. The Veteran seeks ratings higher than 20 percent for his service-connected peripheral neuropathy of right lower extremity and peripheral neuropathy of the left lower extremity. However, he does not explain why he believes such ratings are merited. The Board finds that ratings higher than 20 percent are not warranted because these disabilities do not more nearly approximate moderately severe incomplete paralysis. The Veteran primarily has reported burning, tingling, stinging, and numbness in his legs that is worse at night. He also has reported cramps/aches and discoloration. Multiple VA treatment records reflect his description of his left lower extremity disability as an "extra layer of skin." His history of painful sensory neuropathy also was noted in a February 2016 VA treatment record. Otherwise, however, they contain little relevant information. As such, the Veteran's VA medical examinations provide the most comprehensive assessment of his disabilities. The June 2014 examination specifically characterized his paresthesias and/or dysesthesias as moderate and his numbness at mild in both legs. He did not have constant or intermittent pain. His deep tendon reflexes were decreased (1+ on a scale of 0-4+, where 0 is absent and 2+ is normal) in his left leg. Yet his strength and sensation were normal in that leg. Assessment of the Veteran's right leg was extremely limited due to the cast on his right ankle, put in place after surgery to fix a fracture. He did not have any muscle atrophy or trophic changes. Overall, his left lower extremity disability was found to be akin to mild incomplete paralysis. His right lower extremity was found to be normal, but this finding is not probative given the difficulties in assessing it. At his January 2021 examination, the Veteran's paresthesias and/or dysesthesias, intermittent pain, numbness, and burning sensation specifically was characterized as moderate in both legs. He did not have constant pain. Both legs had normal strength, with no muscle atrophy. His deep tendon reflexes in both legs were decreased (1+). So was his sensation in both legs (as opposed to absent or normal). Neither had any hair, which was noted as a trophic change. Overall, the Veteran's lower extremity disabilities were found to be akin to moderate incomplete paralysis. He, in sum, has manifested decreased sensation and deep tendon reflexes as well as a trophic change in both legs. His involvement is not wholly sensory, in other words. It follows that his ratings are not capped at the moderate degree, which for the sciatic nerve is 20 percent. It does not follow, however, that ratings higher than 20 percent must be assigned because the Veteran manifests non-sensory involvement. Miller v. Shulkin, 28 Vet. App. 376, 380 (2017). That he does not have marked muscle atrophy forecloses the assignment of 60 percent ratings for severe incomplete paralysis. If he had some but not marked muscle atrophy, a lesser rating like 40 percent for moderately severe incomplete paralysis would be warranted. Yet he has no muscle atrophy in his legs whatsoever. This signifies that his disabilities are less than moderately severe. So does the fact that the Veteran's sensation and deep tendon reflexes were decreased but not absent. Further, none of his symptoms ever were characterized as moderately severe or worse. He lastly has not described any, with one exception, in terms of moderately severe or worse. Concerning this exception, the Veteran testified at his hearing that his cramps and aches get as bad as 8 on a scale to 10 during daily flare-ups. This suggests that these particular symptoms approach moderately severe at times each day. Yet it also suggests that it is less than moderately severe for the rest of each day. The preponderance of the evidence concerning the Veteran's symptoms, in sum, does not favor a moderately severe characterization of his disabilities. The same is true of the evidence concerning the effects of his symptoms. Such evidence is relevant for rating purposes, given that the terms moderate, moderately severe, and severe are not defined or associated with specific symptoms (except marked muscular atrophy for severe). Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018). The Veteran testified to having discomfort while sleeping despite using a pillow for his legs in this regard. He states that this results in poor sleep, as he shifts position all night, with consequent daytime sleepiness and irritability. Yet he indicated that he tolerates his discomfort and makes it through the night. He is not unable to sleep, in other words. There further is nothing to suggest that he is too sleepy or irritable to engage in any daytime activity. Although the Veteran also reported stumbling and falling to his knees, he denied ever falling completely to the ground. He finally has reported having to sit down and elevate his legs and being unable to jog/run, ride a bike, or participate in other sports. However, he is able to walk some. This all points to moderate, as opposed to a moderately severe or worse, characterizations of his disabilities. Ratings higher than 20 percent for them, in conclusion, are denied for the entire period on appeal. TDIU A TDIU is warranted if a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disability or disabilities rated less than 100 percent. 38 C.F.R. § 4.16(a). It may be granted on a schedular basis when there is one such disability rated at 60 percent or more or when there are two or more such disabilities with a combined rating of 70 percent or more and one is rated individually at 40 percent or more. Id. If neither percentage threshold is met, it may be granted on an extraschedular basis provided referral first is made to the Director of the Compensation Service. 38 C.F.R. § 4.16(b). The economic component of "unable to secure and follow a substantially gainful occupation," means an occupation earning more than marginal income (outside of a protected environment) as determined by the US Department of Commerce as the poverty threshold for one person. 38 C.F.R. § 4.16(a); Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). The non-economic component involves consideration of the veteran's history, education, skill, and training as well as whether he/she has the physical and mental ability to perform the type of activities required for that occupation. Id.; Pederson v. McDonald, 27 Vet. App. 276, 286 (2015). As such, there must be an impairment of body or mind which renders it impossible for the average person to follow a substantially gainful occupation, in other words. 38 C.F.R. § 3.340(a)(1). The veteran's age is not for consideration, however. 38 C.F.R. §§ 3.341(a), 4.19. Neither is the impairment attributable to his/her nonservice-connected disabilities. When the evidence is in approximate balance, the claimant is afforded the benefit of the doubt. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. The applicable standard thus is at least as likely as not. The Veteran contends that he is unable to work because of his peripheral neuropathy of the right and left lower extremities, which is attributable to his diabetes mellitus. In this regard, he notes that he quit his last job due to his legs and feet. He also notes that he is totally dependent on his insulin pump. A 20 percent rating has been in effect throughout the period on appeal for the Veteran's service-connected diabetes mellitus with impotency and nephropathy, peripheral neuropathy of right lower extremity, and peripheral neuropathy of the left lower extremity. He does not have any other service-connected disabilities. Disabilities resulting from common etiology are considered as one in determining whether the 60 percent or 40 percent single disability threshold for a schedular TDIU is met. 38 C.F.R. § 4.16(a). Here, all of the Veteran's service-connected disabilities have a common etiology. Service connection for his diabetes mellitus was granted in a September 2002 rating decision based on his presumed exposure to herbicides during service. His peripheral neuropathy of the right and left lower extremities is linked to his diabetes mellitus, and thus also to this herbicide exposure. These disabilities accordingly are considered as one. However, their combined rating (including the bilateral factor) is only 50 percent. 38 C.F.R. §§ 4.25, 4.26. The Veteran therefore does not meet the required 60 percent single disability threshold for a schedular TDIU. As such, a TDIU can be granted only on an extraschedular basis following referral to the Director of the Compensation Service. The Board finds that such referral is not warranted because the Veteran's service-connected disabilities have not rendered him unable to secure or follow a substantially gainful occupation. The Veteran has reported some college education and no other education or training. A September 2001 private treatment record reflects that he was working at the post office. This corresponds with a June 2014 VA treatment record, which denotes that he used to be a postal worker. With respect to his most recent job, the Veteran reports working as a patient transporter at a hospital from 2004 to May or June 2014. His primary responsibility was pushing patients around in wheelchairs. He seemingly reports working about 30 hours per week, but ultimately reducing his hours to 20 per week. This corresponds with the notation in an April 2014 VA treatment record the he works only three days per week. He relates that reducing his hours and his ultimate retirement were because he could no longer walk the required 5 to 8 miles per day given the pain and discomfort in his legs and feet. Largely confirming the Veteran's reports, the hospital that employed him indicates that he worked in temporary services from January 2005 to January 2006 and in patient transport from January 2005 to July 31, 2014. He finally reports earning $13 per hour, or $20,000, in 2014. He, in sum, was employed part-time for the first few months of the period on appeal. For these months, the Veteran's aforementioned reported earnings exceed the poverty threshold for one person as established by the U.S. Department of Commerce, Bureau of the Census. https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html. There is no indication that the Veteran has been employed since mid-2014. He therefore has no earnings, which makes exceeding the poverty threshold for one person impossible. While the hospital that employed the Veteran did not specify why he quit his position as a patient transport, his reports that it was due to his lower extremity peripheral neuropathy symptoms are competent as well as credible. There indeed is no reason to doubt them. Not only has the Veteran been steadfast in making these reports, but his demeanor at the hearing was sincere. The June 2014 VA medical examination finding that his peripheral neuropathy of the left lower extremity (that the right lower extremity was deemed normal, largely because it could not be assessed properly, is reiterated) does not impact his ability to work is not probative because it is contrary to these reports. It also is contrary to the January 2021 VA medical examination, which found that the Veteran has limited prolonged standing, walking, sitting, and driving as a result of his peripheral neuropathy of both lower extremities. The Veteran's difficulty in getting restful sleep and altered gait during flare-ups also were noted as limitation caused by his peripheral neuropathy of the lower extremities at this examination. While the evidence discussed above shows some changes in these disabilities over the period on appeal, these changes have been minimal. The severity of these disabilities further has remained largely the same (moderate) throughout. They therefore likely caused the same limitations throughout as they were found to be causing in January 2021. In sum, the Veteran's service-connected lower extremity peripheral neuropathy disabilities have precluded him from working as a patient transporter since he retired from such a position. The question is not whether he can work in this chosen field, however. Rather, the question is whether the Veteran can work in any field that pays enough to exceed the poverty threshold for one person. His limited education and training plus his unskilled to semi-skilled work experience qualifies him most for entry level employment. Entry level jobs involving prolonged standing, walking, sitting, and driving once again are precluded by his lower extremity peripheral neuropathy disabilities. However, his diabetes mellitus with impotency and nephropathy does not add any more limitations. No impact on his ability to work indeed was found as a result of diabetes mellitus, impotency, or nephropathy at the June 2014 examination. The January 2021 examination did find such an impact for diabetes mellitus, but the ensuing discussion concerned only peripheral neuropathy. It is silent with respect to any impact for impotency or nephropathy. The Veteran has not reported any impact on his ability to work due to his noncompensable impotency and nephropathy complications of diabetes mellitus. All he has indicated with respect to diabetes mellitus is that he relies on his insulin pump. He appears worried that it will malfunction. However, he did not state that it needs repair so frequently that he would be unable to hold down a job. VA treatment records do not show this to be the case either. The Veteran also did not state that the pump is so large it would get in the way as he worked or that any other of its characteristics are somehow restrictive. That he has used an insulin pump since around 2010 finally is notable. He was able to retain his position as a patient transporter for years despite it, in other words. In sum, the Veteran is qualified for and capable of doing any job that does not involve prolonged standing, walking, sitting, and driving. Identification of a specific job he has been able to work is not required. Pederson v. McDonald, 27 Vet. App. 276, 286-287 (2015). Yet of import here is that the Veteran has reported volunteering with the Red Cross as a transport driver beginning in 2014 after his retirement. He specifically delivers plasma to local hospitals. This strongly suggests that a local delivery driver job is within his functional capacity notwithstanding his service-connected disabilities. Indeed, such a position might be ideal in requiring short periods of sitting and driving alternating with standing and walking. Referral for extraschedular TDIU consideration, in conclusion, is denied based upon the preponderance of the evidence. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Becker 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.