Citation Nr: 21040851 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 17-62 403 ATE: July 7, 2021 ORDER Entitlement to an increased rating higher than 40 percent for diabetes mellitus for substitution purposes is denied. Entitlement to an increased rating higher than 10 percent prior to October 28, 2011, and higher than 30 percent from October 28, 2011, for peripheral neuropathy of the left upper extremity associated with diabetes mellitus for substitution purposes is denied. Entitlement to an increased rating higher than 10 percent prior to October 28, 2011, for peripheral neuropathy of the right upper extremity for substitution purposes is denied. Entitlement to an increased rating higher than 30 percent from October 28, 2011, for Parkinson's disease affecting the right upper extremity with diabetic neuropathy and facial paralysis for substitution purposes is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to August 27, 2013, for substitution purposes, is denied. Entitlement to special monthly compensation (SMC) at the housebound rate for substitution purposes is denied. FINDINGS OF FACT 1. The Veteran did not experience episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. 2. Prior to October 28, 2011, the Veteran's peripheral neuropathy of the left upper extremity was productive of mild incomplete paralysis. 3. From October 28, 2011, the Veteran's peripheral neuropathy of the left upper extremity was productive of moderate incomplete paralysis. 4. Prior to October 28, 2011, the Veteran's right upper extremity peripheral neuropathy was productive of mild incomplete paralysis. 5. From October 28, 2011, the Veteran's Parkinson's disease was productive of mild incomplete paralysis of the right radicular groups including the median nerve, right upper radicular group, and right ulnar nerve. 6. The Veteran's service-connected disabilities did not prevent him from obtaining or maintaining substantially gainful employment prior to August 27, 2013. 7. The Veteran did not have a single disability rated as 100 percent disabling during his appeal; the TDIU was granted based upon the impact of multiple service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 40 percent for diabetes mellitus for substitution purposes are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7913. 2. Prior to October 28, 2011, the criteria for entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity for substitution purposes are not met. 38 C.F.R. § 4.124a, Diagnostic Code 8615. 3. From October 28, 2011, the criteria for entitlement to an initial rating in excess of 30 percent for peripheral neuropathy of the left upper extremity for substitution purposes are not met. 38 C.F.R. § 4.124a, Diagnostic Code 8613. 4. Prior to October 28, 2011, the criteria for entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity for substitution purposes are not met. 38 C.F.R. § 4.124a, Diagnostic Code 8615. 5. From October 28, 2011, the criteria for a rating in excess of 30 percent for Parkinson's disease affecting the right upper extremity with diabetic neuropathy and facial paralysis for substitution purposes are not met. 38 U.S.C. §§ 1155, 5103(a), 5103A; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8004. 6. The criteria for an effective date prior to August 27, 2013, for the grant of entitlement to a TDIU for substitution purposes are not met. 38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.400, 4.16(a). 7. The criteria for SMC at the housebound rate for substitution purposes are not met. 38 U.S.C. §§ 1114, 1502; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1968 to March 1972. He died in January 2017 while the above appeal was pending. His surviving spouse, the appellant, was properly substituted as the claimant for his pending claim. This matter originally comes to the Board of Veterans' Appeals (Board) from a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decision dated in July 2013. The appellant testified before the undersigned Veterans Law Judge at a Board hearing at the AOJ in August 2018. In February 2019, the Board, in pertinent part, denied entitlement to an increased rating for diabetes mellitus and peripheral neuropathy of the bilateral upper extremities. The appellant appealed the Board's February 2019 decision to the U.S. Court of Appeals for Veterans Claims (Court), insofar as it had denied the increased rating claim for diabetes mellitus and peripheral neuropathy of the bilateral upper extremities. Pursuant to an October 2019 joint motion for partial remand (JMPR), in November 2019, the Court vacated the Board's decision with respect to the aforementioned claims. The Board remanded the case in June 2020 pursuant to the JMPR. The AOJ substantially complied with the directives of the Board's remand and as such, the case has been returned for appellate review. On remand, in a March 2021 rating decision, the AOJ granted an increased rating of 40 percent for diabetes mellitus, effective May 22, 2012. As the appellant has not indicated that she is satisfied with this rating, this matter is still before the Board for substitution purposes. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating 1. Entitlement to an increased rating higher than 40 percent for diabetes mellitus for substitution purposes The appellant seeks a higher rating for the Veteran's diabetes mellitus. As noted above, the AOJ granted an increased rating of 40 percent for the diabetes mellitus in a March 2021 rating decision with an effective date of May 22, 2012, the date the Veteran filed his increased rating claim for diabetes. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran's disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran' favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The question in this appeal is whether the Veteran's diabetes mellitus required one or more daily injections of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. The Board finds that the Veteran did not have episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. During the Veteran's lifetime he was evaluated several times and was never found to have any episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. In October 2009, the Veteran was afforded a VA examination. The examiner noted that the Veteran had a diagnosis of diabetes mellitus in 2009. The examiner noted that the Veteran was treated with oral medication. The Veteran did not report episodes of hypoglycemia or ketoacidosis. The Veteran did not require regulation of activities as part of his medical management of diabetes mellitus. A January 2010 VA treatment note indicated that the Veteran lost 60 pounds on a diet to control his diabetes mellitus. A December 2011 VA emergency department note indicated that the Veteran did not have physical activity limitations. The Veteran underwent a subsequent VA examination in April 2013. The VA examiner noted that the Veteran was diagnosed with diabetes mellitus managed by insulin injection twice a day. The Veteran did not report episodes of hypoglycemia or ketoacidosis. The Veteran did not require regulation of activities as part of his medical management of diabetes mellitus. The examiner found that the Veteran's diabetes mellitus was well controlled and did not impede his employment potential. However, the VA examiner also noted that the Veteran used a riding lawn mower to cut the grass and that he had to rest between activities when he would get tired prior to completing the activity. In addition, in April 2013, the Veteran's VA primary care doctor had told him not to do strenuous activities to prevent his blood sugars from going up. A May 2014 VA treatment note indicated that the Veteran treated his diabetes mellitus with insulin injections. In August 2014, the Veteran underwent another VA examination for diabetes mellitus. The Veteran managed his diabetes mellitus with an insulin injection twice a day and a restricted diet. The Veteran did not report episodes of hypoglycemia or ketoacidosis. The Veteran did not require regulation of activities as part of his medical management of diabetes mellitus. The examiner found that the Veteran's diabetes mellitus was well controlled and did not impede his employment potential. After the Veteran died in 2017, the appellant testified at the August 2018 Board hearing that the Veteran administered insulin shots for his diabetes mellitus in the mornings and evenings daily. She noted that the Veteran occasionally kept a diet. Also, the appellant was not aware of a physician regulating the Veteran's activities due to his diabetes mellitus. Additional VA treatment records do not indicate additional treatment for diabetes mellitus other than insulin injections twice a day. After the Board remanded the case pursuant to the JMPR to resolve whether the Veteran's diabetes mellitus required regulation of activities, a VA medical opinion was provided in March 2021 that based on the medical evidence of record the Veteran would have had to regulate his activities due to his diabetes. Specifically he would have had functional impairment involving sitting, standing, and/ or walking for about 3 hours of an 8-hour work day; pushing and/ or pulling; occasional lifting and/ or carrying 10 pounds; climbing ramps/stairs, balancing, stopping/bending at the waist, kneeling, crouching, crawling; climbing ladders/ropes/scaffolds; reaching any direction (including overhead); handling (gross manipulation); and fingering (fine manipulation). The examiner noted that medical records were reviewed and there was no history of hospitalization or surgery, pancreatic trauma, pancreatic neoplasm, treatment of hypertension, episodes of hypoglycemia reaction or ketoacidosis. The Veteran had been instructed to follow a restricted or special diet. The Veteran and appellant are competent to report that which they observed, and their reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran and appellant have not asserted, and the medical treatment records do not show, that the Veteran's diabetes mellitus required twice a month visits and/ or one or more hospitalizations per year. The Veteran had complications associated with diabetes mellitus including peripheral neuropathy of the upper and lower extremities, Parkinson's disease, and erectile dysfunction. These complications are already service connected; and other than the erectile dysfunction, which is rated as 0 percent, the complications involving peripheral neuropathy are all compensable and are addressed below. While the erectile dysfunction has a noncompensable rating, as noted above, the Veteran's diabetes mellitus did not required twice a month visits and/ or one or more hospitalizations per year Accordingly, the preponderance of the evidence is against assigning a rating in excess of 40 percent for substitution purposes during the period on appeal. 2. Entitlement to an increased rating higher than 10 percent prior to October 28, 2011, and higher than 30 percent from October 28, 2011, for peripheral neuropathy of the left upper extremity associated with diabetes mellitus for substitution purposes The issue of entitlement to an increased rating for peripheral neuropathy of the left upper extremity was inextricably intertwined with the issue of entitlement to a TDIU, effective prior to August 27, 2013; so, the Board remanded this matter pending resolution of the TDIU claim. The earlier effective date claim for TDIU is resolved below; thus, adjudication of the claim for an increased rating for peripheral neuropathy of the left upper extremity can proceed. Prior to October 28, 2011, the Veteran's peripheral neuropathy of the left upper extremity was rated 10 percent under 38 C.F.R. § 4.124a, Diagnostic Code 8615 (paralysis of the median nerve). Since October 28, 2011, the Veteran's peripheral neuropathy of the left upper extremity is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8613. The Veteran's left upper extremity was rated 30 percent disabling. The appellant contends that higher ratings are warranted. Diagnostic Code 8615, for neuritis of the median nerve of the minor extremity, provides a 10 percent rating for mild incomplete paralysis, a 20 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis. A 60 percent rating is assigned where there is complete paralysis of the minor extremity. 38 C.F.R. § 4.124a. Under Diagnostic Code 8613, for neuritis of all radicular groups of the minor extremity, a 20 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 60 percent rating for severe incomplete paralysis. An 80 percent rating is assigned where there is complete paralysis of the minor extremity. 38 C.F.R. § 4.124a. The term "incomplete paralysis" with this and other 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 partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The record indicates that the Veteran was right-handed; therefore, his right extremity was his major extremity. During an October 2009 VA examination for diabetes mellitus, the Veteran was diagnosed with peripheral neuropathy of his left upper extremity. The Veteran noted paresthesias and loss of sensation in his fingertips. No motor loss was found. The examiner found that the Veteran's peripheral neuropathy was secondary to his service-connected diabetes mellitus as onset was simultaneous with diabetes mellitus. In February 2012 the Veteran underwent a VA examination for peripheral neuropathy. He was diagnosed with diabetic peripheral neuropathy of all four extremities in 2006 and left ulnar radiculopathy of the upper extremity in 2012. The Veteran was right hand dominant. His symptoms included severe intermittent pain and severe numbness of the left upper extremity and severe paresthesias and/or dysesthesias of the left upper extremity. Muscle strength testing was normal for the left upper extremity; although, grip for the left hand was rated 3/5 as the Veteran was unable to fully flex the last three fingers of his left hand due to a service-connected disability. No muscle atrophy was found. Upon examination, the Veteran's reflexes were normal. Decreased sensation was found for the left hand and fingers; however, the Veteran had normal sensation for the left shoulder area, as well as the right inner and outer forearm. The Veteran's gait was normal. The left radial nerve, left musculocutaneous nerve, left long thoracic nerve, left middle radicular group, left lower radicular group, and left circumflex nerve were normal. The Veteran had mild incomplete paralysis of the left median nerve, left upper radicular group, and left ulnar nerve. No assistive devices were used. A scar was noted; however, it was not unstable, painful, or greater than 39 square centimeters. An imaging study revealed degenerative disc disease of the cervical spine. In April 2013, a VA examiner opined that the Veteran's severe left upper extremity pain was likely due to cervical radiculopathy. She also opined that weakness and severe numbness of the left upper extremity was due to left ulnar neuropathy as a result of his service-connected left-hand injury. During her August 2018 Board hearing, the appellant stated that the Veteran complained about numbness in his bilateral arms from his elbows up, as well as bilateral arm weakness. Prior to October 28, 2011, the preponderance of the evidence reflects that the Veteran's peripheral neuropathy of the left upper extremity did not more nearly approximate the criteria for a rating higher than 10 percent as his symptoms were manifested by paresthesias and loss of sensation in his fingertips. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for increased rating for the left upper extremity peripheral neuropathy must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3, 4.7. From October 28, 2011, the medical evidence does not show that his symptoms more nearly approximated severe incomplete paralysis or complete paralysis of the nerves. Accordingly, the Board finds that a rating in excess of 30 percent is not warranted for peripheral neuropathy of the left upper extremity for substitution purposes. 3. Entitlement to an increased rating higher than 10 percent prior to October 28, 2011, for peripheral neuropathy of the right upper extremity for substitution purposes 4. Entitlement to an increased rating higher than 30 percent from October 28, 2011, for Parkinson's disease affecting the right upper extremity with diabetic neuropathy and facial paralysis for substitution purposes The issue of entitlement to an increased rating for peripheral neuropathy of the right upper extremity was inextricably intertwined with the issue of entitlement to a TDIU, effective prior to August 27, 2013; so, the Board remanded this matter pending resolution of the TDIU claim. The earlier effective date claim for TDIU is resolved below; thus, adjudication of the claim for an increased rating for peripheral neuropathy of the right upper extremity can proceed. Prior to October 28, 2011, the Veteran was rated 10 percent under 38 C.F.R. § 4.124a, Diagnostic Code 8615 for peripheral neuropathy of the right upper extremity. From October 28, 2011, the Veteran was rated under Diagnostic Code 8004 for Parkinson's disease affecting the right upper extremity and with facial paralysis. The appellant contends that higher ratings are warranted. Diagnostic Code 8004 provides for a minimum rating of 30 percent for paralysis agitans. 38 C.F.R. § 4.124a. Paralysis agitans is also known as Parkinson's disease. Dorland's Illustrated Medical Dictionary 972 (26th ed. 1990). The minimum rating is the only rating provided for under Diagnostic Code 8004. If, however, there are identifiable residuals that can be rated under a separate diagnostic code and the combined disability rating resulting from these residuals exceeds 30 percent, the separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. VA should also analyze individual symptoms under the appropriate diagnostic code for that bodily system. See 38 C.F.R. § 4.124a. The Board notes that the following are additional potentially applicable diagnostic codes: Under Diagnostic Code 5325 for muscle injury, facial muscles. Functional impairment is evaluated as seventh (facial) cranial nerve neuropathy (Diagnostic Code 8207), disfiguring scar (Diagnostic Code 7800), etc. Minimum if interfering to any extent with mastication warrants a 10 percent rating. Diagnostic Code 8207 for paralysis of the cranial nerve provides for a 10 percent rating for moderate incomplete paralysis, 20 percent for severe incomplete paralysis, and 30 percent for complete paralysis. In the alternative under Diagnostic Code 8209 for ninth (glossopharyngeal) cranial nerve again provide a 10 percent rating for moderate incomplete paralysis, a 20 percent rating for severe incomplete paralysis, and a 30 percent rating for complete paralysis. Diagnostic Code 8510 provides that mild incomplete paralysis of the upper radicular group (fifth and sixth cervicals) is rated 20 percent disabling for both the major and minor side. Moderate incomplete paralysis is rated as 40 percent disabling on the major side and 30 percent disabling on the minor side. A 50 percent rating is warranted for severe incomplete paralysis of the radicular group of the major extremity, and a 40 percent rating is warranted for severe incomplete paralysis affecting the minor extremity. Complete paralysis of the upper radicular group, with all shoulder and elbow movements lost or severely affected and hand and wrist movements not affected, warrants a 70 percent rating for the major side and a 60 percent rating for the minor side. 38 C.F.R. 4.124a. Under Diagnostic Code 8513, for all radicular groups (upper (long thoracic nerve, median nerve, radial nerve, musculocutaneous nerve, axillary nerve, and their offshoots), middle (long thoracic nerve, median nerve, radial nerve, and musculocutaneous nerve), and lower (radial nerve, median nerve and ulnar nerve) groups), a 20 percent disability rating is warranted for mild incomplete paralysis of all the radicular groups of the minor or major extremity. A 30 percent rating is warranted for moderate incomplete paralysis of all the radicular groups of the minor extremity and a 40 percent rating is warranted for moderate incomplete paralysis of all the radicular groups of the major extremity. A 60 percent rating is warranted for severe incomplete paralysis of all the radicular groups of the minor extremity and a 70 percent rating is warranted for severe incomplete paralysis of all the radicular groups of the major extremity. A maximum 80 percent disability rating is warranted for complete paralysis of all the radicular groups of the minor extremity and a maximum 90 percent rating is warranted for complete paralysis of all the radicular groups of the major extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8513. Under Diagnostic Codes 8515 and 8516, a 10 percent rating is warranted for mild incomplete paralysis of the ulnar or median nerve of either the major or minor side. A 30 percent rating is warranted for moderate incomplete paralysis of the ulnar or median nerve of the major side. With severe symptoms affecting the major side, a 50 percent rating is warranted if the median nerve is involved, and a 40 percent rating is warranted if the ulnar nerve is involved. With complete paralysis affecting the major side, a 70 percent rating is warranted if the median nerve is involved, and a 60 percent rating is warranted if the ulnar nerve is involved. 38 C.F.R. § 4.124a, Diagnostic Codes 8515-8516. 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, note following Diagnostic Code 8719. During an October 2009 VA examination for diabetes mellitus, the Veteran was diagnosed with peripheral neuropathy of his right upper extremity. The Veteran noted paresthesias and loss of sensation in his fingertips. No motor loss was found. The examiner found that the Veteran's peripheral neuropathy was secondary to his service-connected diabetes mellitus as onset was simultaneous with diabetes mellitus. In February 2012 the Veteran underwent a VA examination for peripheral neuropathy. He was diagnosed with diabetic peripheral neuropathy of all four extremities in 2006 and cervical radiculopathy of the right upper extremity in 2012. The Veteran was right hand dominant. His symptoms included severe constant pain of the right upper extremity and severe paresthesias and/or dysesthesias of the right upper extremity. No numbness of the right upper extremity was reported. Muscle strength testing was normal for the right upper extremities. No muscle atrophy was found. Upon examination, the Veteran's reflexes were normal. Decreased sensation was found for the right hand and fingers; however, the Veteran had normal sensation for the right shoulder area, as well as the right inner and outer forearm. The Veteran's gait was normal. The right radial nerve, right musculocutaneous nerve, right long thoracic nerve, right middle radicular group, right lower radicular group, and right circumflex nerve were normal. The Veteran had mild incomplete paralysis of the right median nerve, right upper radicular group, and right ulnar nerve. No assistive devices were used. A scar was noted; however, it was not unstable, painful, or greater than 39 square centimeters. An imaging study revealed degenerative disc disease of the cervical spine. In April 2013, the Veteran was afforded a private Parkinson's disease disabilities benefits questionnaire (DBQ) examination. The Veteran was diagnosed with Parkinson's disease. He had mild slowed motion and mild loss of automatic movements. He did not have speech changes, a balance impairment, or stooped posture. His right upper extremity had mild tremors, as well as mild muscle rigidity and stiffness. Mental manifestations due to Parkinson's disease, such as depression and cognitive impairments, were not found. Further, the Veteran did not have a loss of sense of smell, sleep disturbance, difficulty chewing/swallowing, urinary problems, sexual dysfunction, or constipation due to Parkinson's disease. The Veteran was found to be able to manage his financial affairs responsibly. On an August 2014 VA Parkinson's disease DBQ the examiner found that the Veteran did not have Parkinson's disease. On examination, the Veteran did not have a stooped posture, balance impairment, slowed motion, loss of automatic motions, speech change, or muscle rigidity. Mental manifestations due to Parkinson's disease, such as depression and cognitive impairments, were not found. Further, the Veteran did not have a loss of sense of smell, sleep disturbance, difficulty chewing/swallowing, urinary problems, or constipation. The Veteran did not have a sexual dysfunction due to Parkinson's disease. The examiner noted that the Veteran had a tremor, but it was not a tremor due to Parkinson's disease as the Veteran reported the tremor in his hand for years. He did not have cogwheel rigidity, hypokinesia, or bradykinesia suggestive of Parkinson's disease. He limped on his right leg due to his knee condition, but posture was not stooped, and arm swing was not reduced as with Parkinson's disease. His gait was unsteady due to his right knee condition and peripheral neuropathy of his lower extremities due to his service-connected diabetes mellitus. During her August 2018 Board hearing, the appellant stated that the Veteran's Parkinson's disease caused one of his eyes to be pulled to the side; however, he was still able to see out of the eye. The appellant noted that the Veteran did not have much strength with his right hand and that he dropped objects daily. The Veteran complained about numbness in his bilateral arms from his elbows up, as well as bilateral arm weakness. Prior to October 28, 2011, the preponderance of the evidence reflects that the Veteran's peripheral neuropathy of the right upper extremity did not more nearly approximate the criteria for a rating higher than 10 percent as his symptoms were manifested by paresthesias and loss of sensation in his fingertips. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for increased rating for the left upper extremity peripheral neuropathy must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3, 4.7. From October 28, 2011, based on the evidence of record, the Board notes that the Veteran's Parkinson's disease was manifested by pain and paresthesias of the right upper extremity, mild slowed motion and mild loss of automatic movements, mild tremors and mild muscle rigidity and stiffness of the right upper extremity, as well as mild incomplete paralysis of the right median nerve, right upper radicular group, and right ulnar nerve. The Board notes that if rated separately the Veteran's conditions would not be greater than 30 percent. The Board notes that the VA examiners indicated that the upper radicular group, and median and ulnar nerves of the right upper extremity were affected. However, separate ratings would not afford a higher rating in this case as the upper radicular group (Diagnostic Code 8510) encompasses the median nerve (Diagnostic Code 8515) and would constitute the impermissible rating of the same symptomatology twice if separate ratings were assigned. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. In Esteban v. Brown, 6 Vet. App. 259 (1994), the Court held that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. And, if the Board were to assign a separate rating for mild peripheral neuropathy of the upper radicular group including the median nerve (20 percent) and a separate rating for mild peripheral neuropathy of the ulnar nerve, (10 percent), the combined rating would be 30 percent, which is the already assigned rating under Diagnostic Code 8004. Further, as the peripheral neuropathy has been described as mild, a rating in excess of 30 percent would not be in order under Diagnostic Code 8513 for all radicular groups. Concerning the reported facial droop, 38 C.F.R. § 4.124a, Diagnostic Code 8207 provides for a 10 percent rating for moderate incomplete paralysis of the seventh (facial) cranial nerve. At best, the evidence of record shows the Veteran's loss of automatic movements was slight and non-compensable as a 10 percent disability rating requires evidence of moderate incomplete paralysis. Based on the foregoing, the Board finds that separately rating the peripheral neuropathy including of the right upper extremity and the facial nerve impairment due to the Veteran's Parkinson's disease under various nerve impairment diagnostic codes would not have afforded the Veteran a rating higher than the currently assigned minimum rating under Diagnostic Code 8004. As such, a higher rating is not in order for Parkinson's disease affecting the right upper extremity with diabetic neuropathy and facial paralysis. 5. Entitlement to a TDIU prior to August 27, 2013, for substitution purposes An August 2017 rating decision shows that the AOJ granted entitlement to a TDIU, with an effective date of August 27, 2013 based on the day following the Veteran's last date of work. The JMPR noted that the Board erred in its February 2019 decision by not addressing whether entitlement to a TDIU was warranted, prior to August 27, 2013, due to the Veteran's left and right upper peripheral neuropathy. See October 2019 JMPR, p. 5. A TDIU is a form of increased rating claim, and, therefore, the effective date rules for increased compensation claims apply. See Norris v. West, 12 Vet. App. 413, 420 (1999); Hurd v. West, 13 Vet. App. 449 (2000). The effective date shall be the later of either the date of receipt of claim, or the date entitlement arose. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (o). An effective date for a claim for increase may also be granted prior to the date of claim if it is factually ascertainable that an increase in disability had occurred within one year from the date of claim. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. §§ 3.400 (o)(1), (2). Therefore, the ultimate question in determining the effective date for TDIU is when it was factually ascertainable that the service-connected disabilities rendered a veteran unemployable. The question for the Board is whether the appellant entitled to a TDIU prior to August 26, 2013 for substitution purposes. The Board concludes that the preponderance of the evidence weighs against finding that the appellant is entitled to a TDIU prior to August 26, 2013 for substitution purposes. Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16 (b). TDIU may be assigned where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In cases where a veteran is unemployable by reason of service-connected disabilities but fails to meet the percentage standards set forth in 38 C.F.R. § 4.16 (a), the case should be submitted to the Director, Compensation and Pension Service for extraschedular consideration. See 38 C.F.R. § 4.16 (b). Consideration may be given to the veteran's education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. The central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The Court recently defined "substantially gainful employment," holding that there is both an economic and a noneconomic component; the economic component means "an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person," while the noneconomic component requires consideration of a veteran's ability to secure or follow that type of employment. Ray v. Wilkie, 31 Vet. App. 58 (2019). The Court set forth a number of factors to consider in making the latter determination, including the following: the veteran's history, education, skill, and training; his or her physical abilities, including any audio or visual limitations, as well as limitations in lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching; and his or her mental ability, including limitations in memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Id. The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16 (a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16 (a). Whether a service-connected disability or disabilities renders a Veteran unemployable is a legal determination for adjudicators to make rather than a medical question to be answered by health care professionals. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner"). The Veteran met the percentage requirements for consideration of a total evaluation under 38 C.F.R. § 4.16 (a), effective June 24, 2009, on the basis of the 60 percent combined rating assigned due to service-connected disabilities related to his diabetes mellitus. See 38 C.F.R. §§ 4.16(a)(2) (disabilities resulting from common etiology are considered one disability for purposes of one 60 percent disability); 4.25, Table I Combined Ratings Table. However, the evidence of record shows that the Veteran last worked on August 26, 2013. See, e.g., July 2014 VA-Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability; August 2014 VA-Form 21-4192, Request for Employment Information in Connection with Claim for Disability; and November 2015 statement from the Veteran that he last worked in August 2013. The Veteran noted on his VA-Form 21-8940 that he last worked full-time as a security guard on August 28, 2013, for 40 hours per week, and that his highest gross earnings per month were $2,000. The JMPR found that an April 2013 VA examination report showed that the Veteran's peripheral neuropathy of the bilateral upper extremities affected his employability. Specifically, the examiner found that the Veteran could not secure or maintain any employment requiring him to have good manual dexterity due to the inability to move his hands well, etc. See October 2019 JMPR, pp. 4-5. It was determined that the Board should provide adequate reasons and bases for why entitlement to a TDIU was not warranted prior to August 27, 2013. Id. at 5. The JMPR further found that remand was warranted for the Board to obtain a new or clarifying opinion as to the impact of the Veteran's diabetes mellitus on his work, as the April 2013 VA examiner had made conflicting findings that the Veteran's diabetes mellitus impacted his ability to work, but was also well-controlled. Id. at 6-7. On remand, the appellant was requested to provide any information as to whether the Veteran was not gainfully employed prior to August 27, 2013. The appellant responded that the Veteran did not work after August 27, 2013 and fully retired on August 2, 2013. A notice of award from the US Social Security Administration also noted that the Veteran was entitled to monthly retirement benefits beginning in August 2013. There was no information submitted to show that the Veteran was not gainfully employed prior to August 2013. The appellant has not stated otherwise. Because the evidence shows that the Veteran was gainfully employed prior to August 27, 2013, there is no doubt that he was not unemployable prior that date. None of the evidence of record indicates that the Veteran's employment prior to August 27, 2013 was marginal. He was reportedly earning $2,000 per month (approximately $24,000 annually), which is above the poverty threshold. According to the Census, in 2013, the poverty threshold for a single person was $12,119. There also are no allegations that his employment was in a protected environment. Thus, there is no reason for obtaining any opinion as to employability due to service-connected disabilities. Based on the foregoing discussion, the Board finds that entitlement to an effective date prior to August 27, 2013, for the grant of a TDIU is not warranted. 6. Entitlement to special monthly compensation (SMC) at the housebound rate for substitution purposes The JMPR found that remand was warranted for the Board to adjudicate entitlement to SMC, based on the August 2017 rating decision, which granted entitlement to a TDIU. See October 2019 JMPR, p. 4. Under 38 U.S.C. § 1114 (s), SMC is payable at the housebound rate where the claimant has a single service-connected disorder rated as total and one or more distinct service-connected disabilities, which are independently ratable at 60 percent or more and involve different anatomical segments or bodily systems. 38 U.S.C. § 1114 (s)(1); 38 C.F.R. § 3.350 (i). For purposes of section 1114(s), a TDIU may meet the 100 percent criterion, but only if assigned for a single disability. See Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242 (2011). The August 2017 rating decision shows, however, that the Veteran was posthumously awarded a TDIU, effective August 27, 2013, for multiple service-connected disabilities, including diabetes with neuropathy, Parkinson's, residuals of finger fractures in the left hand, and PTSD and major depressive disorder, as opposed to a single total disability. As the Veteran had no single service-connected disability that is rated at 100 percent, and the Veteran's TDIU was predicated on multiple service-connected disabilities, the percentage rating criteria for SMC at the housebound rate have not been met at any point during the period under consideration in this appeal. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sarah B. Richmond, 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.