Citation Nr: 21042596 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 06-10 049 DATE: July 13, 2021 ORDER An increased rating in excess of 20 percent for diabetes mellitus is denied. An initial rating of 10 percent, but no higher, prior February 7, 2014, for left upper extremity diabetic peripheral neuropathy is granted. An initial compensable rating prior to May 1, 2012, a rating in excess of 10 percent prior February 7, 2014, and in excess of 20 percent, thereafter, for left upper extremity diabetic peripheral neuropathy is denied. An initial rating of 10 percent, but no higher, prior February 7, 2014, for right upper extremity diabetic peripheral neuropathy is granted. An initial compensable rating prior to May 1, 2012, a rating in excess of 10 percent prior February 7, 2014, and in excess of 20 percent, thereafter, for right upper extremity diabetic peripheral neuropathy is granted. An initial increased rating in excess of 10 percent prior February 7, 2014, and in excess of 20 percent, thereafter, for left lower extremity diabetic peripheral neuropathy is denied. An initial increased rating in excess of 10 percent for right lower extremity peripheral neuropathy is denied. Service connection for cystopathy, to include as due to diabetes mellitus, is denied. Service connection for gastroparesis, to include as due to diabetes mellitus, is denied. Service connection for peripheral vascular disease, to include as due to diabetes mellitus, is denied. Service connection for nephropathy, to include as due to diabetes mellitus, is denied. Service connection for obstructive sleep apnea (OSA), to include as due to diabetes mellitus, is denied. Service connection for irritable bowel syndrome (IBS) is denied. REMANDED Entitlement to service connection for hypertension, to include as due to herbicide exposure and due to diabetes mellitus, is remanded. FINDINGS OF FACT 1. The Veteran's diabetes mellitus required oral hypoglycemic agents during the period on appeal. 2. The competent and probative evidence weighs against finding moderate incomplete paralysis of the left upper extremity. 3. The competent and probative evidence weighs against finding moderate incomplete paralysis of the right upper extremity. 4. The competent and probative evidence weighs against finding severe incomplete paralysis of the left lower extremity. 5. The competent and probative evidence weighs against finding moderate incomplete paralysis of the right lower extremity. 6. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of cystopathy. 7. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of gastroparesis. 8. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of peripheral vascular disease. 9. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of nephropathy. 10. The preponderance of competent evidence tends to show that it is less likely than not that the Veteran's current OSA disability was incurred during active service, as a result of herbicide agent exposure, or as a result of his service-connected disabilities. 11. The preponderance of competent evidence tends to show that it is less likely than not that the Veteran's current IBS disability was incurred during active service, as a result of herbicide agent exposure, or as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus type II are not met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.119, Diagnostic Code (DC) 7913. 2. The criteria for an initial rating of 10 percent, but no higher, prior February 7, 2014, for left upper extremity diabetic peripheral neuropathy is granted. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8513. 3. The criteria for a compensable rating prior to May 1, 2012, a rating in excess of 10 percent prior October 7, 2020, and in excess of 20 percent, thereafter, for left upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8513. 4. The criteria for an initial rating of 10 percent, but no higher, prior February 7, 2014, for right upper extremity diabetic peripheral neuropathy is granted. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8513. 5. The criteria for a compensable rating prior to May 1, 2012, a rating in excess of 10 percent prior October 7, 2020, and in excess of 20 percent, thereafter, for right upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8513. 6. The criteria for entitlement to an initial disability rating in excess of 10 percent prior February 7, 2014, and in excess of 20 percent, thereafter, for left lower extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.124a, DC 8526. 7. The criteria for entitlement to an initial disability rating in excess of 10 percent for right lower extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.124a, DC 8521. 8. The criteria for entitlement to service connection for cystopathy, to include as due to diabetes mellitus, are not met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for entitlement to service connection for gastroparesis, to include as due to diabetes mellitus, are not met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 10. The criteria for entitlement to service connection for peripheral vascular disease, to include as due to diabetes mellitus, are not met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 11. The criteria for entitlement to service connection for nephropathy, to include as due to diabetes mellitus, are not met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 12. The criteria for entitlement to service connection for OSA, to include as due to diabetes mellitus, are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.304, 3.310. 13. The criteria for entitlement to service connection for IBS are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1970 to September 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal from July 2005, November 2008, September 2011, November 2011, August 2012, April 2013, and June 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been before the Board previously. To assist with adjudication of the matter listed above, the Board will provide a brief, historical summary. In April 2008, January 2010, August 2011, October 2012, August 2013, and August 2014, the Board remanded the issue of service connection for hypertension for additional development. Additionally, in October 2015, the Board remanded to fulfill the Veteran's request for a Board hearing. Consequently, in October 2017, the Veteran, at his Board hearing, testified before the undersigned at a videoconference hearing. A transcript of that hearing is of record. Furthermore, in February 2018, the Board remanded the issues on appeal for updated VA examinations. Subsequently, after a November 2020 Supplemental Statement of the Case considered the record, this matter was returned to the Board for appellate consideration. The Board finds there has been substantial compliance with its prior remand directives as the RO obtained updated VA examinations for the issues on appeal. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, a November 2020 rating decision granted an increased rating of 20 percent for left and right upper extremity peripheral neuropathy, effective October 7, 2020. Although an increased rating was granted, the issues remain in appellate status as the maximum schedular rating had not been assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The Board, in February 2018, also remanded the issue of entitlement to service connection for gastroesophageal reflux disease (GERD). The November 2020 rating decision granted service connection for GERD, effective September 29, 2009. As such, this matter is no longer on appeal due to the full grant of the benefit sought and it will not be discussed. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate in this case. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Veteran is competent to report symptoms observable by sense and contemporaneous medical diagnoses, but not competent to diagnose or assess the etiology of complex medical disorders. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). The Board shall consider all information and lay and medical 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, the Board shall give the benefit of the doubt to the claimant. Id; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. An increased rating in excess of 20 percent for diabetes mellitus. The Veteran's service-connected diabetes mellitus is rated as 20 percent disabling in accordance with the General Rating Formula for the Endocrine System. 38 C.F.R. § 4.97, DC 7913. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is warranted when diabetes requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted for diabetes requiring 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. The Veteran contends that his diabetes mellitus type II is worse than reflected by his current evaluation of 20 percent. See 4/11/2005 VA 21-4138. A review of the Veteran's outpatient treatment records shows that he has been continuously treated for diabetes mellitus throughout the appeal period. Treatment has included regulation of diet and oral medication. There was no showing of the requirement for regulation of activities. A July 2005 VA diabetes examination documented that the Veteran followed a diabetic diet and was using an oral hypoglycemic medication. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions. There were not complications of diabetes mellitus. See 6/8/2005 VA Examination. The Veteran underwent another VA diabetes examination in August 2008. The examination showed that the Veteran followed a diabetic diet and was using an oral hypoglycemic medication. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions. There were not complications of diabetes mellitus. See 7/3/2008 VA Examination. An additional VA diabetes examination was conducted in December 2009. The examination showed that the Veteran followed a low sugar diet and was using an oral hypoglycemic medication. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions. There were not complications of diabetes mellitus. See 12/21/2009 VA Examination. A May 2012 VA diabetes examination showed that the Veteran did not follow a restricted diet and he used an oral hypoglycemic medication. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions. As complications of diabetes mellitus, the examination showed that he had diabetic peripheral neuropathy. See 5/1/2012 VA Examination. The most recent VA diabetes examination was conducted in October 2020. The Veteran did not follow a restricted diet and he used an oral hypoglycemic medication. His activities were not regulated. The Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions. As complications of diabetes mellitus, the examination showed that he had diabetic peripheral neuropathy and diabetic nephropathy or renal dysfunction. See 10/28/2012 VA Examination. The record also showed a private statement from Dr. N.A.O., M.D., from September 2009. It was noted that the Veteran was being treated with oral hypoglycemic medication and a restricted diet. See 9/29/2009 Medical Treatment Record Non-Government Facility. VA medical records show that in 2019 the Veteran only had hypoglycemic episodes when he delayed his meals and did not exercise. See 10/30/2020 CAPRI, at pages 569 and 724. After having carefully reviewed the evidence of record, the Board finds that the Veteran's symptoms of diabetes mellitus are already compensated by the current rating of 20 percent. In this regard, the evidence of record shows that the Veteran's diabetes mellitus is of such severity that it requires dietary restriction and oral hypoglycemic medication. The Board finds that the competent and probative evidence weighs against showing that Veteran has had regulation of activities as contemplated by the rating criteria. In this regard, the U.S. Court of Appeals for Veterans Claims has explained that the term "regulation of activities" means that a claimant must have a medical need to avoid not only strenuous occupational activity, but also strenuous recreational activity. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Medical evidence is required to show that occupational and recreational activities have been restricted. Id. at 364. None of the VA examinations from August 2008, December 2009, May 2012, or October 2020, or the statements from Dr. N.A.O., documented a regulation of activities. To the contrary, VA treatment records showed that in February 2012 the Veteran was encouraged to diet and exercise. Additionally, in February 2019 the Veteran was recommended to start exercising with a stationary bicycle for 30 minutes four to five times per week. See 5/13/2014 CAPRI, at page 131; see also 11/5/2020 CAPRI, at page 1349. As such, the weight of the competent and probative evidence weighs against a finding of regulation of activity. The evidence of record does not warrant a rating in excess of the 20 percent assigned for the Veteran's diabetes mellitus at any time during the period pertinent to this appeal. Finally, the Board has considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claim, the Board finds that this doctrine is not for application. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53. 2. An initial rating of 10 percent, but no higher, prior February 7, 2014, for left upper extremity diabetic peripheral neuropathy. 3. An initial compensable rating prior to May 1, 2012, a rating in excess of 10 percent prior February 7, 2014, and in excess of 20 percent, thereafter, for left upper extremity diabetic peripheral neuropathy. 4. An initial rating of 10 percent, but no higher, prior February 7, 2014, for right upper extremity diabetic peripheral neuropathy. 5. An initial compensable rating prior to May 1, 2012, a rating in excess of 10 percent prior February 7, 2014, and in excess of 20 percent, thereafter, for right upper extremity diabetic peripheral neuropathy. The Veteran is currently rated with a noncompensable rating from May 5, 2008, 10 percent from May 1, 2012, and 20 percent from October 7, 2020, for left and right upper extremity diabetic peripheral neuropathy under DC 8513. The rating criteria does not include an entry for diabetic peripheral neuropathy. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Diseases affecting the nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. §§ 4.123, 4.124, and 4.124a. Under Diagnostic Code 8513, a 20 percent rating is warranted for mild incomplete paralysis of all radicular groups. For moderate incomplete paralysis of all radicular groups, a 40 percent rating is warranted for the major extremity, and a 30 percent rating is warranted for the minor extremity. For severe incomplete paralysis of all radicular groups, a 70 percent rating is warranted for the major extremity, and a 60 percent rating is warranted for the minor extremity. For complete paralysis of all radicular groups, the maximum schedular rating of 90 percent is warranted for the major extremity, and an 80 percent rating is warranted for the minor extremity. 38 C.F.R. § 4.124a, DC 8513. The terms "major" and "minor" are used in the rating criteria to refer to the dominant or non-dominant upper extremity. 38 C.F.R. § 4.69. The term "incomplete paralysis" indicates a degree of impaired function substantially less than the type of picture for "complete paralysis" given for each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note. When the involvement is wholly sensory, the rating for incomplete paralysis should be for the mild, or, at most, the moderate degree. Id. VA guidance indicates that moderate incomplete paralysis will likely be described by the Veteran and medically graded as significantly disabling and may be demonstrated by combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. The Court recently held in Miller v. Shulkin that, "[a]lthough the note preceding § 4.124a directs the claims adjudicator to award no more than a 20% disability rating for incomplete paralysis of a peripheral nerve where the condition is productive of wholly sensory manifestations, it does not logically follow that any claimant who also exhibits non-sensory manifestations must necessarily be rated at a higher level." 28 Vet. App. 376, 380 (2017). The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating which may be assigned for neuritis not characterized by such organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Tic douloureux may be rated up to complete paralysis of the affected nerve. The Board notes that the record reflects that the Veteran is right hand dominant, to include as noted on the October 2020 VA examination report. After review of the competent and probative evidence, the Board finds that ratings in excess of 20 percent are not warranted. Prior to May 1, 2012 The Veteran was afforded a VA examination in August 2008. The objective examination showed that the Veteran had normal muscle strength, reflexes, and sensation, and no pain or atrophy. See 7/8/2008 VA Examination. These competent medical findings tend to weigh against a compensable rating for the period prior to May 1, 2012. Prior to February 7, 2014 The record also showed a VA examination from May 2012. The Veteran reported symptoms, such as moderate paresthesias and/or dysesthesias, and numbness in his upper extremities. Additionally, he had normal muscle strength, reflexes, position sense and sensation, and no atrophy or trophic changes. Further, the examiner reported normal radial, median, and ulnar nerves upon examination. See 5/1/2012 VA Examination. Overall, these competent medical findings tend to weigh against a rating higher than 10 percent for the period prior to February 7, 2014. The currently assigned10 percent rating contemplates the Veteran's upper extremity neurologic symptomatology for this time period. As of February 7, 2014 An additional VA examination from February 2014 showed mild paresthesias and/or dysesthesias, and numbness in his upper extremities. Additionally, he had normal muscle strength and deep tendon testing, and no atrophy or trophic changes. Further, the examiner reported mild incomplete paralysis. See 2/7/2014 VA Examination. The most recent VA examination from October 2020 showed symptoms, such as moderate intermittent pain, paresthesias and/or dysesthesias, and numbness in his upper extremities. Moreover, the objective examination showed that he had normal muscle strength and deep tendon testing, and no atrophy. He had decreased light touch testing for his hands and fingers, decreased vibration, and his position sense was normal. His cold sensation was not tested. Additionally, as trophic changes, he had bilateral upper extremity loss of extremity hair. Further, the Board acknowledges that the examiner reported mild incomplete paralysis. See 10/28/2020 C&P Examination. As such, the Board finds that the competent and probative evidence weighs against a rating higher than 20 percent for mild incomplete paralysis in the dominant upper extremity and against a rating higher than 20 percent for mild incomplete paralysis in his non-dominant upper extremity. The evidence does not show severe paralysis as he had normal strength and no atrophy. Additionally, clinical examination revealed no more than moderate paresthesias and/or dysesthesias, and numbness. Accordingly, the Board finds that the preponderance of the evidence is against the appeal for ratings in excess of 20 percent and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 6. An initial increased rating in excess of 10 percent prior February 7, 2014, and in excess of 20 percent, thereafter, for left lower extremity diabetic peripheral neuropathy. 7. An initial increased rating in excess of 10 percent for right lower extremity peripheral neuropathy. The Veteran is currently rated at 10 percent from February 7, 2014, for right lower extremity diabetic peripheral neuropathy under DC 8521. Additionally, the Veteran is currently rated at 10 percent from April 11, 2025, and at 20 percent from February 7, 2014, thereafter, for left lower extremity diabetic peripheral neuropathy under DC 8526. Under Diagnostic Code 8521, a 10 percent rating is warranted for mild incomplete paralysis and a 20 percent rating is warranted for moderate incomplete paralysis of the femoral nerve. 38 C.F.R. § 4.124a, DC 8521. A 30 percent evaluation is warranted for severe incomplete paralysis of the femoral nerve. Id. A 40 percent rating is available for complete paralysis (evidenced by foot drop and slight droop 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; anesthesia covers entire dorsum of foot and toes). Id. Under Diagnostic Code 8526, a 10 percent rating is warranted for mild incomplete paralysis and a 20 percent rating is warranted for moderate incomplete paralysis of the femoral nerve. 38 C.F.R. § 4.124a, DC 8526. A 30 percent evaluation is warranted for severe incomplete paralysis of the femoral nerve. Id. A 40 percent rating is available for complete paralysis evidenced by paralysis of quadriceps extensor muscles. Id. The Board will consider all applicable diagnostic codes. In this regard, DC 8522 applies to musculocutaneous (superficial peroneal) nerve and provides for a non-compensable rating for mild incomplete paralysis, a rating of 10 percent for moderate incomplete paralysis, a rating of 20 percent for severe incomplete paralysis, and a rating of 30 percent for complete paralysis of the nerve with eversion of the foot weakened. DC 8523, for the anterior tibial (deep peroneal) nerve, provides for a non-compensable rating for mild incomplete paralysis, a rating of 10 percent for moderate incomplete paralysis, a rating of 20 percent for severe incomplete paralysis, and a 30 percent rating is assigned for complete paralysis of the nerve with dorsal flexion of the foot lost. DC 8524, for the internal popliteal (tibial) nerve, provides for a rating of 10 percent for mild incomplete paralysis, a rating of 20 percent for moderate incomplete paralysis, a rating of 30 percent for severe incomplete paralysis, and a 40 percent rating is assigned for complete paralysis (plantar flexion lost, frank adduction of foot impossible, flexion and separation of toes abolished; no muscle in sole can move; in lesions of the nerve high in popliteal fossa, plantar flexion of foot is lost). DC 8525, for the posterior tibial nerve, provides for a rating of 10 percent for mild incomplete paralysis, a rating of 20 percent for moderate incomplete paralysis, a rating of 30 percent for severe incomplete paralysis, and a 40 percent rating is assigned for complete paralysis (paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; plantar flexion is impaired). The words "mild," "moderate," and "severe" as used in the various DCs are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given to loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). While separate ratings may be assigned for symptoms associated with different nerves, more than one rating assigned to the same symptoms is not permissible. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). After review of the competent and probative evidence, the Board finds that a rating in excess of 20 percent for the left lower extremity and of 10 percent for the right lower extremity are not warranted. Prior to February 7, 2014 for the left lower extremity A July 2005 VA examination showed that the Veteran had mild tenderness to palpation in the left sacral area. See 6/4/2005 VA Examination. The Board notes that the July 2005 rating decision granted the claim due to the Veteran's sensory manifestations during the July 2005 VA examination. These manifestations tend to be wholly sensory manifestations. As such, the Board finds that a rating in excess of 10 percent for left lower extremity diabetic peripheral neuropathy is not warranted for the period prior to February 7, 2014. As of February 7, 2014, for the left and right lower extremities During a February 2014 VA examination, the Veteran's symptoms included mild right lower extremity and moderate left lower extremities numbness and paresthesias and/or dysesthesias. The objective examination showed that the Veteran had normal strength, reflexes, and for his knees/thighs, ankles/lower legs, feet/toes, and left anterior thigh, his light touch testing was decreased. The examiner reported mild incomplete paralysis for the right lower extremity and moderate incomplete paralysis for the left lower extremity. See 2/7/2014 VA Examination. The most recent VA examination was in October 2020. The Veteran reported symptoms, such as moderate bilateral lower extremity intermittent pain, numbness, and paresthesias and/or dysesthesias. The objective examination showed that the Veteran had normal strength, no atrophy, and decreased bilateral ankle reflexes and decreased bilateral lower extremity position sense and vibration sensation. The examiner reported mild incomplete paralysis for the bilateral lower extremities. See 10/28/2020 C&P Examination. The Board finds that the Veteran's symptoms are already compensated by the current 20 percent rating for moderate incomplete paralysis of the left lower extremity and the 10 percent rating for mild incomplete paralysis of the right lower extremity as of February 7, 2014. Additionally, the Board finds that higher ratings of 30 percent for the left lower extremity and of 20 percent for the right lower extremity are not warranted. The February 2014 VA examiner, after taking relevant medical history and performing a physical examination, concluded that the Veteran had moderate incomplete paralysis of the left lower extremity and mild incomplete paralysis of the right lower extremity. Moreover, the Veteran's examinations and treatment records do not show severe incomplete paralysis for the left lower extremity or moderate incomplete paralysis for the right lower extremity during the period on appeal. As such, the evidence reflects the Veteran has moderate incomplete paralysis of the left lower extremity and mild incomplete paralysis of the right lower extremity. Service Connection Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.30(d). Service connection generally requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). The Veteran is competent to report symptoms and experiences observable by his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). 8. Service connection for cystopathy, to include as due to diabetes mellitus. 9. Service connection for gastroparesis, to include as due to diabetes mellitus. 10. Service connection for peripheral vascular disease, to include as due to diabetes mellitus. 11. Service connection for nephropathy, to include as due to diabetes mellitus. The Veteran contends service connection for cystopathy, gastroparesis, peripheral vascular disease, and nephropathy. Specifically, the Veteran contends that his disabilities were caused by his service-connected diabetes mellitus. See 10/30/2017 Hearing Transcript, at page 10; see also 9/29/2009 Medical Treatment Record Non-Government Facility, at page 1. Here, the Veteran's treatment records lack a diagnosis of cystopathy, gastroparesis, peripheral vascular disease, or nephropathy. Regarding cystopathy, gastroparesis, and nephropathy, after service, the record shows no complains and no indication of any symptoms that functionally impair the Veteran's earning capacity. Regarding the peripheral vascular disease, although the Veteran, at his Board hearing, testified to "numbness and sleeping" of the lower extremities, the record showed no diagnosis for such a disability. See 10/30/2017 Hearing Transcript, at page 7. Accordingly, the Board finds that the preponderance of the evidence weighs against a finding that the Veteran has a current diagnosis of cystopathy, gastroparesis, peripheral vascular disease, or nephropathy. The Veteran underwent a VA examination in October 2020 for various disabilities, to include cystopathy, gastroparesis, peripheral vascular disease, and nephropathy. The examiner, after an in-person examination and recording of pertinent medical history, competently, credibly, and persuasively found that the Veteran had no current or past diagnosis of cystopathy, gastroparesis, peripheral vascular disease, or nephropathy. Additionally, the examiner found no functional impact on the Veteran's ability to work. The Board acknowledges that pain alone can constitute a "disability" under § 1110, because pain can cause functional impairment. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). Here, however, the competent and probative evidence, to include post-service treatment records and the October 2020 VA examination report do not tend to support a finding of functional impairment of earning capacity. The Board acknowledges the Veteran's reports that he has cystopathy, gastroparesis, peripheral vascular disease, and nephropathy. However, as a lay person without medical training or expertise, he is not competent to say that he has cystopathy or nephropathy, complex medical issues concerning the body's genitourinary system that does not lend itself to lay opinion, or gastroparesis, a complex medical issue concerning the body's digestive system that does not lend itself to lay opinion, or peripheral vascular disease, a complex medical issue concerning the body's neurological system that does not lend itself to lay opinion. The Veteran has not been shown to have the knowledge, and/or expertise necessary to diagnose such complex medical issues. Therefore, the Veteran's statements that he has cystopathy, gastroparesis, peripheral vascular disease, and nephropathy are not considered competent evidence demonstrating a current disability and lack weight. See Jandreau, 492 F.3d at 1377. The Board affords more probative value to the October 2020 VA examiner's competent, contrary findings that the Veteran has no current or past diagnosis of cystopathy, gastroparesis, peripheral vascular disease, or nephropathy. The competent medical finding is worthy of high weight as is based on a thorough review of the Veteran's medical history and clinical examinations. As such, this competent evidence outweighs the Veteran's non-competent self-diagnosis of cystopathy, gastroparesis, peripheral vascular disease, and nephropathy. Thus, based on the evidence above, the Board finds that, while the Veteran asserts service connection for cystopathy, gastroparesis, peripheral vascular disease, and nephropathy, the more probative evidence weighs against finding that the Veteran has current diagnoses of cystopathy, gastroparesis, peripheral vascular disease, or nephropathy, or that such diagnoses began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection claims require that the Veteran have a current disability. 38 U.S.C. § 1110. The claimant satisfies the current disability requirement when the claimant has a disability proximate to the filing of a claim for VA benefits or has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). For the reasons explained above, this has not been met here. The preponderance of the evidence weighs against finding that the Veteran has cystopathy, gastroparesis, peripheral vascular disease, and nephropathy; therefore, the service connection claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 12. Service connection for OSA. The Veteran contends service connection for OSA. At the outset, the Board notes that the Veteran had a polysomnography, which showed a diagnosis of mild-moderate OSA. See 12/10/2012 STR Medical Photocopy, at pages 12 and 14. Therefore, the first element of service connection is met. The Board will now analyze whether service connection is warranted by analyzing the second and third elements of service connection. As to the second element of service connection, the Veteran, at his Board hearing, testified that his OSA disability was due to his service-connected diabetes mellitus based on the observation that he did not have OSA prior to developing diabetes. See 10/30/2017 Hearing Transcript, at pages 14 and 15. The Veteran is service connected for diabetes mellitus. Thus, the second element of service connection has been met. The question before the Board therefore becomes whether there is a so-called "nexus" between the Veteran's current OSA disability and service. After reviewing the relevant medical and lay evidence, the Board finds that the competent and probative evidence tends to weigh against a finding that the Veteran's OSA disability is proximately due to or aggravated by a service-connected disability. The Veteran underwent a VA sleep apnea examination in October 2020. At the conclusion of the examination, the examiner opined that the Veteran's OSA was less likely than not incurred in service or due to the presumed herbicide agent exposure. Additionally, the examiner opined that the Veteran's OSA was less likely than not due to his service-connected disabilities. As rationale, the examiner stated that OSA and his service-connected disabilities are different entities with different pathophysiological processes unrelated to each other. The examiner further stated that the medical literature did not support a causal relationship between OSA and his service-connected disabilities. See 10/29/2020 C&P Examination. The record showed a private opinion by Dr. N.A.O., M.D., which stated that the Veteran's OSA was more probable than not due to his active duty. Additionally, Dr. N.A.O., stated that "it is more probable than not that his disability is related to his service-connected diabetes mellitus." However, the Board finds the opinion to be too speculative as it lacks a rationale to support a grant of service connection. In this regard, the Board notes that a mere conclusion without an underlying rationale is of no probative value. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board finds the October 2020 VA opinion to be highly persuasive and worthy of much weight regarding the issue of whether the Veteran's current OSA disability is related to service. The Board finds that the rationale is logically supported, based on familiarity with the Veteran's relevant medical history, and deserves great weight. Additionally, the Board places great probative weight on the October 2020 VA opinion in this case, as it is consistent with the evidence of record and based upon medical knowledge and skill, as well as a review and analysis of the Veteran's specific disability picture, to include consideration of relevant facts such as the post-service medical record. The Board also acknowledges the lay statements from the Veteran. Such statements assert that the Veteran's OSA was due to his service-connected diabetes mellitus based on the observation that he did not have OSA prior to developing diabetes. See 10/30/2017 Hearing Transcript, at pages 14 and 15. The Veteran is certainly competent to report his symptoms. However, the Veteran is not competent to attribute his symptoms to the service-connected diabetes mellitus as the record does not reflect that he has medical training and/or experience. Therefore, the Veteran's opinion on the etiology of the current OSA disability is not competent and it lacks weight. The competent medical evidence, such as the October 2020 medical opinion, heavily outweigh the Veteran's opinion and tend to show that the Veteran's OSA disability was not due to service. As discussed above, the Board finds this opinion to be probative and deserving weight as there is a supporting rationale why, to include reference to relevant facts in the record. In sum, service connection for OSA is not warranted, to include on various theories of entitlement. As the preponderance of the evidence is against the claim, reasonable doubt does not arise, and the claim is denied. 38 U.S.C. § 5107(b). 13. Service connection for IBS. The Veteran contends service connection for IBS. At the outset, the Board notes that the Veteran was diagnosed with IBS. See 10/29/2020 C&P Examination. Therefore, the first element of service connection is met. The Board will now analyze whether service connection is warranted by analyzing the second and third elements of service connection. As to the second element of service connection, at his Board hearing, the Veteran testified that his IBS was secondary to the medications for his service-connected diabetes and acquired psychiatric disorder. See 10/30/2017 Hearing Transcript, at page 5. The Veteran is service connected for diabetes mellitus and an acquired psychiatric disorder. Thus, the second element of service connection has been met. The question before the Board therefore becomes whether there is a so-called "nexus" between the Veteran's current IBS disability and service. After reviewing the relevant medical and lay evidence, the Board finds that the competent and probative evidence tends to weigh against a finding that the Veteran's IBS disability is proximately due to or aggravated by a service-connected disability. The Veteran underwent a VA intestinal condition examination in October 2020. At the conclusion of the examination, the examiner opined that the Veteran's IBS was less likely than not incurred in service or due to the presumed herbicide agent exposure. Additionally, the examiner opined that the Veteran's IBS was less likely than not due to his service-connected disabilities or due to the medication for his service-connected disabilities. As rationale, the examiner stated that OSA and his service-connected disabilities are different entities with different pathophysiological processes unrelated to each other. The examiner further stated that the medical literature did not support a causal relationship between IBS and his service-connected disabilities. The examiner further stated that the medical literature did not support a causal relationship between IBS and the chronic medication for the service-connected diabetes and acquired psychiatric disorder. See 10/29/2020 C&P Examination. The Board finds the October 2020 VA opinion to be highly persuasive and worthy of much weight regarding the issue of whether the Veteran's current IBS disability is related to service. The Board finds that the rationale is logically supported, based on familiarity with the Veteran's relevant medical history, and deserves great weight. Additionally, the Board places great probative weight on the October 2020 VA opinion in this case, as it is consistent with the evidence of record and based upon medical knowledge and skill, as well as a review and analysis of the Veteran's specific disability picture, to include consideration of relevant facts such as the post-service medical record. The Board also acknowledges the lay statements from the Veteran. Such statements assert that the Veteran's IBS is secondary to the medications for his service-connected diabetes and acquired psychiatric disorder. See 10/30/2017 Hearing Transcript, at page 5. The Veteran is certainly competent to report his symptoms. However, the Veteran is not competent to attribute his symptoms to the service-connected diabetes mellitus or acquired psychiatric disorder, as the record does not reflect that he has medical training and/or experience. Therefore, the Veteran's opinion on the etiology of the current IBS disability is not competent and it lacks weight. The competent medical evidence, such as the October 2020 medical opinion, heavily outweigh the Veteran's opinion and tend to show that the Veteran's IBS disability was not due to service. As discussed above, the Board finds this opinion to be probative and deserving weight as there is a supporting rationale why, to include reference to relevant facts in the record. In sum, service connection for IBS is not warranted, to include on various theories of entitlement. As the preponderance of the evidence is against the claim, reasonable doubt does not arise, and the claim is denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Service connection for hypertension, to include as due to herbicide exposure and due to diabetes mellitus. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends that his service-connected diabetes mellitus has aggravated his hypertension beyond its natural progression. See 12/12/2005 VA 21-4138. In the alternative, the Veteran contends that his hypertension was due to exposure to herbicide agents. See 1/6/2012 VA 21-4138. The record shows that exposure to herbicide agents is presumed. See 9/4/2002 Rating Decision, at page 2. Although hypertension is not on the list of disabilities presumed to be related to herbicide agent exposure (38 C.F.R. § 3.309(e)), direct service connection may be warranted. 38 U.S.C. § 1113(b); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In accordance with the February 2018 Board remand, the Agency of Original Jurisdiction (AOJ) obtained an October 2020 medical opinion. However, this medical opinion did not provide an adequate rationale regarding whether the Veteran's hypertension is related to his exposure to herbicide agents. At the conclusion of the October 2020 VA examination, the examiner opined that the Veteran's hypertension was less likely than not related to an in-service injury, event, or disease. Additionally, the examiner opined that hypertension was not listed as one of the presumed disabilities due to herbicide agent exposure. Further, the examiner opined that the Veteran's hypertension was not proximately due or aggravated by the Veteran's service-connected disabilities because hypertension and his service-connected disabilities are different entities with different pathophysiological processes unrelated to each other. The examiner added that the medical literature did not support a causal relationship between hypertension and his service-connected disabilities. However, the Board finds this opinion inadequate. As mentioned above, the examiner stated that hypertension was not listed as one of the presumed disabilities due to herbicide agent exposure. However, he did not directly discuss exposure to herbicide agents as a factor for hypertension or the 2018 NAS report, as instructed by the prior February 2018 Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). Thus, the Board finds that an addendum opinion is required for clarification of the opinion provided before an adjudication on the merits. The Board notes that the National Academy of Sciences (NAS) has found that there is "limited or suggestive evidence of an association between" hypertension and exposure to herbicide agents (such as Agent Orange) based on a recent statistical study. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2012, 79 Fed. Reg. 20,308 (Apr. 11, 2014); see also 38 U.S.C. § 1116(b) (2012). The category "limited or suggestive evidence of an association" means that the "evidence suggests an association between exposure to herbicide agents and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence." Id. A more recent study by NAS released on November 15, 2018, concluded that after an examination of the literature that had been previously reviewed with the additional new evidence, the committee determined that there is sufficient evidence of an association between at least one of the chemical of interest and hypertension. Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 2018, at 498, available at https://www.nap.edu/read/25137. The Board finds that the suggestive evidence of an association between hypertension and herbicide exposure is also sufficient to establish an "indication" that the current disability "may be related" to herbicide exposure during service, as contemplated by 38 U.S.C. § 5103A(d)(2)(B). The Court of Appeals for Veterans Claims has described the threshold of the statute as being low. McLendon v. Nicholson, 20 Vet. App. 79, at 83. Therefore, considering the aforementioned, the Board finds a remand is necessary. This matter is REMANDED for the following actions: 1. Update any outstanding VA treatment records. All requests and responses for the records must be documented. If any identified records cannot be obtained, notify the Veteran of the missing records, the efforts taken, and any further efforts that will be made by VA to obtain such evidence, and allow him an opportunity to provide the missing records. 2. After completing step #1, return the claims file to the examiner who conducted the October 2020 examination and authored the opinion. The clinician is to review the virtual file, including a copy of this Remand. After review of the claims file, the examiner is to specifically address: Whether it is at least as likely as not that the Veteran's hypertension is related to an in-service injury, event, or disease, to include presumed exposure to herbicide agents. **The examiner must address the significance of the NAS 2018 publication "Veterans & Agent Orange: Update 2018," on whether the Veteran's hypertension was caused by his presumed exposure to herbicide agents, such as Agent Orange.** If the October 2020 examiner is no longer available, then the claims file and the October 2020 examination report and opinion should be forwarded to another examiner of at least equal qualifications to obtain the requested opinion. A new physical examination is not required unless deemed necessary by the clinician. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. (Continued on the next page) If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.F., Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.