Citation Nr: 22013333 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 14-07 347 DATE: March 9, 2022 ORDER Entitlement to an evaluation in excess of 10 percent from September 12, 2011 to June 14, 2017 for right lower extremity (RLE) peripheral neuropathy is denied. A 40 percent evaluation from June 15, 2017 to the present for RLE peripheral neuropathy is granted. Entitlement to an evaluation in excess of 10 percent from September 12, 2011 to June 14, 2017 for left lower extremity (LLE) peripheral neuropathy is denied. A 40 percent evaluation from June 15, 2017 to November 26, 2018 for LLE peripheral neuropathy is granted. Entitlement to an evaluation in excess of 40 percent from November 27, 2018 to the present for LLE peripheral neuropathy is denied. A 10 percent evaluation from September 12, 2011 to November 26, 2018 for right upper extremity (RUE) peripheral neuropathy of the ulnar nerve is granted. A 50 percent evaluation from November 27, 2018 to the present for RUE peripheral neuropathy of the radial nerve is granted. A separate 40 percent evaluation from November 27, 2018 to the present for RUE peripheral neuropathy of the ulnar nerve is granted. A 10 percent evaluation from September 12, 2011 to November 26, 2018 for left upper extremity (LUE) peripheral neuropathy of the ulnar nerve is granted. A 40 percent evaluation from November 27, 2018 to the present for LUE peripheral neuropathy of the radial nerve is granted. A separate 30 percent evaluation from November 27, 2018 to the present for LUE peripheral neuropathy of the ulnar nerve is granted. REMANDED Entitlement to an initial evaluation in excess of 10 percent from September 12, 2011 to November 26, 2018, and an initial evaluation in excess of 50 percent from November 27, 2018 to the present, for unspecified anxiety disorder and unspecified depressive disorder is remanded. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. From September 12, 2011 to June 14, 2017, the Veteran's RLE peripheral neuropathy more closely approximates mild incomplete paralysis of the sciatic nerve. 2. Resolving all reasonable doubt in favor of the Veteran, from June 15, 2017 to the present, his RLE peripheral neuropathy more closely approximates moderately severe incomplete paralysis of the sciatic nerve. 3. From September 12, 2011 to June 14, 2017, the Veteran's LLE peripheral neuropathy more closely approximates mild incomplete paralysis of the sciatic nerve. 4. Resolving all reasonable doubt in favor of the Veteran, from June 15, 2017 to November 26, 2018, his LLE peripheral neuropathy more closely approximates moderately severe incomplete paralysis of the sciatic nerve. 5. From November 27, 2018 to the present, the Veteran's LLE peripheral neuropathy more closely approximates moderately severe incomplete paralysis of the sciatic nerve. 6. Resolving all reasonable doubt in favor of the Veteran, from September 12, 2011 to November 26, 2018, his RUE peripheral neuropathy more closely approximates mild incomplete paralysis of the ulnar nerve. 7. Resolving all reasonable doubt in favor of the Veteran, from November 27, 2018 to the present, his RUE peripheral neuropathy more closely approximates severe incomplete paralysis of the radial nerve. 8. Resolving all reasonable doubt in favor of the Veteran, from November 27, 2018 to the present, his RUE peripheral neuropathy more closely approximates severe incomplete paralysis of the ulnar nerve. 9. Resolving all reasonable doubt in favor of the Veteran, from September 12, 2011 to November 26, 2018, his LUE peripheral neuropathy more closely approximates mild incomplete paralysis of the ulnar nerve. 10. Resolving all reasonable doubt in favor of the Veteran, from November 27, 2018 to the present, his LUE peripheral neuropathy more closely approximates severe incomplete paralysis of the radial nerve. 11. Resolving all reasonable doubt in favor of the Veteran, from November 27, 2018 to the present, his LUE peripheral neuropathy more closely approximates severe incomplete paralysis of the ulnar nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation in excess of 10 percent from September 12, 2011 to June 14, 2017 for RLE peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Codes 8520, 8620. 2. The criteria for a 40 percent evaluation from June 15, 2017 to the present for RLE peripheral neuropathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Codes 8520, 8620. 3. The criteria for entitlement to an evaluation in excess of 10 percent from September 12, 2011 to June 14, 2017 for LLE peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8520, 8620. 4. The criteria for a 40 percent evaluation from June 15, 2017 to November 26, 2018 for LLE peripheral neuropathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8520. 5. The criteria for entitlement to an evaluation in excess of 40 percent from November 27, 2018 to the present for LLE peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8520. 6. The criteria for a 10 percent evaluation from September 12, 2011 to November 26, 2018 for RUE peripheral neuropathy of the ulnar nerve have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Codes 8513, 8516. 7. The criteria for a 50 percent evaluation from November 27, 2018 to the present for RUE peripheral neuropathy of the radial nerve have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Codes 8513, 8514. 8. The criteria for a separate 40 percent evaluation from November 27, 2018 to the present for RUE peripheral neuropathy of the ulnar nerve have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Codes 8513, 8516. 9. The criteria for a 10 percent evaluation from September 12, 2011 to November 26, 2018 for LUE peripheral neuropathy of the ulnar nerve have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8514. 10. The criteria for a 40 percent evaluation from November 27, 2018 to the present for LUE peripheral neuropathy of the radial nerve have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Codes 8514, 8516. 11. The criteria for a separate 30 percent evaluation from November 27, 2018 to the present for LUE peripheral neuropathy of the ulnar nerve have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8514. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1967 to June 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Jurisdiction of the case is now before the RO in Huntington, West Virginia. In the April 2012 rating decision, the RO, in pertinent part, granted service connection for anxiety disorder and assigned a 10 percent evaluation, effective September 12, 2011; denied a higher than 10 percent evaluation for RLE peripheral neuropathy; denied a higher than 10 percent evaluation for LLE peripheral neuropathy; denied a compensable evaluation for RUE peripheral neuropathy; and denied a compensable evaluation for LUE peripheral neuropathy. The Veteran appealed for higher evaluations. The Veteran testified before a Veterans Law Judge (VLJ) at a November 2017 Travel Board hearing. A transcript of this hearing is of record. In May 2018, the Board, in pertinent part, found that the issue of entitlement to a TDIU had been raised by the record under Rice v. Shinseki, 22 Vet. App. 447 (2009) and remanded the issues on appeal for additional development. As the actions specified in the remand have been substantially completed, the matters have been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). During the pendency of the appeal, the RO issued a January 2019 rating decision granting a 50 percent evaluation for unspecified anxiety disorder, effective November 27, 2018; granting a 40 percent evaluation for LLE peripheral neuropathy, effective November 27, 2018; granting a 40 percent evaluation for RUE peripheral neuropathy, effective November 27, 2018; granting a 20 percent evaluation for LUE peripheral neuropathy, effective November 27, 2018; and denying entitlement to a TDIU. The Veteran continued to appeal for higher evaluations and entitlement to a TDIU. AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claimant is presumed to be seeking the maximum rating). The Veteran was notified that the VLJ who held his November 2017 hearing was no longer employed by the Board. 38 C.F.R. § 20.604. In January 2019, the Veteran requested another hearing before a VLJ. The Veteran testified before the undersigned Veterans Law Judge at an October 2021 Virtual hearing. A transcript of this hearing is of record. In October 2021, the Veteran submitted additional evidence in support of his appeal along with a signed waiver of RO consideration of evidence. The Board accepts this evidence for inclusion in the record. See 38 C.F.R. § 20.1305. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Evaluation 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 rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. The veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14. VA is required to evaluate the Veteran's disability under the most appropriate rating criteria that will provide the most benefit to the Veteran. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). 1. Entitlement to an evaluation in excess of 10 percent for RLE peripheral neuropathy 2. Entitlement to an evaluation in excess of 10 percent from September 12, 2011 to November 26, 2018, and an evaluation in excess of 40 percent from November 27, 2018 to the present, for LLE peripheral neuropathy The Veteran asserts that his RLE and LLE peripheral neuropathy are worse than his current evaluations reflect. During the relevant appeal period, the Veteran's RLE peripheral neuropathy has been currently evaluated as 10 percent disabling, effective February 9, 2005, under 38 C.F.R. § 4.124a, Diagnostic Code 8620 for neuritis of the sciatic nerve. The Veteran's LLE peripheral neuropathy has been currently evaluated as 10 percent disabling, effective February 9, 2005, and as 40 percent disabling, effective November 27, 2018, under 38 C.F.R. § 4.124a, Diagnostic Codes 8520, 8620. Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve, and therefore, neuritis and neuralgia of that nerve. 38 U.S.C. § 4.124a, Diagnostic Code 8520. Disability ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis, which is mild, moderate, or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Words such as "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Additionally, 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. 38 C.F.R. § 4.124a, Note at Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. Id. At a February 2012 VA examination, the Veteran reported having dull pain, numbness, tingling, and weakness in his lower extremities. The Veteran had reported having numbness in his heels. Following an objective evaluation, the February 2012 VA examiner found that the Veteran had normal muscle strength and normal reflexes, except decreased at ankles bilaterally. He also had normal light touch/monofilament, position sense, and cold sensation testing results bilaterally. He had normal vibration sensation testing results, except decreased at RLE. The February 2012 VA examiner found that the Veteran had lower extremity diabetic peripheral neuropathy, but the February 2012 VA examiner did not identify the severity of the neuropathy. The February 2012 VA examiner determined that the Veteran had a sensory neuropathy with no motor paralysis. VA treatment records from 2012 to 2013 document the Veteran's complaints of bilateral lower extremity (BLE) peripheral neuropathy symptoms. At an April 2012 VA clinic visit, the VA treating physician found that the Veteran had slightly impaired sensation on his heels. At an October 2012 VA clinic visit, the Veteran reported being very concerned by the neuropathy in his legs as it caused pain, numbness, and tingling. At a September 2013 VA clinic visit, the VA treating physician found that the Veteran had no actual weakness or sensory abnormality, which was noted upon objective examination of his lower extremities and no atrophy of his muscles. The VA treating physician did note slightly impaired sensation on the Veteran's heels. An October 2014 electromyography (EMG)/nerve conduction studies (NCS) report revealed that the Veteran's left sural nerve potential was absent, which was consistent with neuropathy, but all of the other nerve conditions in his legs were normal. There was no denervation. At an October 2014 private clinic visit, the Veteran complained of shooting pains in his legs. VA treatment records from 2017 to 2018 document the Veteran's worsening symptoms of BLE peripheral neuropathy. The Veteran sought treatment for painful diabetic neuropathy who was now experiencing balance issues. A lower extremity examination revealed normal dorsalis pedis (DP) and posterior tibial (PT) pulses bilaterally, no hair growth, warm skin temperature, and no edema or claudication. A neurologic evaluation revealed paresthesia and burning. Monofilament and vibratory testing results were absent bilaterally. The VA treating physician found that the Veteran had loss of protective sensation on his distal plantar and had some sensation on his dorsal foot bilaterally. The Veteran was prescribed contract shoes and accommodative insoles. See June 2017 and April 2018 VA treatment records. According to an October 2017 letter from the Veteran's private physician, Dr. M.S., she explained that the Veteran had peripheral neuropathy which interfered with his ability to have normal sensation in his feet and caused constant pain. In November 2017, the Veteran submitted a document identifying the rating schedule under 38 C.F.R. § 4.124a in which a physician was directed to identify the particular ratings for the Veteran's BLE peripheral neuropathy. Dr. M.S. placed notations on the document for moderate incomplete paralysis of the sciatic nerve, moderate incomplete paralysis of the external popliteal nerve, severe incomplete paralysis of the musculocutaneous nerve, severe incomplete paralysis of the anterior tibial nerve, severe incomplete paralysis of the posterior tibial nerve, mild incomplete paralysis of the anterior crural nerve, mild to moderate paralysis of the internal saphenous nerve, mild to moderate paralysis of the obturator nerve, severe to complete paralysis of the external cutaneous nerve of thigh, and mild to moderate paralysis of ilio-inguinal nerve. Dr. M.S. did not provide any clinical findings associated with her notations. Dr. M.S. wrote that the Veteran had fallen twice in the last week due to foot drop and had decreased sensation of the feet. At the November 2017 Board hearing, the Veteran testified that due to his BLE peripheral neuropathy, he had problems walking and used a cane. He said that without his cane, he would fall. In one week, he fell about four or five times. He described how he had no feeling in his heels, his toes, or the top of his feet, and that the feel felt as it if they were asleep. He said that if he was poked with a pin on his feet, he would not feel it. The diabetic shoes he was prescribed helped with the falling, but he said that they did not help with the "knifing pain in [his] toes." At a November 2018 VA examination, the Veteran reported having constant pain in the LLE and numbness and tingling that began in the left heel and radiated up. He reported how he fell three times per week. His symptoms were aggravated by prolonged sitting. He was unable to stand or walk for prolonged periods. The November 2018 VA examiner found that the Veteran had moderate constant pain, moderate paresthesias and/or dysesthesias, and moderate numbness bilaterally. Muscle strength was at 4/5 bilaterally. There was no muscle atrophy. His reflexes were 1+ at his ankles. Sensory examination results were normal bilaterally. The Veteran had trophic changes, which was exhibited by smooth BLE where loss of hair was noted. The Veteran had an antalgic gait and used a cane due to the neuropathy in his BLE. The November 2018 VA examiner determined that the Veteran had moderately severe incomplete paralysis of the left sciatic nerve. No paralysis was found on the right side. At the October 2021 Board hearing, the Veteran testified that his left leg symptoms were the same as his right leg symptoms. He described how his BLE peripheral neuropathy affected his ability to walk, his ability to feel his feet, and his balance, which caused him to walk with a cane prescribed by a doctor. He said that his doctors were concerned with the circulation in his legs and prescribed him special shoes and inserts, but they did not provide relief. Due to his bilateral leg problems, he had fallen 40 to 50 in the last few years, because he had no feeling in his legs and lost his balance. As a preliminary matter, the Board recognizes the findings of Dr. M.S. that were submitted in November 2017, in which she indicated several of the Veteran's lower extremity nerves were affected by his BLE peripheral neuropathy. However, in making those notations, Dr. M.S. did not support her conclusions with any clinical evidence. Therefore, the Board concludes that the notations are insufficient for rating purposes and provide no probative value. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Based on a careful review of all the subjective and clinical evidence, the Board finds that from September 12, 2011 to June 14, 2017, the Veteran's RLE and LLE peripheral neuropathy do not warrant a 20 percent evaluation under Diagnostic Code 8520. In other words, during the relevant appeal period, the most persuasive evidence does not demonstrate that the Veteran's RLE and LLE peripheral neuropathy are more appropriately characterized as moderate incomplete paralysis of the sciatic nerve. On that basis, the Board recognizes that at his February 2012 VA examination, the Veteran had numbness in his heels, however, during VA clinic visits in 2012 and 2013, his heels were characterized as "slightly impaired." Moreover, at the time, the Veteran did not indicate the numbness in his heels impacted his ability to walk or stand. Finally, the results of an October 2014 EMG/NCS study were normal in his legs, except for absent left sural nerve potential, which was consistent with neuropathy, and there was no denervation. Given the above reported symptomatology without an associated functional decline coupled with the clinical findings, the Board concludes that from September 12, 2011 to June 14, 2017, the evidence does not support finding that the Veteran's RLE and LLE peripheral neuropathy demonstrate more than mild incomplete paralysis of the sciatic nerve. Therefore, the Board finds that there is no basis upon which to award higher 20 percent evaluations under Diagnostic Code 8520. Accordingly, from September 12, 2011 to June 14, 2017, the Veteran's RLE and LLE peripheral neuropathy are each no more than 10 percent disabling. However, resolving all reasonable doubt in favor of the Veteran, from June 15, 2017 to the present, the Veteran's RLE peripheral neuropathy warrants a higher 40 percent evaluation under Diagnostic Code 8520. Similarly, from June 15, 2017 to November 26, 2018, the Veteran's LLE peripheral neuropathy warrants a higher 40 percent evaluation under Diagnostic Code 8520. In other words, during the relevant appeal period, the most persuasive evidence demonstrates that the Veteran's RLE and LLE peripheral neuropathy more closely approximates moderately severe incomplete paralysis of the sciatic nerve. Viewing the evidence in the light most favorable to the Veteran, the Board finds that his subjective reports of having the same symptoms of neuropathy in both legs, his reports of balance problems and falling, which required the use of prescribed assistive devices, coupled with the clinical findings of loss of protective sensation on his feet support that the Veteran's BLE peripheral neuropathy had demonstrably worsened and caused significant functional impairment. Although the November 2018 VA examiner found no paralysis on the right side, the Board finds that the other evidence of record documenting RLE symptoms of similar severity to his LLE symptoms more persuasive. Because the Veteran indicated that his LLE symptoms were the same as his RLE symptoms and the November 2018 VA examiner found that his LLE symptoms were consistent with moderately severe incomplete paralysis, the Board finds no basis upon which to find a less severe finding for his RLE. Given that the Veteran's BLE symptoms were clinically shown to have worsened at his June 2017 VA clinic visit, the Board finds that the Veteran warrants higher evaluations as of that date. Accordingly, the Board concludes that from June 15, 2017 to the present, the Veteran's RLE peripheral neuropathy is no more than 40 percent disabling, and from June 15, 2017 to November 26, 2018, the Veteran's LLE peripheral neuropathy is no more than 40 percent disabling. Finally, the Board finds that from November 27, 2018 to the present, the Veteran's LLE peripheral neuropathy does not warrant a higher 60 percent evaluation under Diagnostic Code 8520. In other words, during the relevant appeal period, the most persuasive evidence does not demonstrate that the Veteran's LLE peripheral neuropathy more closely approximates severe incomplete paralysis with marked muscular atrophy of the sciatic nerve. On that basis, the Board notes that the clinical findings at the November 2018 VA examination showed muscle strength at 4/5 and no muscle atrophy. Although the Veteran indicated that he had multiple falls over the past few years, he also explained that he was able to maintain his balance and keep from falling by using his cane. Overall, the Board finds that the evidence tends to support that the Veteran's LLE symptoms were not significantly worse to warrant a higher 60 percent evaluation. Thus, from November 27, 2018 to the present, the Veteran's LLE peripheral neuropathy is no more than 40 percent disabling. In summary, from September 12, 2011 to June 14, 2017, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claims for higher than 10 percent evaluations for RLE and LLE peripheral neuropathy are warranted. Further, from November 27, 2018 to the present, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's LLE peripheral neuropathy for a higher than 40 percent is warranted. Rather, the evidence persuasively weighs against these higher evaluation claims for RLE and LLE peripheral neuropathy. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to these claims. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). According, these higher evaluations claims for RLE and LLE peripheral neuropathy are denied. However, resolving all reasonable doubt in favor of the Veteran, from June 15, 2017 to the present, the Veteran's claim for a higher 40 percent evaluation for RLE peripheral neuropathy is granted. Further, from June 15, 2017 to November 26, 2018, the Veteran's claim for a higher 40 percent evaluation for LLE peripheral neuropathy is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to a compensable evaluation from September 12, 2011 to November 26, 2018, and an evaluation in excess of 40 percent from November 27, 2018 to the present, for RUE peripheral neuropathy 4. Entitlement to a compensable evaluation from September 12, 2011 to November 26, 2018, and an evaluation in excess of 20 percent from November 27, 2018 to the present, for LUE peripheral neuropathy The Veteran asserts that his RUE and LUE peripheral neuropathy are worse than his current evaluations reflect. During the relevant appeal period, the Veteran's RUE peripheral neuropathy has been currently evaluated as noncompensable, effective March 1, 2010, under 38 C.F.R. § 4.124a, Diagnostic Code 8615 for neuritis of the median nerve, and as 40 percent disabling, effective November 27, 2018, under 38 C.F.R. § 4.124a, Diagnostic Code 8513. The Veteran's LUE peripheral neuropathy has been currently evaluated as noncompensable, effective March 1, 2010, under 38 C.F.R. § 4.124a, Diagnostic Code 8615 for neuritis of the median nerve, and as 20 percent disabling, effective November 27, 2018, under 38 C.F.R. § 4.124a, Diagnostic Code 8514. Handedness for the purpose of a dominant extremity rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. In this case, the evidence (e.g., February 2012 VA examination) shows that the Veteran is right-handed. Consequently, for rating purposes, the RUE is the major upper extremity and the LUE is the minor upper extremity. Under Diagnostic Code 8513 (all radicular groups), a disability rating of 20 percent is assigned for mild incomplete paralysis all radicular groups of the major and minor extremities. A disability rating of 30 percent is assigned for moderate incomplete paralysis of the minor upper extremity, and a disability rating of 40 percent is assigned for moderate incomplete paralysis of the major upper extremity. A disability rating of 60 percent is also assigned for severe incomplete paralysis of the minor upper extremity, and a disability rating of 70 percent is assigned for severe incomplete paralysis of the major upper extremity. A disability rating of 80 percent is assigned for complete paralysis of the minor upper extremity, and a disability rating of 90 percent is assigned for complete paralysis of the major upper extremity. Diagnostic Code 8514 provides the rating criteria for paralysis of the radial nerve, and therefore, neuritis and neuralgia of that nerve. For the major extremity, disability ratings of 20 percent, 30 percent and 50 percent are assignable for incomplete paralysis, which is mild, moderate or severe in degree, respectively. For the minor extremity, disability ratings of 20 percent, 20 percent, and 40 percent are assignable for incomplete paralysis, which is mild, moderate or severe in degree, respectively. A 60 percent rating is warranted for the minor extremity and a 70 percent rating is warranted for the major extremity for complete paralysis, which contemplates the drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. Diagnostic Code 8515 provides the rating criteria for paralysis of the median nerve, and therefore, neuritis and neuralgia of that nerve. For the major extremity, disability ratings of 10 percent, 30 percent and 50 percent are assignable for incomplete paralysis, which is mild, moderate or severe in degree, respectively. For the minor extremity, disability ratings of 10 percent, 20 percent, and 40 percent are assignable for incomplete paralysis, which is mild, moderate or severe in degree, respectively. A 60 percent rating is warranted for the minor extremity and a 70 percent rating is warranted for the major extremity for complete paralysis, which contemplates the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. Diagnostic Code 8516 provides the rating criteria for paralysis of the ulnar nerve, and therefore, neuritis and neuralgia of that nerve. For the major extremity, disability ratings of 10 percent, 30 percent and 40 percent are assignable for incomplete paralysis, which is mild, moderate or severe in degree, respectively. For the minor extremity, disability ratings of 10 percent, 20 percent, and 30 percent are assignable for incomplete paralysis, which is mild, moderate or severe in degree, respectively. A 50 percent rating is warranted for the minor extremity and a 60 percent rating is warranted for the major extremity for complete paralysis, which contemplates the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. Words such as "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Additionally, 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. 38 C.F.R. § 4.124a, Note at Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. Id. In a September 2011 statement, the Veteran's girlfriend described how she observed the Veteran's symptoms of bilateral upper extremity (BUE) peripheral neuropathy. She saw him repeatedly raising his arms above his head to try to increase the circulation to his hands. His hands and fingers felt ice cold, even in hot weather. He had a markedly decreased ability to grip objects, and she had to open his bottles and jars. She said that the Veteran had continuously reported his pain and tingling in his arms, hands, and fingers with no decrease in their severity. At a February 2012 VA examination, the Veteran reported having dull pain, numbness, and tingling in his upper extremities. He also had poor grip strength. The February 2012 VA examiner found that the Veteran had moderate BUE intermittent pain, moderate BUE paresthesias and/or dysesthesias, and moderate BUE numbness. Muscle strength testing was normal. There was no muscle atrophy. Reflexes were normal bilaterally. Sensory examination testing results were normal bilaterally. The February 2012 VA examiner found that the Veteran had upper extremity diabetic peripheral neuropathy, but the February 2012 VA examiner did not identify the severity of the neuropathy. The February 2012 VA examiner determined that the Veteran had a sensory neuropathy with no motor paralysis. VA treatment records from 2012 to 2013 document the Veteran's complaints of BUE peripheral neuropathy symptoms. At an April 2012 VA clinic visit, the Veteran reported having swelling in his hands at times. An objective evaluation revealed no actual weakness or sensory abnormalities of the upper extremities and no atrophy of the muscles. His bilateral hands had a 5/5 grip, and good pulses in his bilateral arms when his arms were held up to positional changes. At a June 2012 VA clinic visit, the VA treating physician noted that the Veteran had a five-year history of pain in his hands, mainly in the palmar area with radiation to the forearms. The Veteran described the pain as a "pins and needle sensation." He experienced morning stiffness in his hands bilaterally for about one and a half hours each morning, which was alleviated with movement. The pain fluctuated throughout the day. His pain was aggravated with computer usage. The pain and tingling in his hands were relieved by holding his arms straight up or holding them down and shaking them out. An objective evaluation revealed a positive Tinel test bilaterally with radiation of tingling into his distal hand and increased tingling and pain in the ulnar distribution of his hand with deep palpation of the medial elbow epicondyle. At a September 2013 VA clinic visit, the Veteran reported that the chronic discomfort in his BUE was still present but unchanged. The VA treating physician noted that the objective evaluation again showed no weakness or other abnormalities. An October 2014 EMG/NCS report revealed that the Veteran had mild bilateral carpal tunnel entrapment and slowing of both ulnar nerves at his elbows but no denervation. In November 2017, the Veteran submitted a document identifying the rating schedule under 38 C.F.R. § 4.124a in which a physician was directed to identify the particular ratings for the Veteran's BUE peripheral neuropathy. Dr. M.S. placed notations on the document for moderate paralysis of upper radicular group, moderate paralysis of middle radicular group, moderate paralysis of lower radicular group, moderate paralysis of all radicular groups, moderate paralysis of radial nerve, moderate paralysis of median nerve, moderate paralysis of ulnar nerve, moderate paralysis of musculocutaneous nerve, severe paralysis of circumflex nerve, and complete paralysis and incomplete severe paralysis of long thoracic nerve. Dr. M.S. did not provide any clinical findings associated with her notations. At the November 2017 Board hearing, the Veteran testified that he indicated that he took pain medication for his BUE symptoms. He described having hands which felt like ice and had blue nails, which occurred every day and night. He said that there was no remedies for his coldness other than him putting his hands under his shirt. He also said that his hands hurt and felt like shockwaves, which ran all the way up and down his arms. He only had relief from shaking his hands and holding them up and down. It was difficult to grab and hold things. At home, he had difficulty opening a bottle or holding a cup of coffee, unless he used both hands. He had difficulty writing checks and signing his name, because he would have spasms suddenly. When he sat, his arms and hands would shake. At a November 2018 VA examination, the Veteran reported having had surgery to his LUE in the past year for neuropathy, but his symptoms returned three months following surgery. He said his condition had worsened in the last 18 months. He experienced constant numbness and tingling in the fourth and fifth digits of his LUE. His symptoms were aggravated from pressure on his elbow. The November 2018 VA examiner found that the Veteran had moderate BUE constant pain, moderate BUE paresthesias and/or dysesthesias, and moderate BUE numbness. Muscle strength testing was t 4/5 bilaterally, except it was normal at wrist extension bilaterally. There was no muscle atrophy. Reflexes were at 1+ at the left biceps, triceps, and brachioradialis. Sensory examination results were normal bilaterally. The November 2018 VA examiner observed that the Veteran had bilateral mottled blueish fingertips and palms which were cool to the touch. Due to the Veteran's BUE neuropathy and weakness, the November 2018 VA examiner found that the Veteran frequently dropped objects. The November 2018 VA examiner determined that the Veteran had severe incomplete paralysis of the right radial nerve, severe incomplete paralysis of the left radial nerve, severe incomplete paralysis of the right ulnar nerve, and severe incomplete paralysis of the left ulnar nerve. At the October 2021 Board hearing, the Veteran testified that his RUE and LUE symptoms were the same and had worsened. He had problems holding items in his arms and lifting items. He had difficulty twisting his arms or maneuvering them in different ways. He had problems lifting his arms over his head. Performing activities like shaving, putting on deodorant and bending over and tying his shoes were problematic. He could not reach back into his back pocket to retrieve his billfold. The weakness in his arms also affected his ability to write his name. He also had muscle cramps, which caused excruciating pain, numbness, and feelings of hot and cold. The symptoms felt like someone was "sticking him with a pin or knife." He rubbed his arms for relief. The medication he was prescribed worked temporarily and then his symptoms would return. As a preliminary matter, the Board recognizes the findings of Dr. M.S. that were submitted in November 2017, in which she indicated several of the Veteran's upper extremity nerves were affected by his BUE peripheral neuropathy. However, in making those notations, Dr. M.S. did not support her conclusions with any clinical evidence. Therefore, the Board concludes that the notations are insufficient for rating purposes and provide no probative value. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor the Veteran, the Board finds that from September 12, 2011 to November 26, 2018, his RUE and LUE peripheral each warrant higher 10 percent evaluations under Diagnostic Code 8516. In other words, the most persuasive evidence demonstrates that the Veteran's RUE and LUE peripheral neuropathy more closely approximates mild incomplete paralysis of the ulnar nerve. Although the February 2012 VA examiner did not specify the severity of the Veteran's BUE peripheral neuropathy, other evidence of record support that the Veteran had mild symptomatology during the appeal period. According to subjective reports from the Veteran's girlfriend, the Veteran had difficulty performing basic functions, such as opening bottles and jars, because he had difficulty grasping objects. Moreover, during VA clinic visits in 2012 and 2013, clinical findings showed that he had increased tingling and pain in the ulnar distribution of his hand with deep palpation of medial elbow epicondyle. Notably, the result of an October 2014 EMG/NCS showed mild bilateral carpal tunnel entrapment and slowing of both ulnar nerves at the Veteran's elbows. Finally, the November 2017 Board testimony continued to report similar symptoms as identified throughout the relevant appeal period. Taking into consideration the totality of the evidence, the Board finds that the Veteran's RUE and LUE peripheral neuropathy warrant higher 10 percent evaluations under Diagnostic Code 8516. Accordingly, the Board concludes that from September 12, 2011 to November 26, 2018, the Veteran's RUE and LUE peripheral neuropathy are no more than 10 percent disabling. Additionally, resolving all reasonable doubt in favor of the Veteran, the Board finds that from November 26, 2018 to the present, the Veteran's RUE and LUE peripheral neuropathy warrant higher 50 percent and 40 percent evaluations, respectively, under Diagnostic Code 8514. In other words, the most persuasive evidence demonstrates that the Veteran's RUE and LUE peripheral neuropathy more closely approximate severe incomplete paralysis of the radial nerve. On that basis, the Board finds that the clinical findings of the November 2018 VA examination provide the most favorable evidence, as the November 2018 VA examiner found severe incomplete paralysis of the right radial nerve and severe incomplete paralysis of the left radial nerve. Moreover, the Veteran did indicate that his BUE symptoms has worsened, and the November 2018 VA examiner noted that the Veteran was frequently dropping objects. Given the subjective reports coupled with the clinical findings, the Board concludes that the Veteran's RUE and LUE peripheral neuropathy had demonstrably deteriorated. Accordingly, from November 26, 2018 to the present, the Veteran's RUE and LUE peripheral neuropathy are more consistent with severe incomplete paralysis of the radial nerve under Diagnostic Code 8514. Therefore, the Veteran's RUE and LUE peripheral neuropathy is no more than 50 percent and 40 percent disabling, respectively. Finally viewing the evidence in the light most favorable to the Veteran, the Board has also considered whether he is entitled to separate ratings for any additional nerve disabilities associated with his service-connected RUE and LUE peripheral neuropathy. However, the "amputation rule" must be kept in mind when assigning multiple ratings for an extremity. The amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. 38 C.F.R. § 4.68. A 70 percent rating is provided for either amputation of the major arm below insertion of the pronator teres or for loss of use of the major hand. A 60 percent rating is provided for either amputation of the minor arm below insertion of the pronator teres or for loss of use of the minor hand. 38 C.F.R. § 4.71a, Diagnostic Codes 5124, 5125. In this case, resolving all reasonable doubt in favor of the Veteran, the Board finds that from November 27, 2018 to the present, separate 40 percent and 30 percent evaluations for RUE and LUE peripheral neuropathy, respectively, are warranted under Diagnostic Code 8516 and will not violate the amputation rule. On that basis, the Board finds that the November 2018 clinical findings provide the most favorable evidence, as the November 2018 VA examiner found severe incomplete paralysis of the right ulnar nerve and severe incomplete paralysis of the left ulnar nerve. Overall, the Board concludes that this evidence supports finding that from November 27, 2018 to the present, a separate 40 percent evaluation for the RUE peripheral neuropathy of the ulnar nerve as a major extremity and a separate 30 percent evaluation for LUE peripheral neuropathy of the ulnar nerve as a minor extremity are warranted. Additionally, when considering the separate ratings of 50 percent for RUE peripheral neuropathy of the radial nerve and 40 percent for RUE peripheral neuropathy of the ulnar, the combined ratings under 38 C.F.R. § 4.25 result in a 70 percent rating for the Veteran's RUE. Further, when considering the separate ratings of 40 percent for LUE peripheral neuropathy of the radial nerve and 30 percent for LUE peripheral neuropathy of the ulnar nerve, the combined ratings under 38 C.F.R. § 4.25 result in a 60 percent rating for the Veteran's LUE. Thus, assigning these separate 40 percent and 30 percent ratings for RUE and LUE peripheral neuropathy of the ulnar nerve would not violate the amputation rule. In summary, resolving all reasonable doubt in favor of the Veteran, from September 12, 2011 to November 26, 2018, 10 percent evaluations for RUE and LUE peripheral neuropathy of the ulnar nerve must be granted. Additionally, from November 27, 2018 to the present, a 50 percent evaluation for RUE peripheral neuropathy of the radial nerve and a 40 percent evaluation for LUE peripheral neuropathy of the radial nerve must be granted. Finally, from November 27, 2018 to the present, a separate 40 percent evaluation for RUE peripheral neuropathy of the ulnar nerve and a separate 30 percent evaluation for LUE peripheral neuropathy of the ulnar nerve must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to an initial evaluation in excess of 10 percent from September 12, 2011 to November 26, 2018, and an initial evaluation in excess of 50 percent from November 27, 2018 to the present, for unspecified anxiety disorder and unspecified depressive disorder is remanded. The Veteran's last VA examination for his service-connected unspecified anxiety disorder and unspecified depressive disorder was in November 2018. At the October 2021 Board hearing, the Veteran testified that his mental health symptoms had worsened since his last evaluation, including being more isolated, worsening sleep problems, discontinuing all outside activities, suicidal ideation, and memory and focus problems. VA is required to afford the Veteran a contemporaneous VA examination to assess the current nature, extent, and severity of his service-connected disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also 38 C.F.R. § 3.326(a). As the Veteran's unspecified anxiety disorder and unspecified depressive disorder may have worsened since his last VA examination, a remand is required to determine the current severity of his service-connected disability. Additionally, VA treatment records reflect that the Veteran had been receiving mental health treatment from a non-VA provider. However, the record does not include any such private mental health treatment records. On remand, the Veteran should be provided another opportunity to submit relevant private mental health treatment records. 2. Entitlement to a TDIU is remanded. The Veteran is seeking entitlement to a TDIU. However, the claim for entitlement to a TDIU may be affected by the outcome of the higher initial evaluation claim for unspecified anxiety disorder and unspecified depressive disorder. Thus, it would be premature to adjudicate the TDIU claim until the higher initial evaluation claim has been considered. Therefore, the issues are inextricably intertwined, and the TDIU claim must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. Obtain all the outstanding treatment records for the Veteran's unspecified anxiety disorder and unspecified depressive disorder that are not currently of record, to include any psychiatric records from the Veteran's non-VA provider. 2. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by an appropriately qualified clinician (M.D.) to determine the current severity of his service-connected unspecified anxiety disorder and unspecified depressive disorder. To the extent possible, the examiner should provide current findings regarding all symptoms associated with the service-connected unspecified anxiety disorder and unspecified depressive disorder and should opine as to its severity. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should comment on the extent of any functional impairment caused by the Veteran's service-connected unspecified anxiety disorder and unspecified depressive disorder, to include in an occupational setting and in performing ordinary, daily activities. All findings should be fully documented in the examination report. 3. To avoid another remand, the Agency of Original Jurisdiction (AOJ) must review the requested development and ensure that the Board's specific instructions have been completed in full. If any development is found to be inadequate, it must be returned to the providing examiner for corrective action. If such corrective action is not requested, then the Board will be required to return the case to the AOJ for substantial compliance with its remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). 4. After ensuring the above development has been completed, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, send the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. Then, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Journet Shaw, 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.