Citation Nr: 22018778 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 17-61 767 DATE: March 30, 2022 ORDER Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with depressive disorder, not otherwise specified, is denied. Entitlement to an increased rating for diabetic peripheral neuropathy of the right upper extremity, currently rated as 10 percent disabling prior to June 9, 2017, 30 percent disabling from June 9, 2017 to November 16, 2017, and 40 percent disabling thereafter, is denied. Entitlement to an increased rating for diabetic peripheral neuropathy of the left upper extremity, currently rated as 10 percent disabling prior to June 9, 2017, 20 percent disabling from June 9, 2017 to November 16, 2017, and 30 percent disabling thereafter, is denied. Prior to November 19, 2018, entitlement to a rating in excess of 10 percent for diabetic peripheral neuropathy of the right lower extremity (sciatic nerve) is denied. From November 19, 2018, entitlement to an increased 20 percent rating for diabetic peripheral neuropathy of the right lower extremity (sciatic nerve) is granted. Entitlement to an initial rating in excess of 30 percent for diabetic peripheral neuropathy of the right lower extremity (femoral nerve) is denied. Prior to November 19, 2018, entitlement to a rating in excess of 10 percent for diabetic peripheral neuropathy of the left lower extremity (sciatic nerve) is denied. From November 19, 2018, entitlement to an increased 20 percent rating for diabetic peripheral neuropathy of the left lower extremity (sciatic nerve) is granted. Entitlement to an initial rating in excess of 30 percent for diabetic peripheral neuropathy of the left lower extremity (femoral nerve) is denied. FINDINGS OF FACT 1. The Veteran's PTSD with depressive disorder, not otherwise specified, has not been shown to cause total occupational and social impairment. 2. Prior to June 9, 2017, the Veteran's diabetic peripheral neuropathy of the right (major) upper extremity was manifested by no more than mild incomplete paralysis of the median nerve; from June 9, 2017 to November 16, 2021, his symptoms were manifested by no more than moderate incomplete paralysis of the median nerve; and from November 17, 202, his symptoms have been manifested by no more than moderate incomplete paralysis of all radicular groups. 3. Prior to June 9, 2017, the Veteran's diabetic peripheral neuropathy of the left (minor) upper extremity was manifested by no more than mild incomplete paralysis of the median nerve; from June 9, 2017 to November 16, 2021, his symptoms were manifested by no more than moderate incomplete paralysis of the median nerve; and from November 17, 202, his symptoms have been manifested by no more than moderate incomplete paralysis of all radicular groups. 4. Prior to November 19, 2018, the Veteran's diabetic peripheral neuropathy of the right lower extremity (sciatic nerve) was manifested by no more than mild incomplete paralysis. 5. From November 19, 2018, the Veteran's diabetic peripheral neuropathy of the right lower extremity (sciatic nerve) has been manifested by no more than moderate incomplete paralysis. 6. The Veteran's diabetic peripheral neuropathy of the right lower extremity (femoral nerve) has been manifested by no more than moderately severe incomplete paralysis. 7. Prior to November 19, 2018, the Veteran's diabetic peripheral neuropathy of the left lower extremity (sciatic nerve) was manifested by no more than mild incomplete paralysis. 8. From November 19, 2018, the Veteran's diabetic peripheral neuropathy of the left lower extremity (sciatic nerve) has been manifested by no more than moderate incomplete paralysis. 9. The Veteran's diabetic peripheral neuropathy of the left lower extremity (femoral nerve) has been manifested by no more than moderately severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD with depressive disorder, not otherwise specified, has not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for increased ratings for diabetic peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DCs 8513, 8515. 3. The criteria for increased ratings for diabetic peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DCs 8513, 8515. 4. Prior to November 19, 2018, the criteria for a rating in excess of 10 percent for diabetic peripheral neuropathy of the right lower extremity (sciatic nerve) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DC 8520. 5. From November 19, 2018, the criteria for an increased rating of 20 percent for diabetic peripheral neuropathy of the right lower extremity (sciatic nerve) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DC 8520. 6. The criteria for a rating in excess of 30 percent for diabetic peripheral neuropathy of the right lower extremity (femoral nerve) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DC 8526. 7. Prior to November 19, 2018, the criteria for a rating in excess of 10 percent for diabetic peripheral neuropathy of the left lower extremity (sciatic nerve) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DC 8520. 8. From November 19, 2018, the criteria for an increased rating of 20 percent for diabetic peripheral neuropathy of the left lower extremity (sciatic nerve) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DC 8520. 9. The criteria for a rating in excess of 30 percent for diabetic peripheral neuropathy of the left lower extremity (femoral nerve) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, DC 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1969 to November 1971. These matters come before the Board of Veterans' Appeals (Board) from a January 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Veteran and his spouse testified before the undersigned at a virtual Board hearing. A transcript of the hearing is of record. In August 2021, the Board remanded the listed issues for evidentiary development. Also in that decision, the Board dismissed a claim of entitlement to service connection for ischemic heart disease; granted an increased 40 percent rating for diabetes mellitus type II; denied a rating in excess of 40 percent for diabetes mellitus; and granted a total disability rating based upon individual unemployability (TDIU) prior to June 9, 2017. As such, those claims are no longer on appeal. During the pendency of this appeal, the RO granted increased ratings for the Veteran's diabetic peripheral neuropathy in September 2017, September 2021, and November 2021 rating decisions. Because higher ratings are available for these disorders throughout the appeal period, and the Veteran is presumed to seek the maximum available benefit, the claims for increased ratings remain on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); AB v. Brown, 6 Vet. App. 35 (1993). 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 (2012); 38 C.F.R. § 3.159 (2021). Since the Board's August 2021 remand, neither the Veteran nor his representative have 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 Ratings Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. PTSD with depressive disorder, not otherwise specified The Veteran contends he is entitled to a rating in excess of 70 percent for his PTSD with depressive disorder, not otherwise specified. For the following reasons, the Board finds an increased rating is not warranted. The Veteran's symptoms are rated under 38 C.F.R. § 4.130, DC 9411. All psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A total schedular rating of 100 percent is warranted when the disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." The Federal Circuit further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. Thus, "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118. As such, the Board will consider both the Veteran's specific symptomatology as well as the occupational and social impairment associated with the DC to determine whether an increased evaluation is warranted. As with all claims for VA disability compensation, the Board must assess the credibility and weigh all the evidence, including lay and medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert denied, 523 U.S. 1046 (1998). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; see Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. Id. The "such symptoms as" language means "for example," and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The Board notes that the Diagnostic and Statistical Manual, Fourth Edition, allowed for the assignment of Global Assessment of Functioning (GAF) scores, which are a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. However, VA regulations were amended to adopt the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), which eliminated the use of GAF scores for evaluating mental illness. 80 Fed. Reg. 14,308 (Mar. 19, 2015). As GAF scores are no longer held to be an effective method of evaluating the severity of psychiatric disabilities, the Board will not rely on any GAF scores in adjudicating the present claim. Golden v. Shulkin, 29 Vet. App. 221, 22426 (2018). The Veteran was afforded a VA Compensation and Pension (C&P) examination in December 2013. The examiner concluded the Veteran's psychiatric symptoms caused occupational and social impairment with deficiencies in most areas, but was not totally incapacitating. He stated he had been married for 43 years but described the relationship as "bad." He denied engaging in any activities and claimed he did not associate with anybody. The Veteran reported being unemployed. He described having suicidal thoughts which were "always there." He denied any physical altercations but said he had verbal confrontations with his wife and daughter. The examiner noted the Veteran's symptoms included depressed mood, anxiety, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impairment of short- and long-term memory; flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and suicidal ideation. The examiner noted the Veteran rarely made eye contact; his answers were simple and vague; his mood was depressed; and he displayed little emotion besides irritability. However, the examiner noted that while the Veteran may have problems interacting with others given his limited social skills, he would be able to function appropriately if left to his own with minimal interactions. In other words, the Veteran was not totally incapacitated. In January 2015, the Veteran submitted a psychiatric/psychological impairment questionnaire (dated in November 2014) which noted that his prognosis was "poor to fair." Observed symptoms included deficiencies in family relations, depression affecting the ability to function independently, deficiencies in mood, difficulty in adapting to stressful circumstances, intrusive recollections of a traumatic experience, and suicidal ideation. The report also identified symptoms of memory loss, markedly limited concentration, and other forms of impairment. The examiner opined the Veteran would likely be incapable of performing gainful employment due to his psychological impairment. In June 2017, the Veteran received another C&P examination. The examiner determined the Veteran suffered from the same level of overall level of impairment. Specific symptoms included (in addition to those noted at the December 2013 examination) chronic sleep impairment, impaired judgment and abstract thinking, inability to establish and maintain effective relationships, impaired impulse control, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. At his July 2020 Board hearing, the Veteran testified that he was suffering hallucinations and delusions every day, including mistakenly believing there was someone in the closet. He reported sometimes going into a "frenzy" of anxiety. The Veteran's wife testified that she witnessed the Veteran talking to himself in the closet or garage. She stated she believed the Veteran could be a danger to himself or others. The Veteran also reported that he has severe memory loss. In addition, the Veteran described engaging in inappropriate behavior, to include urinating outside (which he explained by saying "that's what we used to do in Nam"). In September 2020, the Veteran submitted a private psychological evaluation which described many of the same symptoms listed above. The examiner noted the Veteran's capacities were "markedly limited" in the areas of attention and concentration, the ability to perform activities within a schedule, and the ability to sustain ordinary routines, among other areas. The examiner opined that the Veteran would not be capable of performing gainful employment due to his psychiatric impairment. In November 2021, the Veteran was afforded another C&P examination. According to the report, the examiner determined the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas. The Veteran reported being treated for his PTSD about once a month. No new behavioral or legal issues were noted. The Veteran's symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired abstract thinking, and disturbances of motivation and mood. Behaviorally, the Veteran was oriented to all four dimensions. He denied suicidal or homicidal ideations. There was no evidence of a psychotic process. The Veteran was courteous and polite. In addition to the C&P reports and private evaluations discussed above, the Veteran has received ongoing mental health treatment at his VA medical facility. Records from this treatment is broadly consistent with the C&P reports. Most recently, in November 2021, the Veteran reported struggling with anxiety and depressive symptoms. After careful review, the Board finds the Veteran's PTSD with depressive disorder, not otherwise specified, has not been shown to result in total occupational and social impairmentthe main criterion of a 100 percent ratingas the Veteran was, by his own admission, able to maintain his relationship with his wife and largely able to function if left to himself. As a result, he cannot be considered "totally" impaired socially. Furthermore, the C&P examinations did not demonstrate that the Veteran suffered from gross impairment in thought processes or communication, being a persistent danger of hurting self or others, or disorientation to time or place. No other symptoms of similar severity, frequency, and duration to those listed under the 100 percent criteria have been demonstrated. The Board acknowledges the Veteran's testimony that he suffered delusions and hallucinations and has a tendency to engage in inappropriate behavior. Likewise, the June 2017 C&P report notes the Veteran had intermittent inability to perform activities of daily living. The Board notes, however, that the C&P reports of record are negative for persistent delusions and hallucinations. Likewise, there is no medical evidence to suggest the Veteran has engaged in psychotic behavior or indeed suffers from psychosis. The Veteran's VA treatment records are negative for any signs of hallucinations or delusions. He denied inappropriate behavior at his most recent C&P examination. As a result, when considering all pertinent evidence, the Board finds that although the Veteran may have demonstrating some of the symptoms listed in the 100 percent rating criteria, his psychiatric symptoms have not been persuasively shown to cause total social and occupational impairment during the appeal period. In sum, the evidence demonstrates that the overall impairment caused by the Veteran's PTSD with depressive disorder, not otherwise specified, more nearly approximates occupational and social impairment with deficiencies in most areas. Total impairment due to this disorder alone has not been established. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record with respect to this claim. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Diabetic peripheral neuropathy of the upper extremities The Veteran seeks higher ratings for right and left upper extremity diabetic peripheral neuropathy. The right upper extremity is rated as 10 percent disabling prior to June 9, 2017 (under DC 8515); 30 percent disabling from June 9, 2017 to November 16, 2021 (under DC 8515); and 40 percent disabling thereafter (under DC 8513). The left upper extremity is rated as 10 percent disabling prior to June 9, 2017 (under DC 8515); 20 percent disabling from June 9, 2017 to November 16, 2021 (under DC 8515); and 30 percent disabling thereafter (under DC 8513). When rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124A, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type of 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 only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, 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. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. DC 8515 provides different criteria for the major (dominant) and minor (non-dominant) extremities. Here, the relevant C&P reports of record note that the Veteran's right upper extremity is dominant. DC 8515 addresses paralysis of the median nerve. Under this DC, a 10 percent rating is assigned for mild incomplete paralysis in the major extremity as well as in the minor extremity. A 20 percent rating is warranted for moderate incomplete paralysis in the minor extremity. A 30 percent rating is warranted for moderate incomplete paralysis in the major extremity. Severe incomplete paralysis warrants a 40 percent evaluation in the minor extremity and a 50 percent rating in the major extremity. The highest available ratings are 70 percent in the major extremity and 60 percent in the minor extremity; these ratings are reserved for complete paralysis. 38 C.F.R. § 4.124A, DC 8515. DC 8513 addresses paralysis of all radicular groups of nerves. Under this DC, a 20 percent rating is assigned for mild incomplete paralysis in the major extremity as well as in the minor extremity. A 30 percent rating is warranted for moderate incomplete paralysis in the minor extremity, while a 40 percent rating is warranted for moderate incomplete paralysis in the major extremity. Severe incomplete paralysis warrants a 60 percent evaluation in the minor extremity and a 70 percent rating in the major extremity. The highest ratings of 80 percent in the minor extremity and 90 percent in the major extremity are reserved for complete paralysis. 38 C.F.R. § 4.124A, DC 8513. The Board finds, first, that ratings in excess of 10 percent are not warranted for the right or left upper extremities prior to June 9, 2017. The appeal period dates from February 2013. The Veteran received a VA C&P peripheral nerves examination in December 2013. At that time, the Veteran reported bilateral upper extremity symptoms of intermittent pain, paresthesias and/or dysesthesias, and numbness. These symptoms were observed by the examiner to be mild. The Veteran had normal strength and reflexes but decreased sensation of both upper extremities. Overall, the examiner determined that the Veteran's neuropathy was mild in degree and involved the median nerve. The Veteran's VA treatment records prior to June 2017 reflect that he was followed for neuropathy; however, there is no conclusive determination that such symptoms were more than mild in degree. The Veteran did not provide any specific allegations regarding his symptoms during this period. Based on the above, the Board finds that, prior to June 9, 2017, the most persuasive evidence of record shows that the severity of the Veteran's diabetic peripheral neuropathy of the upper extremities was no more than "mild" in degree for each upper extremity. As noted above, a VA examination report characterized the Veteran's symptoms as mild and involving the median nerve. There is nothing in the pertinent lay statements or VA treatment records that call these findings into question. Accordingly, the Board finds that, prior to June 9, 2017, entitlement to ratings in excess of 10 percent for the right and left upper extremities are not warranted. Moreover DC 8515 is the appropriate DC to evaluate these symptoms. From June 9, 2017 to November 16, 2021, the pertinent evidence includes results from a June 2017 VA examination. The report showed the Veteran described constant and intermittent pain, paresthesias and/or dysesthesias, and numbness in both upper extremities. Less than normal strength was also noted in the wrists, to include with gripping and pinching. Reflexes were normal. Sensation was decreased in the hands and fingers. The Veteran presented with trophic changes, to include shiny skin and loss of hair. Most notably, the examiner indicated that the overall nerve impairment was "moderate" in degree in both upper extremities, involving both the median and ulnar nerves. (The Board notes that separate ratings for median and ulnar nerves are inappropriate, as these ratings would compensate for overlapping symptomatology. See 38 C.F.R. § 4.14.) The Veteran was also afforded a VA examination in November 2018. The report showed the Veteran described constant and intermittent pain and numbness in both upper extremities. Less than normal strength was also noted in gripping and pinching. Reflexes were normal. Sensation was decreased in the inner/outer forearms, hands, and fingers. The Veteran presented with trophic changes, to include shiny skin and loss of hair. Most notably, the examiner indicated that the overall nerve impairment was "mild" in degree in both upper extremities, involving both the median and ulnar nerves. In July 2020, the Veteran testified at his Board hearing that he suffered symptoms of pain which fluctuated during the day, usually occurring about seven times per day. He testified his pain had gotten worse since his last exam. The Veteran's VA treatment records prior to November 2021 reflect that he was followed for neuropathy; however, once again there is no conclusive determination that such symptoms were more than moderate in degree. From June 9, 2017 to November 16, 2021, the Veteran's current evaluation is consistent with moderate symptoms in the bilateral upper extremities, with ulnar and median nerve involvement. As such, a staged rating is appropriate from the date of the prior C&P examination, June 9, 2017. Based on the above, the Board finds that the most persuasive evidence of record shows that the severity of the Veteran's bilateral diabetic peripheral neuropathy of the upper extremities was no more than "moderate" in degree for each upper extremity. As noted above, the VA C&P reports characterized the Veteran's symptoms as moderate (according to the June 2017 C&P report) or mild (according to the November 2018 C&P report), and there is nothing in the pertinent lay statements or VA treatment records that call these findings into question. The Board acknowledges the Veteran's testimony at his Board hearing that his symptoms had worsened since his last examination. However, at that time his last examination, from November 2018, revealed overall mild symptoms, and the Veteran was in fact being compensated for moderate symptoms. As such, his lay testimony is consistent with worsening symptoms which nonetheless warranted 30 percent and 20 percent ratings for moderate incomplete paralysis in his major and minor upper extremities, respectively. Accordingly, the Board finds that, from June 9, 2017 to November 16, 2021, entitlement to a rating in excess of 30 percent for the right upper extremity and in excess of 20 percent for the left upper extremity are not warranted, under DC 8515. From November 17, 2021, the pertinent evidence includes results from a November 2021 VA C&P examination. That report shows the Veteran described constant and intermittent pain, paresthesias and/or dysesthesias, and numbness in both upper extremities. Less than normal strength was noted in elbow flexion and extension and wrist flexion and extension. The Veteran had no movement against resistance in grip and pinch. Sensation was decreased or absent in the shoulders, forearms, hands, and fingers. Position sense and cold sensation was absent in both upper extremities. No muscle atrophy was noted. The Veteran had trophic changes, to include absence of hair and dry, smooth, pale, shiny skin. The examiner indicated that the overall nerve impairment was "moderate" in degree in both upper extremities, involving the radial, median, and ulnar nerves. It was noted that EMG studies showed that bilateral upper nerve extremity nerve impairment. The Veteran's VA treatment records from November 2021 include no conclusive determination that such symptoms were more than moderate in degree. In November 2021, the RO issued a rating decision granting increased ratings for both upper extremities. The RO changed the applicable DC from 8515 to 8513. As noted above, DC 8513 provides a 40 percent rating for moderate incomplete paralysis of the major upper extremity and a 30 percent rating for moderate incomplete paralysis of the minor upper extremity involving all radicular groups. This change was made based on the November 2021 VA examination report noting involvement of three upper extremity radicular groups (prior reports only noted involvement of the median and ulnar nerve roots). The Veteran's current evaluation is consistent with moderate symptoms in the bilateral upper extremities when considering involvement of all radicular groups under DC 8515, from November 17, 2021. As such, a staged rating is appropriate from the date of the examination. Based on the above, the Board finds the most persuasive evidence of record shows the severity of the Veteran's bilateral diabetic peripheral neuropathy of the upper extremities was no more than "moderate" in degree for each upper extremity. As noted above, the most recent VA C&P report characterized the Veteran's symptoms as moderate but involving all radicular groups, consistent with 40 and 30 percent ratings under DC 8513. There is nothing in the pertinent lay statements or VA treatment records that call these findings into question. Accordingly, the Board finds that, from November 17, 2021, entitlement to a rating in excess of 40 percent for the right upper extremity and in excess of 30 percent for the left upper extremity are not warranted. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record in connection with his claim for increased ratings for bilateral peripheral neuropathy of the upper extremities. See Doucette, 28 Vet. App. 366. 3. Diabetic peripheral neuropathy of the lower extremities The Veteran seeks higher ratings for right and left lower extremity diabetic peripheral neuropathy. Each extremity is rated as 10 percent disabling prior to November 17, 2021 (under DC 8520) and 30 percent disabling thereafter (under DC 8526. DC 8520 provides the rating criteria for paralysis of the sciatic nerve. Disability ratings of 10 percent, 20 percent, and 40 percent are assignable for incomplete paralysis which is mild, moderate, or moderately severe. A 60 percent rating is warranted for incomplete paralysis which is severe, with marked muscular atrophy. A rating of 80 percent is warranted for complete paralysis, where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124A, DC 8520. DC 8526 provides the rating criteria for paralysis of the anterior crural (femoral) nerve. Disability ratings of 10 percent, 20 percent, and 30 percent are assignable for incomplete paralysis which is mild, moderate, or severe; a 40 percent rating is warranted for complete paralysis, which contemplates paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124A, DC 8526. The Board finds that, prior to November 19, 2018, ratings in excess of 10 percent are not warranted for either lower extremity. The Veteran received a VA C&P examination of the peripheral nerves in December 2013. At that time, the Veteran reported constant and intermittent pain, paresthesias and/or dysesthesias, and numbness of both lower extremities. Strength was normal. Reflexes and sensation were reduced in both legs. There was no evidence of muscle atrophy. Overall, the examiner determined that the Veteran's neuropathy was mild in degree; it was noted that the symptoms involved the sciatic nerve. The Veteran underwent another VA C&P examination in June 2017. He reported constant and intermittent pain, paresthesias and/or dysesthesias, and numbness. Strength and sensation of the lower extremities was reduced. There was no indication of muscle atrophy. Trophic changes were noted. Overall, the examiner determined the Veteran's peripheral neuropathy was mild in degree and involved only the sciatic nerve. No other symptoms were identified. The Veteran's VA treatment records during this period reflect that he was followed for neuropathy; however, there is no conclusive determination that such symptoms were more than mild in degree. The Veteran did not provide any specific allegations regarding his symptoms during this period. Based on the above, the Board finds that, prior to November 19, 2018, the most persuasive evidence of record shows that the severity of the Veteran's bilateral diabetic peripheral neuropathy was no more than "mild" in degree. As noted above, two separate VA examination reports from December 2013 and June 2017 characterized the symptoms as mild and involving the sciatic nerve root, and there is nothing in the lay statements or VA treatment records that call these findings into question. Accordingly, the Board finds that ratings in excess of 10 percent for diabetic peripheral neuropathy of the right and left lower extremities prior to November 19, 2018 are not warranted. From November 19, 2018, the record shows the Veteran experienced increased symptoms of diabetic peripheral neuropathy of the right and left lower extremity so as to warrant increased 20 percent ratings. Specifically, the Veteran was afforded a VA C&P examination in November 2018. At that time, it was noted that his peripheral neuropathy had increased in severity; his symptoms were noted to be moderate in degree. As moderate incomplete paralysis involving the sciatic nerve is consistent with 20 percent ratings, the Board finds a staged rating is appropriate from the date of the examination, November 19, 2018. To that extent, the Veteran's claim will be granted. As noted above, the Veteran is in receipt of an increased 30 percent rating under DC 8526, effective November 17, 2021. That date corresponds to a November 2021 VA C&P examination, which revealed the Veteran's diabetic peripheral neuropathy involved the femoral nerve root. (This examination marked the first evidence of femoral nerve involvement.) Moreover, the Veteran's symptoms at that time were identified as being moderate in degree. This is consistent with a 30 percent rating under DC 8526, as noted above. (Continued on the next page) However, the Board further finds that from November 17, 2021, the criteria for ratings in excess of 30 percent are not met for either lower extremity. The Veteran's overall impairment involving the femoral nerve root was determined to be no more than moderate in degrees. Accordingly, evaluations in excess of 30 percent for diabetic peripheral neuropathy of the right and left lower extremities are not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with the Veteran's claim for increase for his peripheral neuropathy of the lower extremities. See Doucette, 28 Vet. App. 366. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ryan, 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.