PSYCHONEUROTIC DISORDERS

M. M. CELLI · 2026 · Case ID: A26028438

MIXED

Summary

The veteran, who served from December 1973 to March 1976, appeals the denial of initial ratings for several conditions and the propriety of rating reductions for others. The Board denied entitlement to initial ratings in excess of 70 percent for somatic symptom disorder, finding that while the veteran experienced social impairment, it was not total, and his hobbies and relationships indicated some level of functioning. The Board also denied higher ratings for cholecystectomy with hepatic steatosis, status post umbilical hernia, scar status post hernia surgery, Peyronie's disease, and diabetes mellitus type II, concluding the veteran's symptoms did not meet the criteria for higher evaluations. The Board found the reductions in ratings for diabetic peripheral neuropathy of the bilateral upper and lower extremities to be proper, as the evidence indicated improvement in the veteran's ability to function, and the reductions did not affect his overall 100 percent combined rating. However, the Board granted special monthly compensation (SMC) based on the need for aid and attendance, effective January 21, 2020, finding that the veteran's service-connected somatic symptom disorder and polycythemia vera rendered him unable to perform activities of daily living and requiring assistance on a regular basis, as supported by a physician assistant's opinion and the veteran's son's statements. The Board denied SMC prior to January 21, 2020, finding insufficient evidence of medical necessity for assistance.

Rationale

Veteran's social impairment not total; Maintained relationships and hobbies; Normal mental status exam results

Special Benefit

SMC - AID & ATTENDANCE

Docket No.

250908-585057

Full Decision Text

Citation Nr: A26028438
Decision Date: 03/30/26 Archive Date: 03/30/26

DOCKET NO. 250908-585057
DATE: March 30, 2026

ORDER

An initial rating in excess of 70 percent for somatic symptom disorder is denied.

An initial rating in excess of 10 percent for cholecystectomy with hepatic steatosis is denied.

An initial compensable rating for status post umbilical hernia is denied.

An initial compensable rating for scar status post hernia surgery is denied.

An initial rating in excess of 20 percent for Peyronie's disease is denied.

An initial rating in excess of 20 percent for diabetes mellitus, type II, is denied.

The reduction from a 30 percent rating to a 20 percent rating for diabetic peripheral neuropathy of the left upper extremity, effective December 1, 2024, was proper; the appeal is denied.

The reduction from a 40 percent rating to a 20 percent rating for diabetic peripheral neuropathy of the right upper extremity, effective December 1, 2024, was proper; the appeal is denied.

The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve, effective December 1, 2024, was proper; the appeal is denied.

The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve, effective December 1, 2024, was proper; the appeal is denied.

The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the left lower extremity affecting the femoral nerve, effective December 1, 2024, was proper; the appeal is denied.

The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the right lower extremity affecting the femoral nerve, effective December 1, 2024, was proper; the appeal is denied.

An initial rating in excess of 30 percent prior to December 1, 2024, and in excess of 20 percent thereafter for diabetic peripheral neuropathy of the left upper extremity is denied.

An initial rating in excess of 40 percent prior to December 1, 2024, and in excess of 20 percent thereafter for diabetic peripheral neuropathy of the right upper extremity is denied.

An initial rating in excess of 10 percent prior to April 13, 2023, in excess of 20 percent from April 13, 2023, to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve is denied.

An initial rating in excess of 10 percent prior to April 13, 2023, in excess of 20 percent from April 13, 2023, to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve is denied.

An initial rating in excess of 20 percent prior to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the left lower extremity affecting the femoral nerve is denied.

An initial rating in excess of 20 percent prior to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the right lower extremity affecting the femoral nerve is denied.

As of January 21, 2020, but no earlier, special monthly compensation (SMC) based on the need for the aid and attendance of another person is granted, subject to the laws and regulations governing the payment of monetary awards.

FINDINGS OF FACT

1. For the entire appeal period, the Veteran's somatic symptom disorder is manifested by psychiatric symptomatology resulting in no more than occupational and social impairment with deficiencies in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment.

2. For the entire appeal period, the Veteran's cholecystectomy with hepatic steatosis is manifested by an asymptomatic liver disability with no more than mild symptoms status post cholecystectomy.

3. For the entire appeal period, the Veteran's status post umbilical hernia did not result in an irreparable (new or recurrent) hernia, muscle weakening, or an indication that the use of a supporting belt was needed.

4. For the entire appeal period, the Veteran's scar status post hernia surgery is not painful or unstable, of a size to warrant a compensable rating, and does not result in any disabling effects.

5.
without more severe manifestations that more nearly approximate total occupational and social impairment.

2. For the entire appeal period, the Veteran's cholecystectomy with hepatic steatosis is manifested by an asymptomatic liver disability with no more than mild symptoms status post cholecystectomy.

4. For the entire appeal period, the Veteran's scar status post hernia surgery is not painful or unstable, of a size to warrant a compensable rating, and does not result in any disabling effects.

5. For the entire appeal period, the Veteran is in receipt of the maximum schedular rating of 20 percent for Peyronie's disease, and such disability does not result in symptomatology that is not contemplated by the currently assigned rating.

6. For the entire appeal period, the Veteran's diabetes mellitus, type II, required insulin, oral hypoglycemic agents, and a restricted diet, but did not necessitate regulation of activities or result in separately compensable complications other than his already separately rated diabetic peripheral neuropathy of the bilateral upper and lower extremities.

7. In a September 2024 rating decision, the Agency of Original Jurisdiction (AOJ) effectuated the reductions of the disability ratings for the Veteran's service-connected diabetic peripheral neuropathy of the bilateral lower and upper extremities, effective December 1, 2024.

8. At the time of the September 2024 rating decision, the disability ratings for the Veteran's service-connected diabetic peripheral neuropathy of the bilateral lower and upper extremities had been in effect for less than five years and such reductions did not result in a reduction in payment of compensation benefits.

9. The evidence of record at the time of the September 2024 rating decision demonstrated an improvement in the Veteran's service-connected diabetic peripheral neuropathy of the bilateral lower and upper extremities in regard to his ability to function under ordinary conditions of life and work.

10. Prior to December 1, 2024, the Veteran's diabetic peripheral neuropathy of the left upper extremity resulted in no more than moderate incomplete paralysis of all radicular groups.

11. As of December 1, 2024, the Veteran's diabetic peripheral neuropathy of the left upper extremity resulted in no more than mild incomplete paralysis of the radial nerve.

12. Prior to December 1, 2024, the Veteran's diabetic peripheral neuropathy of the right upper extremity resulted in no more than moderate incomplete paralysis of all radicular groups.

13. As of December 1, 2024, the Veteran's diabetic peripheral neuropathy of the right upper extremity resulted in no more than mild incomplete paralysis of the radial nerve.

14. Prior to April 13, 2023, the Veteran's diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve resulted in no more than mild incomplete paralysis of the sciatic nerve.

15. From April 13, 2023, to December 1, 2024, the Veteran's diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve resulted in no more than moderate incomplete paralysis of the sciatic nerve.

16. As of December 1, 2024, the Veteran's diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve resulted in no more than mild incomplete paralysis of the sciatic nerve.

17. Prior to April 13, 2023, the Veteran's diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve resulted in no more than mild incomplete paralysis of the sciatic nerve.

18. From April 13, 2023, to December 1, 2024, the Veteran's diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve resulted in no more than moderate incomplete paralysis of the sciatic nerve.

19. As of December 1, 2024, the Veteran's diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve resulted in no more than mild incomplete paralysis of the sciatic nerve.

20. Prior to December 1, 2024, the Veteran's diabetic peripheral neuropathy of the left lower extremity affecting the femoral nerve resulted in no more than moderate incomplete paralysis of the femoral nerve.

21. As of December 1, 2024, the Veteran's diabetic peripheral neuropathy of the left lower extremity affecting the femoral nerve resulted in no more than mild incomplete paralysis of the femoral nerve.

22. Prior to December 1, 2024, the Veteran's diabetic peripheral neuropathy of the right lower extremity affecting the femoral nerve resulted in no more than moderate incomplete paralysis
right lower extremity affecting the sciatic nerve resulted in no more than mild incomplete paralysis of the sciatic nerve.

23. As of December 1, 2024, the Veteran's diabetic peripheral neuropathy of the right lower extremity affecting the femoral nerve resulted in no more than mild incomplete paralysis of the femoral nerve.

24. As of January 21, 2020, but no earlier, the Veteran has required the regular aid and attendance of another person as a result of his service-connected disabilities.

CONCLUSIONS OF LAW

1. The criteria for an initial rating in excess of 70 percent for somatic symptom disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9421.

2. The criteria for an initial rating in excess of 10 percent for cholecystectomy with hepatic steatosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.113, 4.114, DC 7345-7318.

3. The criteria for an initial compensable rating for status post umbilical hernia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.114, DC 7339.

4. The criteria for an initial compensable rating for scar status post hernia surgery have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7805.

5. The criteria for an initial rating in excess of 20 percent for Peyronie's disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.115b, DC 7522.

6. The criteria for an initial rating in excess of 20 percent for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, DC 7913.

7. The reduction from a 30 percent rating to a 20 percent rating for diabetic peripheral neuropathy of the left upper extremity, effective December 1, 2024, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8514.

8. The reduction from a 40 percent rating to a 20 percent rating for diabetic peripheral neuropathy of the right upper extremity, effective December 1, 2024, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8514.

9. The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve, effective December 1, 2024, was proper. 38 U.S.C. §§ 1155, 5107;
for diabetic peripheral neuropathy of the right upper extremity, effective December 1, 2024, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8514.

10. The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve, effective December 1, 2024, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8520.

11. The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the left lower extremity affecting the femoral nerve, effective December 1, 2024, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8526.

12. The reduction from a 20 percent rating to a 10 percent rating for diabetic peripheral neuropathy of the right lower extremity affecting the femoral nerve, effective December 1, 2024, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8526.

13. The criteria for an initial rating in excess of 30 percent prior to December 1, 2024, and in excess of 20 percent thereafter 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, 4.3, 4.7, 4.124a, DCs 8513, 8514.

14. The criteria for an initial rating in excess of 40 percent prior to December 1, 2024, and in excess of 20 percent thereafter 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, 4.3, 4.7, 4.124a, DCs 8513, 8514.

15. The criteria for an initial rating in excess of 10 percent prior to April 13, 2023, in excess of 20 percent from April 13, 2023, to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.120, 4.124a, DC 8520.

16. The criteria for an initial rating in excess of 10 percent prior to April 13, 2023, in excess of 20 percent from April 13, 2023, to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.
4.3, 4.7, 4.10, 4.120, 4.124a, DC 8520.

17. The criteria for an initial rating in excess of 20 percent prior to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the left lower extremity affecting the femoral nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.120, 4.124a, DC 8526.

18. The criteria for an initial rating in excess of 20 percent prior to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the right lower extremity affecting the femoral nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.120, 4.124a, DC 8526.

19. As of January 21, 2020, but no earlier, the criteria for SMC based on the need for aid and attendance of another person have been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from December 1973 to March 1976.

This matter comes before the Board of Veterans' Appeals (Board) on an appeal from a September 2024 rating decision issued by a Department of Veterans Affairs (VA) Regional Office under the modernized appeals system known as the Appeals Modernization Act (AMA).

In September 2025, the Veteran timely appealed such rating decision to the Board by filing Decision Review Request: Board Appeal (Notice of Disagreement) (VA Form 10182) and requested direct review of the evidence considered by the AOJ. Therefore, the Board may only consider the evidence of record at the time of the September 2024 AOJ decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. If evidence was submitted during the period after the AOJ issued the decision, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, he may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Initial Rating Claims

Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7.

Separate ratings can be assigned for separate periods based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id.

1. Entitlement to an initial rating in excess of 70 percent for somatic symptom disorder.

In the instant case, the Veteran is in receipt of a 70 percent rating for his somatic symptom disorder for the entire appeal period stemming from the April 25, 2017, date of service connection pursuant to the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9421.

In this regard, a 70 percent evaluation is warranted where there is 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; intermittently illogical, obscure, or irrelevant speech; 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 circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id.

A 100 percent evaluation is warranted where there is 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 minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id.

As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, DC 9411.

Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38
- i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, DC 9411.

At the outset, the Board notes that a prior award of a total disability rating based on individual unemployability due to service-connected disability (TDIU) for the entire appeal period was predicated on the Veteran's somatic symptom disorder (see December 2021 rating decision), which reflects the determination that such psychiatric disability is of sufficient severity to preclude the Veteran from successfully securing or following a substantially gainful occupation. Thus, the Board finds that such conclusion is tantamount to a finding that the Veteran's somatic symptoms disorder has rendered him totally occupationally impaired throughout the entire appeal period. However, as outlined above, to warrant the assignment of a 100 percent rating for such disability, the evidence of record must reflect total social, in addition to occupational, impairment.

The relevant evidence of record includes VA examinations performed in January 2020, October 2021, and May 2024, VA and private treatment records, and the Veteran's lay statements. However, upon review of this evidence, the Board finds that such reflects that, while the Veteran experiences social impairment as a result of his service-connected psychiatric disability, such is not total.

In that regard, a September 2017 private treatment record indicates that the Veteran's son was a big source of support and helped him with current issues, and his family was supportive. An additional September 2017 private treatment record notes that he and his son were close. In February 2018, the Veteran reported that he enjoyed his trip to Florida, to include Disney World, to reunite with his girlfriend. He further reported that he met his brother there. At the January 2020 VA examination, the Veteran reported that the relationship with his surviving brothers was good; he had a good relationship with his current girlfriend whom he had been dating for the previous 10 months; he had a good relationship with his son who took care of him; and he spent his time boating, going out to dinner, and shopping with his girlfriend. He denied any difficulty with making or keeping friends at any time. At the October 2021 VA examination, the Veteran reported that he had a good relationship with his children and two grandchildren, and his son took care of him. He noted that his only relationships were with his children and his one best friend. In a February 2022 written statement from the Veteran's son, he indicated that he moved in with the Veteran in 2013 and assisted him with activities of daily living since such time. At the May 2024 VA examination, the Veteran reported that his son and his son's girlfriend lived with him and helped him. He further reported that his relationship with one of his daughters was "okay," and he felt closer to his other daughter as she was a military veteran. The Veteran also indicated that he walked his dog, went to the supermarket, and spent time on his boat. He noted that he had a girlfriend for three years until September 2023.

Here, the Board notes that the Veteran was able to maintain a relationship with a girlfriend for a majority of the appeal period. Additionally, it was noted that he had a good/close relationship with his son (who lives with him) and two grandchildren; he maintained a relationship with his daughters, albeit strained at times; his family was supportive, and the relationship with his surviving brothers was good; he was in communication with one best friend; and he stayed involved with his hobbies, to include boating, walking his dog, and shopping. Further, the mental status examinations performed throughout the appeal period from September 2017 to May 2024 revealed largely normal results, to include that he was appropriately dressed, he was oriented times, he had no hallucinations or delusions, his insight and judgment were fair/average, there were no signs or symptoms of psychosis or mania, he was a low risk of harm to self or others, and he denied suicidal thoughts and suicidal/homicidal ideation. Moreover, none of the January 2020, October 2021, or May 2024 VA
brothers was good; he was in communication with one best friend; and he stayed involved with his hobbies, to include boating, walking his dog, and shopping. Further, the mental status examinations performed throughout the appeal period from September 2017 to May 2024 revealed largely normal results, to include that he was appropriately dressed, he was oriented times, he had no hallucinations or delusions, his insight and judgment were fair/average, there were no signs or symptoms of psychosis or mania, he was a low risk of harm to self or others, and he denied suicidal thoughts and suicidal/homicidal ideation. Moreover, none of the January 2020, October 2021, or May 2024 VA examiners found the Veteran's psychiatric symptoms produced total social impairment.

In sum, the totality of the evidence fails to suggest that at any point during the appeal period, the Veteran's service-connected somatic symptom disorder has produced total social impairment. Consequently, an initial rating in excess of 70 percent for such disability is not warranted.

2. Entitlement to an initial rating in excess of 10 percent for cholecystectomy with hepatic steatosis.

Since April 25, 2017, the date of service connection, the Veteran's cholecystectomy with hepatic steatosis is rated as 10 percent disabling pursuant to DC 7345-7318. 38 C.F.R. § 4.114.

The Board notes that, while the Veteran is service connected for gallbladder removal (cholecystectomy) and chronic liver disease without cirrhosis, separate ratings for such disabilities were prohibited by regulation prior to May 19, 2024. In this regard, VA published amendments to 38 C.F.R. § 4.114, the Schedule of Ratings for the Digestive System, effective May 19, 2024. Specifically, prior to May 19, 2024, the rating schedule expressly prohibited combining ratings under DCs 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive). Here, at such time, certain coexisting diseases of the digestive system, as indicated in the instruction under the title "Disease of the Digestive System," did not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Rather, a single rating was to be assigned under the DC that reflected the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warranted such elevation.

DC 7345 provides for a noncompensable rating if the chronic liver disease is nonsymptomatic. Intermittent fatigue, malaise, and anorexia; or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period, warrants a 10 percent rating. A 20 percent rating is assigned for daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. Higher ratings are also available for greater levels of severity of chronic liver disease.

DC 7318 provides for a noncompensable rating for nonsymptomatic gallbladder removal. A 10 percent rating is warranted for gallbladder removal with mild symptoms. The highest 30 percent rating is reserved for gallbladder removal with severe symptoms.

As noted previously, as of May 19, 2024, VA amended the criteria for rating diseases of the digestive system. 38 C.F.R. § 4.114. As pertinent, both DC 7345 and DC 7318 were amended. In this regard, where the rating criteria are amended during the course of the appeal, the Board must consider both the former and the current rating criteria; however, should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Moreover, as the Veteran's claim was pending at the time of the regulatory amendments
§ 4.114. As pertinent, both DC 7345 and DC 7318 were amended. In this regard, where the rating criteria are amended during the course of the appeal, the Board must consider both the former and the current rating criteria; however, should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Moreover, as the Veteran's claim was pending at the time of the regulatory amendments, he is entitled to the application of the criteria most favorable to his claim. See generally, Kuzma, supra. Thus, the rating criteria in effect prior to May 19, 2024, should be considered for the entire appeal period, and the rating criteria in effect as of such date must be considered for the appeal period beginning May 19, 2024.

As of May 19, 2024, under DC 7345, a noncompensable rating is assigned for a previous history of liver disease, currently asymptomatic. A 20 percent rating is assigned for chronic liver disease with at least one of the following: (1) intermittent fatigue, (2) malaise, (3) anorexia, (4) hepatomegaly, or (5) pruritus. Higher ratings are also available for greater levels of severity of chronic liver disease.

DC 7318 provides for a noncompensable rating for asymptomatic gallbladder removal. A 10 percent rating is warranted for gallbladder removal with intermittent abdominal pain; and diarrhea characterized by one to two watery bowel movements per day. The highest 30 percent rating is reserved for gallbladder removal with recurrent abdominal pain (post-prandial or nocturnal); and chronic diarrhea characterized by three or more watery bowel movements per day.

By way of background, the Veteran's private treatment records reflect that he underwent a laparoscopic cholecystectomy in June 2014.

In connection with the instant claim, the Veteran underwent a VA liver examination in November 2017. At such time, a diagnosis of hepatic steatosis shown on a September 2017 CT scan was noted (which was a common finding); however, there were no liver lesions or "spots," the Veteran was asymptomatic, and he was not on any treatment. Additionally, it was noted that the Veteran was not on continuous medication for control of his liver disability; he did not currently have any signs or symptoms attributable to chronic or infectious liver disease, cirrhosis of the liver, biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis; and his laboratory studies showed normal results.

At a January 2020 VA liver examination, it was noted that the Veteran's medical records indicated that he was recently seen in October 2019 and was diagnosed with a fatty liver; however, there were no signs of cirrhosis, no diagnosis of liver cancer, and the physician indicated that his fatty liver was associated with his diabetes and excess weight. Additionally, the Veteran denied any abdominal pain; he was not taking continuous medication for control of his liver disability; he did not currently have any signs or symptoms attributable to chronic or infectious liver disease, cirrhosis of the liver, biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis; and his laboratory studies showed normal results. At a January 2020 VA hernia examination, the Veteran reported that, after his gallbladder removal, he had a fatty food intolerance and recurring gastroesophageal reflux disease symptoms, which were aggravated by exposures to fatty and spicy products. At a September 2020 VA gallbladder examination, it was noted that continuous medication was not required for control of the Veteran's gallbladder disability, and he did not have any signs or symptoms attributable to any gallbladder disorder or residuals of treatment for such. Additionally, his laboratory studies showed normal results.

A September 2022 VA treatment record reflects the Veteran's complaint of abdominal pain, diarrhea, and vomiting after eating a greasy breakfast the previous week. Here, he noted that such pain was similar to when his "gallbladder went bad." Such record further reflects that the Veteran's diarrhea and minimal vomiting resolved after one day, but his pain persisted for several days. Following testing, an assessment noted the following: the Veteran's acute abdominal pain with short-lived symptoms of diarrhea and vomiting could possibly be gastroenteritis; such could have been consistent with biliary-type pain; however, he
or symptoms attributable to any gallbladder disorder or residuals of treatment for such. Additionally, his laboratory studies showed normal results.

A September 2022 VA treatment record reflects the Veteran's complaint of abdominal pain, diarrhea, and vomiting after eating a greasy breakfast the previous week. Here, he noted that such pain was similar to when his "gallbladder went bad." Such record further reflects that the Veteran's diarrhea and minimal vomiting resolved after one day, but his pain persisted for several days. Following testing, an assessment noted the following: the Veteran's acute abdominal pain with short-lived symptoms of diarrhea and vomiting could possibly be gastroenteritis; such could have been consistent with biliary-type pain; however, he was post-cholecystectomy, and on review of his imaging, he had no bile duct changes or choledocholithiasis, and his liver function tests were normal except for a mildly elevated T bili; and he had multiple EGDs and colonoscopies without concerning findings. It was also noted that the Veteran was currently symptom-free in terms of his abdomen but was somewhat constipated.

At an April 2023 VA liver examination, it was noted that the Veteran was currently not receiving any treatment and was only watching/monitoring his liver enzymes. Additionally, he was not taking continuous medication for control of his liver disability; he did not currently have any signs or symptoms attributable to chronic or infectious liver disease, cirrhosis of the liver, biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis; he had not had any incapacitating episodes due to his liver disability during the past 12 months; and his laboratory studies showed normal results (with the exception of high glucose related to his diabetes). At an April 2023 VA gallbladder examination, the Veteran reported that he had colic pain sometimes and he could not eat certain foods. It was noted that continuous medication was required for the control of his gallbladder disability, to include Omeprazole. Additionally, upon examination, it was also noted that the Veteran experienced four or more attacks of gallbladder colic, and frequent attacks of gallbladder colic. His laboratory studies showed normal results. The examiner also indicated that the Veteran had physical activity and exercise intolerances, and fatigue. In a September 2023 VA addendum opinion, the same VA examiner determined that the Veteran's post-cholecystectomy residuals were mild in severity. At a May 2024 VA liver examination, it was noted that the Veteran was currently asymptomatic. Additionally, he did not currently have any signs or symptoms attributable to chronic or infectious liver disease, or cirrhosis of the liver, biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis. At a May 2024 VA gallbladder examination, the Veteran did not report any symptoms. It was noted that continuous medication was not required for control of his gallbladder disability. Additionally, upon examination, it was also noted that the Veteran underwent a cholecystectomy and experienced intermittent abdominal pain (however, he was currently asymptomatic as a result of such), and he experienced two attacks per year of gallbladder colic.

Based on the foregoing, the Board finds that for the entire appeal period, a rating in excess of 10 percent for the Veteran's cholecystectomy with hepatic steatosis is not warranted. In this regard, his gallbladder disability resulted in no more than mild symptoms. Specifically, while the Board acknowledges that the Veteran had his gallbladder removed in June 2014 following reports of abdominal pain, subsequent treatment records are negative for any complaints, treatment, or diagnosis referable to such symptomatology other than an acute episode of abdominal pain with short-lived symptoms of diarrhea and vomiting in September 2022. Furthermore, the September 2020, April 2023 (with a September 2023 addendum opinion), and May 2024 VA examination reports reflect that the Veteran's status post cholecystectomy results in, at most, mild symptoms consisting of intermittent, but not recurrent, abdominal pain and without chronic diarrhea. Based on such reported symptoms, the Board finds that the Veteran's symptomatology related to his gallbladder disability does not result in severe symptoms. Therefore, the Board finds that a rating in excess of 10 percent is not warranted under the pre- or post-May 2024 DC 7318. Furthermore, as the evidence of record reflects the Veteran's liver disability was asymptomatic for the entirety of the appeal period, a higher rating is not warranted under the pre- or post-May 2024 DC 7345.

3. Entitlement to an initial compensable rating for status post umbilical
ectomy results in, at most, mild symptoms consisting of intermittent, but not recurrent, abdominal pain and without chronic diarrhea. Based on such reported symptoms, the Board finds that the Veteran's symptomatology related to his gallbladder disability does not result in severe symptoms. Therefore, the Board finds that a rating in excess of 10 percent is not warranted under the pre- or post-May 2024 DC 7318. Furthermore, as the evidence of record reflects the Veteran's liver disability was asymptomatic for the entirety of the appeal period, a higher rating is not warranted under the pre- or post-May 2024 DC 7345.

3. Entitlement to an initial compensable rating for status post umbilical hernia.

Since April 25, 2017, the date of service connection, the Veteran's status post umbilical hernia is rated as noncompensably disabling pursuant to DC 7339. 38 C.F.R. § 4.114.

In this regard, the Board notes that VA published amendments to 38 C.F.R. § 4.114, the Schedule of Ratings for the Digestive System, effective May 19, 2024. As pertinent to the instant appeal, such amendment removed DC 7399 (post-operative ventral hernias), and added DC 7388 for hernias, including femoral, inguinal, umbilical, ventral, incisional, and other (but not including hiatal). In this regard, where the rating criteria are amended during the course of the appeal, the Board must consider both the former and the current rating criteria; however, should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma, supra. Moreover, as the Veteran's claim was pending at the time of the regulatory amendments, he is entitled to the application of the criteria most favorable to his claim. See generally, Kuzma, supra. Thus, the rating criteria in effect prior to May 19, 2024, should be considered for the entire appeal period, and the rating criteria in effect as of such date must be considered for the appeal period beginning May 19, 2024.

Prior to May 19, 2024, DC 7339 provides that a noncompensable rating is assigned when there is a healed post-operative wound for which the use of a supporting belt is not indicated and there is no disability. A 20 percent rating is assigned when the hernia is small, not well supported by a belt under ordinary conditions, or there are a healed ventral hernia or postoperative wounds with weakening of abdominal wall and indication of the need for a supporting belt. A 40 percent rating is assigned when the hernia is large and not well supported by a belt under ordinary conditions. A 100 percent rating is assigned when the hernia results in massive, persistent, severe diastasis of recti muscles or extensive diffuse destruction or weakening of muscular and fascial support of the abdominal wall so as to be inoperative.

As of May 19, 2024, DC 7338 provides that a noncompensable rating is assigned for an asymptomatic hernia; present and repairable, or repaired. A 10 percent rating is assigned for an irreparable hernia (new or recurrent) present for 12 months or more; with hernia size smaller than 3 cm. A 20 percent rating is assigned for an irreparable hernia (new or recurrent) present for 12 months or more; with both of the following present for 12 months or more: size equal to 3 cm or greater but less than 15 cm in one dimension; and pain when performing one of the following activities: (1) bending over, (2) activities of daily living (ADLs), (3) walking, and (4) climbing stairs. A 30 percent rating is assigned for an irreparable hernia (new or recurrent) present for 12 months or more; with both of the following present for 12 months or more: size equal to 3 cm or greater but less than 15 cm in one dimension; and pain when performing at least two of the following activities: (1) bending over, (2) ADLs, (3) walking, and (4) climbing stairs. A 60 percent rating is assigned for an irreparable hernia (new or recurrent) present for 12 months or more; with both of the following present for 12 months or more: size equal to 15 cm or greater in one dimension; and pain when performing two of
30 percent rating is assigned for an irreparable hernia (new or recurrent) present for 12 months or more; with both of the following present for 12 months or more: size equal to 3 cm or greater but less than 15 cm in one dimension; and pain when performing at least two of the following activities: (1) bending over, (2) ADLs, (3) walking, and (4) climbing stairs. A 60 percent rating is assigned for an irreparable hernia (new or recurrent) present for 12 months or more; with both of the following present for 12 months or more: size equal to 15 cm or greater in one dimension; and pain when performing two of the following activities: (1) bending over, (2) ADLs, (3) walking, and (4) climbing stairs. A 100 percent rating is assigned for irreparable hernia (new or recurrent) present for 12 months or more; with both of the following present for 12 months or more: size equal to 15 cm or greater in one dimension; and pain when performing at least three of the following activities: (1) bending over, (2) ADLs, (3) walking, and (4) climbing stairs.

Turning to the evidence of record, the Veteran's private treatment records reflect that he underwent a laparoscopic cholecystectomy in June 2014, wherein he was noted to have an existing umbilical hernia. Thereafter, his private treatment records indicate he underwent a hernia repair. Additionally, VA treatment records dated in July 2017, October 2017, January 2018, and October 2022 reflect examination of the Veteran's abdomen showed no hernia.

Further, a January 2020 VA examination report reflects that during the Veteran's gallbladder removal procedure in June 2014, he was noted to have an existing umbilical hernia, and he subsequently underwent a hernia repair in 2014. Here, the examiner indicated that since such time, there had been no recurrence for the hernia. The examiner further indicated that there was no hernia detected, the Veteran had a healed postoperative ventral hernia repair, and there was no indication for a supporting belt. A September 2020 VA examination report reflects the examiner found there was no evidence of a hernia or scarring at such time. At an April 2023 VA examination, the Veteran complained of pain, infection, adhesion, and bowel obstruction. However, despite such subjective complaints, the examiner indicated that the Veteran had underwent a hernia repair. Here, such examination report is negative for any evidence of a recurrence of a hernia or residual symptoms following the repair. A May 2024 VA examination report reflects that the Veteran underwent a laparoscopic hernia repair surgery, and a current/recurrent hernia was not present upon examination or had been documented.

Thus, while the Veteran has reported symptoms that he believes are related to the recurrence of his umbilical hernia, he, as a lay person, is not competent to associate his complaints to a specific diagnosis. Furthermore, as the evidence shows that the Veteran's residuals of umbilical hernia repair did not result in an irreparable (new or recurrent) hernia, muscle weakening, or the use of a supporting belt, a compensable rating for such disability is not warranted.

4. Entitlement to an initial compensable rating for scar status post hernia surgery.

Since April 25, 2017, the date of service connection, the Veteran's scar status post hernia surgery is rated as noncompensably disabling pursuant to DC 7805. 38 C.F.R. § 4.118.

In this regard, scars are rated under 38 C.F.R. § 4.118, DCs 7800 through 7805. During the pendency of the appeal, VA amended the criteria for rating the skin, to include scars. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018). As pertinent to the instant appeal, such amendment changed DC 7801 by removing the term "deep and nonlinear" and replacing it with "associated with underlying soft tissue damage," and changed DC 7802 by removing the term "superficial and nonlinear" and replacing it with "not associated with underlying soft tissue damage." Such also amended the accompanying notes to read: Note (1): For the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk
83 Fed. Reg. 32,592 (July 13, 2018). As pertinent to the instant appeal, such amendment changed DC 7801 by removing the term "deep and nonlinear" and replacing it with "associated with underlying soft tissue damage," and changed DC 7802 by removing the term "superficial and nonlinear" and replacing it with "not associated with underlying soft tissue damage." Such also amended the accompanying notes to read: Note (1): For the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2): A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this DC.

With regard to the effective date of the new criteria, VA indicated in the Supplementary Information to the Final Rule that its "intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied." The Veteran's claim in this case was pending prior to the August 13, 2018, effective date of the new criteria and, therefore, the Board will consider both the old and new criteria.

DC 7800 pertains to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. However, as the scar at issue affects the Veteran's anterior trunk, DC 7800 is inapplicable and will not be further considered.

DC 7801 pertains to burn scars or scars due to other causes, not of the head, face, or neck, that are, prior to August 13, 2018, deep and nonlinear and, after such date, associated with underlying soft tissue damage. Under this DC, a 10 percent rating is assigned when the scar(s) cover an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). Higher ratings are available for greater areas affected.

DC 7802 pertains to burn scars or scars due to other causes not of the head, face, or neck that are, prior to August 13, 2018, superficial and nonlinear and, after such date, not associated with underlying soft tissue damage. Under this DC, a single 10 percent rating is assigned when the scar(s) cover an area or areas of 144 square inches (929 sq. cm) or greater.

DC 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation. Three or four scars that are unstable or painful warrant a 20 percent rating, while five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) states that if one or more scars are both unstable and painful, the rater is to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. Note (3).

DC 7805 provides that other scars (including linear scars) and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804 that require the evaluation of any disabling effect(s) not considered in a rating provided under DCs 7800-7804 should be rated under an appropriate DC.

In order to afford the Veteran all possible avenues of entitlement to a higher rating, the Board has considered all applicable DCs, to include both the old and new criteria, as well as his specific reports of his symptoms and the medical evidence.

In this regard, as noted previously, the Veteran's private treatment records reflect that he underwent a laparoscopic cholecystectomy in June 2014, wherein he was noted to have an existing umbilical hernia. Thereafter, the January 2020 VA hernia examination report indicates the Veteran had an umbilicus scar, which measured 2 centimeters (cm) by 0.3 cm. It was noted that his scar was not painful or unstable. While the September 2020 and April 2023 VA hernia examination reports are negative for any complaints, treatment, or diagnosis referable to an abdominal scar, a May 2024 VA scars examination report indicates the Veteran had an anterior trunk scar status post hernia surgery (cholecystectomy), which measured 1 cm by 0.5 cm. It was noted that his scar was not painful, unstable, tender to palpation, or had underlying tissue soft tissue damage. The examiner also determined that the Veteran's anterior trunk scar did not result in limitation of function.

Based on the foregoing, the Board finds that an initial compensable rating for the Veteran's scar status post hernia surgery is not warranted. Specifically, as pertinent to DC 7801, the Board finds that there is no indication the Veteran's abdominal scar is deep or nonlinear, and the evidence shows that such is not associated with underlying soft tissue damage and does not affect an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). Thus, a higher or separate rating under such DC is not warranted. In regard to DC 7802, the Board finds that the evidence does not show the Veteran's abdominal scar affects an area or areas of 144 square inches (929 sq. cm) or greater. Thus, a higher or separate rating under such DC is not warranted.

As pertinent to DC 7804, at no point during the appeal period has the Veteran's abdominal scar been painful or unstable. Thus, higher or separate ratings based on such symptomatology under DC 7804 are not warranted. Finally, as relevant to DC 7805, the evidence does not show, nor does the Veteran contend, that his abdominal scar results in any disabling effects. Consequently, a higher or separate rating is not warranted under DC 7805.

5. Entitlement to an initial rating in excess of 20 percent for Peyronie's disease.

The Veteran has been awarded: (1) service connection for Peyronie's disease, evaluated as 20 percent disabling as of April 25, 2017; and (2) SMC based on loss of use of a creative organ pursuant to U.S.C. § 1114(k), effective April 25, 2017.

Where a condition is unlisted in the specific diagnostic codes, it may be rated under the code for a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The U.S. Court of Appeals for the Federal Circuit clarified that where rating by analogy is appropriate, the symptoms of the unlisted condition need not precisely match the criteria for a rating for the listed disease to warrant the indicated rating. Webb v. McDonough, 71 F.4th. 1377 (2023).

VA amended the regulations pertaining to the evaluation of erectile dysfunction during the pendency of the appeal. The criteria that are most favorable to the Veteran's pending claim will apply; however, an award based on the amended regulations may not be made effective before the effective date of the change. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma, 341 F.3d 1327.

Prior to November 14, 2021, erectile dysfunction was not specifically listed in the rating schedule, so it was rated by analogy under DC 7522, which provided that deformity of the penis with loss of erectile power was rated 20 percent disabling, and the adjudicator should review for entitlement to SMC under 38 C.F.R. § 3.350 based on loss of use of a creative organ. 38 C.F.R. § 4.115b (2021). For this purpose, "deformity" means either internal or external distortion of the penis. Williams v. Wil
.R. § 3.114; Kuzma, 341 F.3d 1327.

Effective November 14, 2021, DC 7522 specifically lists erectile dysfunction and provides for a 0 percent (noncompensable) rating for the condition, with or without penile deformity. 38 C.F.R. § 4.115b (2022).

In this regard, for the entire appeal period, the Veteran is in receipt of the maximum schedular rating of 20 percent for his Peyronie's disease. Specifically, a July 2017 VA treatment record reflects the Veteran's complaint of Peyronie's disease for the previous two months. He further reported that he experienced erectile dysfunction, had plaque buildup, and his erection had a curvature downward (deformity) and was painful. In January 2018, it was noted that the Veteran had a vacuum erection device, and he wished to receive a penile prosthesis.

Additionally, at a January 2020 VA hernia examination, the Veteran reported ongoing penile pain, especially with an erection. A September 2020 VA examination report reflects a diagnosis of Peyronie's disease, and notes the Veteran was taking continuous medication for treatment, he had erectile dysfunction, he was unable to achieve an erection sufficient for penetration and ejaculation without medication, and he had not had an orchiectomy. Upon examination, his penis was normal. At an April 2023 VA examination, the Veteran reported that he felt scar tissue under the skin of his penis (which was later noted to be an active, benign, primary neoplasm), he experienced pain and shortening of his penis, and he had erection problems and a curved penis. Such report also reflects that he was not taking continuous medication for treatment, he had erectile dysfunction, and he had not had an orchiectomy. Upon examination, the examiner indicated that the Veteran's penis was abnormal, noting a penis deformity. At a May 2024 VA examination, the Veteran complained of pain in his penis and erectile dysfunction. It was noted that he was not taking continuous medication for treatment, he had erectile dysfunction, and he had not had an orchiectomy. At such time, the Veteran's penis was not examined per his request.

Based on the foregoing, the Board finds that the Veteran's current 20 percent rating for Peyronie's disease contemplates the entirety of his related symptoms, and such disability does not result in symptomatology that is not contemplated by the currently assigned rating. Thus, referral for extra-schedular consideration is not warranted. 38 C.F.R. § 3.21; Thun v. Peake, 22 Vet. App. 111 (2008); Long v. Wilkie, 33 Vet. App. 167 (2020).

6. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus, type II.

Since April 25, 2017, the date of service connection, the Veteran's diabetes mellitus, type II, is rated as 20 percent disabling pursuant to DC 7913. 38 C.F.R. § 4.119.

In this regard, such DC provides that a 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider,
restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met).

Note (1) provides that complications of diabetes mellitus are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process under DC 7913.

"Regulation of activities" is defined under DC 7913 as the "avoidance of strenuous occupational and recreational activities." Id. Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007).

Due to the successive nature of the rating criteria for diabetes, e.g., the evaluation for each higher disability rating includes the criteria of each lower disability rating, each criterion listed in a rating must be met or more closely approximated in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Stated another way, if a component is not met at any one level, a veteran can only be rated at the level that did not require the missing component.

The Veteran's currently assigned 20 percent rating for his diabetes mellitus, type II, has been assigned based on his need for an oral hypoglycemic agent, insulin, and a restricted diet. Thus, in order to warrant a rating in excess of 20 percent, the evidence must show that, in addition to such requirements, regulation of activities was necessary.

In this regard, the examiners who conducted the relevant September 2020, April 2023, and May 2024 VA examinations found that the Veteran's diabetes did not require regulation of activities, and his VA and private treatment records likewise fail to show such regulation. In fact, his VA treatment records reflect that, in February 2018, he indicated that his farm kept him very active. Additionally, VA treatment records dated in February, May, and July 2019 reveal that, following evaluation for his diabetes, it was noted that the Veteran was encouraged to exercise as tolerated, with a goal of 150 minutes a week. In March 2019, exercise compliance was discussed at a diabetic clinic. In July 2019, the Veteran reported that he exercised with his dog. In October 2019, February 2022, and August 2023, following evaluation for his diabetes, the Veteran was counseled on the importance of regular exercise.

In January 2020, it was noted that the staff nurse reviewed diet and exercise for the Veteran to control his diabetes. In December 2020, the Veteran reported that he was exercising. In March 2021, it was noted that the Veteran walked his dog for exercise. In June 2021, he indicated that he tried to walk for exercise. In May 2023, during a call regarding health coaching for diabetes, the Veteran indicated that he wanted to do more exercise, including walking for 30 minutes every day. In August 2023, following lab results pertaining to his diabetes, the Veteran was told to continue to eat a healthy diet and exercise. Finally, in August 2024, the Veteran reported that he walked for exercise. Thus, the evidence of record does not reflect that his diabetes required regulation of activities. Therefore, as such is required for a 40, 60, or 100 percent rating, a rating in excess of 20 percent for his diabetes is not warranted.

Pursuant to Note (1) of DC 7913, the Board has considered whether the Veteran had separately compensable complications of his diabetes mellitus, type II. In this regard, he has already been awarded separate ratings for diabetic peripheral neuropathy of the bilateral upper and lower extremities.
his diabetes, the Veteran was told to continue to eat a healthy diet and exercise. Finally, in August 2024, the Veteran reported that he walked for exercise. Thus, the evidence of record does not reflect that his diabetes required regulation of activities. Therefore, as such is required for a 40, 60, or 100 percent rating, a rating in excess of 20 percent for his diabetes is not warranted.

Pursuant to Note (1) of DC 7913, the Board has considered whether the Veteran had separately compensable complications of his diabetes mellitus, type II. In this regard, he has already been awarded separate ratings for diabetic peripheral neuropathy of the bilateral upper and lower extremities. However, he does not have any additional separately compensable complications of his diabetes. In this regard, his VA and private treatment records are negative for any additional complications, and the September 2020, April 2023, and May 2024 VA examiners found that the Veteran's diabetes did not result in any complications, to include nephropathy or retinopathy, or other conditions that were caused or aggravated by such disease. Therefore, no additional separately compensable ratings for diabetic complications are warranted.

Based on the foregoing, the Board finds that, as the Veteran's diabetes mellitus, type II, did not necessitate regulation of activities or result in separately compensable complications other than his already separately rated diabetic peripheral neuropathy of the bilateral upper and lower extremities, a rating in excess of 20 percent for such disability is not warranted.

7. Entitlement to an initial rating in excess of 30 percent prior to December 1, 2024, and in excess of 20 percent thereafter for diabetic peripheral neuropathy of the left upper extremity, to include whether the reduction in the rating from 30 percent to 20 percent was proper.

8. Entitlement to an initial rating in excess of 40 percent prior to December 1, 2024, and in excess of 20 percent thereafter for diabetic peripheral neuropathy of the right upper extremity, to include whether the reduction in the rating from 40 percent to 20 percent was proper.

9. Entitlement to an initial rating in excess of 10 percent prior to April 13, 2023, in excess of 20 percent from April 13, 2023, to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the left lower extremity affecting the sciatic nerve, to include whether the reduction in the rating from 20 percent to 10 percent was proper.

10. Entitlement to an initial rating in excess of 10 percent prior to April 13, 2023, in excess of 20 percent from April 13, 2023, to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the right lower extremity affecting the sciatic nerve, to include whether the reduction in the rating from 20 percent to 10 percent was proper.

11. Entitlement to an initial rating in excess of 20 percent prior to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the left lower extremity affecting the femoral nerve, to include whether the reduction in the rating from 20 percent to 10 percent was proper.

12. Entitlement to an initial rating in excess of 20 percent prior to December 1, 2024, and in excess of 10 percent thereafter for diabetic peripheral neuropathy of the right lower extremity affecting the femoral nerve, to include whether the reduction in the rating from 20 percent to 10 percent was proper.

By way of background, in a September 2023 rating decision, service connection was awarded for diabetic peripheral neuropathy of: (1) the bilateral lower extremities affecting the sciatic nerves with initial 10 percent ratings as of October 6, 2017, and 20 percent ratings assigned as of April 13, 2023; (2) the bilateral lower extremities affecting the femoral nerves with initial 20 percent ratings as of April 13, 2023; (3) the left upper extremity with an initial 30 percent rating as of April 13, 2023; and (4) the right upper extremity with an initial 40 percent rating as of April 13, 2023. In this regard, the Veteran has continuously pursued his claims as to the propriety of the initially assigned ratings. 38 C.F.R. § 3.2400; Chisolm v. Collins, 38 Vet. App. 140 (2025).

In the September 2024 rating decision on appeal, the AOJ reduced the disability ratings for the
ities affecting the femoral nerves with initial 20 percent ratings as of April 13, 2023; (3) the left upper extremity with an initial 30 percent rating as of April 13, 2023; and (4) the right upper extremity with an initial 40 percent rating as of April 13, 2023. In this regard, the Veteran has continuously pursued his claims as to the propriety of the initially assigned ratings. 38 C.F.R. § 3.2400; Chisolm v. Collins, 38 Vet. App. 140 (2025).

In the September 2024 rating decision on appeal, the AOJ reduced the disability ratings for the Veteran's diabetic peripheral neuropathy of: (1) the bilateral lower extremities affecting the sciatic nerves from 20 percent to 10 percent, effective December 1, 2024; (2) the bilateral lower extremities affecting the femoral nerves from 20 percent to 10 percent, effective December 1, 2024; (3) the left upper extremity from 30 percent to 20 percent, effective December 1, 2024; and (4) the right upper extremity from 40 percent to 20 percent, effective December 1, 2024. The Board finds that the Veteran has appealed with respect to the propriety of the currently assigned disability ratings, as well as the propriety of the reductions. See Dofflemyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992).

Generally, certain notice and due process procedures are applicable when a disability rating is reduced. However, VA's General Counsel has held that these provisions, which are set forth in 38 C.F.R. § 3.105(e), do not apply where there is no reduction in the amount of compensation payable. As such, these provisions are only applicable where there is both a reduction in evaluation and a reduction or discontinuance of compensation payable. Therefore, where the evaluation of a specific disability is reduced, but the amount of compensation is not reduced, section 3.105(e) is not applicable. See VAOPGCPREC 71-91 (Nov. 1991); Stelzel v. Mansfield, 508 F.3d 1345, 1347-49 (Fed. Cir. 2007).

In this instant case, the reductions in the ratings assigned for the Veteran's diabetic peripheral neuropathy of the lower and upper extremities did not result in a reduction in payment of compensation benefits. Specifically, prior to such reductions, he was in receipt of a 100 percent combined schedular rating and, despite the aforementioned reductions in the September 2024 rating decision, his combined schedular rating remained at 100 percent. Thus, the Board concludes that the procedural requirements outlined in 38 C.F.R. § 3.105(e) are not applicable.

The criteria governing rating reductions for certain service-connected disabilities are found in 38 C.F.R. § 3.344. The Court stated that this regulation applied to ratings that had been continued for long periods of time at the same level (five years or more). Brown v. Brown, 5 Vet. App. 413 (1993). In the present case, the ratings for the Veteran's diabetic peripheral neuropathy of the bilateral lower and upper extremities were in effect from April 13, 2023, to December 1, 2024, i.e., less than five years. Thus, the provisions of 38 C.F.R. § 3.344 pertaining to stabilization of disability evaluations are not applicable. 38 C.F.R. § 3.344(c).

However, the Court also noted in Brown that there are several general VA regulations that apply to all rating reductions regardless of whether the rating has been in effect for five years or more. Id. at 420-421. Specifically, 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history. Furthermore, 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Additionally, in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21; 38 C.F.R. §§ 4.2, 4.10. A claim as to whether
requires that each disability be viewed in relation to its history. Furthermore, 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Additionally, in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21; 38 C.F.R. §§ 4.2, 4.10. A claim as to whether a rating reduction was proper must be resolved in the Veteran's favor unless the Board concludes that the probative evidence weighs against the claim. Id.

In considering the propriety of a reduction, the Board must focus on the evidence of record available to the AOJ at the time the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition had demonstrated actual improvement. Dofflemyer, supra, at 277.

As to the Veteran's diabetic peripheral neuropathy of the bilateral upper extremities, prior to December 1, 2024, his left (minor/non-dominant) upper extremity has been evaluated as 30 percent disabling, and his right (major/dominant) upper extremity has been evaluated as 40 percent disabling pursuant to DC 8513, and both have been evaluated as 20 percent disabling pursuant to DC 8514 thereafter.

Per DC 8513, which pertains to involvement of all radicular nerves, a 20 percent rating is assigned for mild incomplete paralysis of both the major and minor extremity; moderate incomplete paralysis warrants a 40 percent rating in the major extremity and a 30 percent rating in the minor extremity; and severe incomplete paralysis warrants a 70 percent rating in the major extremity and a 60 percent rating in the minor extremity. A maximum 90 percent rating in the major extremity and 80 percent rating in the minor extremity are assigned for complete paralysis.

Per DC 8514, which pertains to the paralysis of the musculospiral (radial) nerve, ratings of 20 percent, 30 percent, and 50 percent are assignable for incomplete paralysis that is mild, moderate, or severe in degree, for the major arm, respectively. Disability ratings of 20 percent, 20 percent, and 40 percent are assignable for incomplete paralysis that is mild, moderate, or severe in degree, for the minor arm, respectively. Complete paralysis of such nerve, which is rated as 70 disabling for the major side and 60 percent disabling for the minor side, contemplates 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 the 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.

As to the Veteran's diabetic peripheral neuropathy of the bilateral lower extremities, such affecting the sciatic nerves have been evaluated as 10 percent disabling prior to April 13, 2023, 20 percent disabling from April 13, 2023, to December 2024, and 10 percent disabling thereafter pursuant to DC 8520. Such affecting the femoral nerves have been evaluated as 20 percent disabling prior to December 1, 2024, and 10 percent disabling thereafter pursuant to DC 8526.

Per DC 8520, which pertains to paralysis of the sciatic nerve, a 10 percent rating is assigned for mild incomplete paralysis; a 20 percent rating is assigned for moderate incomplete paralysis; a 40 percent rating is assigned for moderately severe incomplete paralysis; and a 60 percent rating for severe incomplete paralysis with marked muscular atrophy. Further, an 80 percent rating is warranted where there is complete paralysis of the sciatic nerve where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost.

Per DC 8526, which pertains to paralysis of the femoral nerve, a 10 percent rating is assigned for mild incomplete paralysis; a 20 percent rating is assigned for moderate incomplete paralysis; and a 30 percent rating is assigned for severe incomplete paralysis. Further, a 40 percent rating is warranted where there is complete paralysis of the femoral nerve with paralysis of the
moderately severe incomplete paralysis; and a 60 percent rating for severe incomplete paralysis with marked muscular atrophy. Further, an 80 percent rating is warranted where there is complete paralysis of the sciatic nerve where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost.

VA regulations provide that, in 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 wholly sensory, the rating should be for the mild, or at most, the moderate degree.

Although the words "mild," "moderate," "moderately severe," and "severe" are not defined in the VA rating schedule the Board must evaluate all of the evidence in order to render a decision that is "equitable and just." 38 C.F.R. § 4.6. Additionally, "VA's Adjudication Procedures Manual [M21-1] provides benchmarks for mild, moderate, moderately severe, and severe peripheral nerve conditions," and "[a]lthough the Board is not bound by the M21-1, the standards provided in the M21-1 are 'relevant guidance promulgated for the purpose of facilitating the efficient and proper resolution of claims,' which the Board must consider and address as part of its duty to provide a reasoned explanation for its decision." Chavis v. McDonough, 34 Vet. App. 4, 17-18 (2021) (citing Healey v. McDonough, 33 Vet. App. 321 (2021) and Overton v. Wilkie, 30 Vet. App. 257, 264 (2018)).

In this regard, the M21-1 provides that, in cases where a peripheral nerve disability is only manifested by sensory impairment, 38 C.F.R. § 4.124a directs decision makers to assign the evaluation corresponding with the mild or at most the moderate degree of impairment. M21-1, V.iii.12.A.2.b. Such further provides that, to make a choice between mild and moderate, the adjudicator should consider the evidence of record and the following guidelines:

" The mild level of evaluation would be more reasonably assigned when sensory symptoms are:

" recurrent but not continuous;

" assigned a lower medical grade reflecting less impairment;

" and/or affecting a smaller area in the nerve distribution.

" Reserve the moderate level of evaluation for the most significant and disabling cases of sensory-only involvement. These are cases where the sensory symptoms are:

" continuous;

" assigned a higher medical grade reflecting greater impairment; and/or

" affecting a larger area in the nerve distribution.

The M21-2 also provides general guidelines for each level of incomplete paralysis of the upper and lower peripheral nerves. M21-1, V.iii.12.A.2.c. A "mild" degree of incomplete paralysis is characterized by disability limited to sensory deficits that are lower graded, less persistent, or affecting a small area. A very minimal reflex or motor abnormality potentially could also be consistent with mild incomplete paralysis.

"Moderate" is the maximum evaluation available for the most significant cases of sensory-only impairment and is characterized by symptoms described by the claimant and medically graded as significantly disabling and involving a larger area in the nerve distribution. Other sign or symptom combinations that may fall into the moderate category include combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment, such as weakness or diminished or hyperactive reflexes (with or without
.2.c. A "mild" degree of incomplete paralysis is characterized by disability limited to sensory deficits that are lower graded, less persistent, or affecting a small area. A very minimal reflex or motor abnormality potentially could also be consistent with mild incomplete paralysis.

"Moderately severe" contemplates motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability. Additionally, atrophy may be present; however, for marked muscular atrophy, a rating contemplating severe incomplete paralysis is warranted.

"Severe" is characterized by motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe long-standing neuropathy cases. For the sciatic nerve, marked muscular atrophy is expected. Although severe incomplete paralysis cases should show findings substantially less than those for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contain signs or symptoms that resemble some of those expected in cases of complete paralysis of the nerve.

Diabetic peripheral neuropathy of the bilateral upper extremities

The Board finds that, for the period prior to December 1, 2024, ratings in excess of 30 percent for the Veteran's left (minor) upper extremity and in excess of 40 percent for his right (major) upper extremity are not warranted. In that regard, the evidence of record must reflect that such disabilities produce severe incomplete paralysis of all radicular groups so as to warrant a higher rating under DC 8513. However, the evidence of record fails to reflect that the Veteran's disabilities are of such severity. In that regard, his April 2023 VA examination report reflects the examiner's assessment that the Veteran's diabetic peripheral neuropathy of the bilateral upper extremities was productive of moderate incomplete paralysis of the affected nerves. Additionally, while the Veteran demonstrated slight deviation from normal strength measured as 4/5 (representing active movement against some resistance) in his bilateral upper extremities, there was no muscle atrophy and no impairment of his deep tendon reflexes. Further, sensation in his bilateral upper extremities was entirely normal. Moreover, he only reported moderate constant pain, paresthesias and/or dysesthesias, and numbness. Thus, the Veteran's overall clinical picture based on the results of these neurological tests fails to indicate that his diabetic peripheral neuropathy of the bilateral upper extremities approximated severe incomplete paralysis of all radicular nerves, thereby warranting higher ratings than those currently assigned for the period prior to December 1, 2024.

Diabetic peripheral neuropathy of the bilateral lower extremities

With regard to the period prior to April 13, 2023, when the Veteran is in receipt of 10 percent ratings for diabetic peripheral neuropathy of the bilateral lower extremities affecting the sciatic nerves, such ratings have been assigned based on evidence of mild incomplete paralysis; thus, higher ratings of 20 percent require evidence that such produce at least moderate incomplete paralysis of the sciatic nerves. However, at an October 2017 VA examination, he demonstrated no impairment of muscle strength, he did not have muscle atrophy, and his gait was normal. Additionally, while the Veteran's vibratory sensation was slightly decreased in his feet, pinprick, light touch, and position sense were intact. Further, while he also had absent deep tendon reflexes in his ankles, his reflexes were decreased, but not absent, in his knees. Moreover, the Veteran's VA treatment records reflect that, in June 2017, his sensation was intact and symmetric to light touch in his bilateral lower extremities. In August 2017, his deep tendon reflexes and sensation were normal.

In March 2018, the Veteran denied weakness, numbness, or tingling. In October 2018, he complained of tingling/numbness under his toes on the right foot. A December 2019 VA treatment record reflects the Veteran's denial of extremity numbness. In November 2021, he denied neuropathy. In December 2022, it was noted that the Veteran had 5/5 muscle strength in his lower extremities. VA treatment records dated in February, May, July, and October 2019; July and September 2020; March, June, and November 2021; February and September 2022; and January 2023 reflect the Veteran denied weakness and a peripheral burning sensation in his limbs. In March 2019, and October and November 2022, it was noted that he had no neurological deficits. The Board finds that these clinical findings, when viewed in their totality, fail to suggest that the Veteran's symptoms were productive of moderate incomplete paralysis of his sciatic nerves, warranting the next higher ratings of 20 percent for the period prior to April 13, 2023.

With regard to the period commencing on April 13, 2023, when the Veteran is in receipt of 20 percent ratings assigned based on moderate incomplete paralysis of the sciatic nerves, in order to warrant the next higher rating of 40 percent, the evidence must reflect that such disabilities result in moderately severe incomplete paralysis of the sciatic nerves. At the Veteran's April 2023 VA examination, the examiner found that such disability produced moderately severe incomplete paralysis of the sciatic nerves; however, the Board finds such characterization of the severity of the Veteran's sciatic nerve impairment was inconsistent with the clinical findings recorded during such examination. Specifically, while the Veteran demonstrated slight deviation from normal strength measured as 4/5 (representing active movement against some resistance) in his bilateral lower extremities, there was no muscle atrophy, no impairment of his deep tendon reflexes, and his sensation was entirely normal. He also reported moderate constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness. Based on this clinical evidence, the Board finds such subjective symptoms and minimal objective findings result in, at most, moderate incomplete paralysis of the sciatic nerves. As such, the Board finds that the record fails to reflect a basis for awarding the next higher ratings of 40 percent for moderately severe incomplete paralysis of the sciatic nerves for the period commencing on April 13, 2023.

With regard to the period prior to December 1, 2024, when the Veteran is in receipt of 20 percent ratings assigned based on moderate incomplete paralysis of the femoral nerves, in order to warrant the next higher rating of 30 percent, the evidence must reflect that such disabilities result in severe incomplete paralysis of the femoral nerves. However, during the Veteran's April 2023 VA examination, the examiner found that such disability produced, at most, moderate incomplete paralysis of the femoral nerves. Further, the Board finds that the examiner's expert characterization of the severity of the Veteran's femoral nerve impairment is consistent with the clinical findings recorded during this examination (as detailed above). Based on such clinical evidence, the Board finds that the examiner's assessment of the Veteran's diabetic peripheral neuropathy of the lower extremities affecting the femoral nerves as producing moderate, but not severe, impairment of his femoral nerves is supported by the record. As such, the Board finds that the record fails to reflect a basis for awarding the next higher ratings of 30 percent for severe incomplete paralysis of the femoral nerves for the period prior to December 1, 2024.

Reductions

At the May 2024 VA examination, which was the basis for the reductions in the ratings assigned for the Veteran's diabetic peripheral neuropathy of the bilateral lower and upper extremities, the examiner assessed the Veteran's diabetic peripheral neuropathy of the bilateral upper extremities as productive of mild incomplete paralysis of only the radial nerves. Here, it was noted that the Veteran's median and ulnar nerves were found to be normal. Additionally, the examiner assessed his diabetic peripheral neuropathy of the bilateral lower extremities as productive of mild incomplete paralysis of the sciatic and femoral nerves. Further, during the examination, while the Veteran had decreased, but not absent, sensation to light touch/monofilament testing of his hands, fingers, ankles, lower legs, feet, and toes
which was the basis for the reductions in the ratings assigned for the Veteran's diabetic peripheral neuropathy of the bilateral lower and upper extremities, the examiner assessed the Veteran's diabetic peripheral neuropathy of the bilateral upper extremities as productive of mild incomplete paralysis of only the radial nerves. Here, it was noted that the Veteran's median and ulnar nerves were found to be normal. Additionally, the examiner assessed his diabetic peripheral neuropathy of the bilateral lower extremities as productive of mild incomplete paralysis of the sciatic and femoral nerves. Further, during the examination, while the Veteran had decreased, but not absent, sensation to light touch/monofilament testing of his hands, fingers, ankles, lower legs, feet, and toes and normal sensation on testing to his shoulder areas, inner/outer forearms, and knees/thighs. While he also had decreased, but not absent, cold sensation of the bilateral lower and upper extremities, and vibration sensation of the bilateral lower extremities, he demonstrated normal muscle strength and deep tendon reflexes in his bilateral lower and upper extremities, he had normal vibration sensation in his bilateral upper extremities, he had normal position sense, and there was no muscle atrophy. Moreover, the Veteran only reported mild constant pain in his bilateral lower extremities, mild intermittent pain in his bilateral upper extremities, mild paresthesias and/or dysesthesias in his bilateral upper extremities - and moderate in his bilateral lower extremities, and mild numbness in his bilateral upper and lower extremities. With regard to such reported symptoms, the examiner assessed his overall bilateral lower and upper extremity diabetic sensory neuropathy as mild. The Board finds that these clinical findings, when viewed in their totality, fail to suggest that the Veteran's diabetic peripheral neuropathy of the bilateral lower and upper extremities were productive of more than mild incomplete paralysis of the radial, sciatic, and femoral nerves, to warrant ratings in excess of 20 percent pursuant to DC 8514, and in excess of 10 percent pursuant to DC 8520 and DC 8526 as of December 1, 2024.

Based on the foregoing evidence, the Board finds that the evidence of record at the time of the September 2024 rating decision demonstrated an improvement in the Veteran's service-connected diabetic peripheral neuropathy of the lower and upper extremities in regard to his ability to function under ordinary conditions of life and work. In this regard, the May 2024 VA examination was complete and thorough; the Veteran's claims file was reviewed and a complete medical history was obtained from him; and the examination clearly addressed the severity of the Veteran's nerve disabilities for rating purposes, which showed that he only met the criteria for 20 percent ratings for his diabetic peripheral neuropathy of the bilateral upper extremities, and 10 percent ratings for his diabetic peripheral neuropathy of the bilateral lower extremities affecting the sciatic and femoral nerves. Further, the Board acknowledges that the Veteran continued to have pain, numbness, and paresthesia in his hands and feet; however, the Board finds that the most probative evidence reflects that his diabetic peripheral neuropathy of the bilateral lower and upper extremities had improved. Accordingly, the evidence of record persuasively supports a finding that the reduction was proper.

Other Considerations

In making its determinations in the instant case, the Board acknowledges the Veteran's belief that his somatic symptom disorder, cholecystectomy with hepatic steatosis, status post umbilical hernia, scar status post hernia surgery, Peyronie's disease, diabetes mellitus, type II, and diabetic peripheral neuropathy of the bilateral lower and upper extremities are more severe than as reflected by the currently assigned ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that he is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Rather, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive.

The Board has also considered whether additional staged ratings are appropriate for the Veteran's service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such disabilities is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claims adjudicated herein. Doucette v.
Vet. App. 456, 462 (2007). Rather, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive.

The Board has also considered whether additional staged ratings are appropriate for the Veteran's service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such disabilities is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (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).

In reaching the foregoing determinations, the Board has also considered the applicability of the benefit of the doubt doctrine. However, for the reasons previously discussed, the evidence of record persuasively weighs against the Veteran's claims. Therefore, the benefit of the doubt doctrine is inapplicable, and his initial rating claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

13. Entitlement to SMC based on the need for aid and attendance of another person.

The Veteran and his representative have advanced the narrow theory of entitlement to SMC based on the need for the regular aid and attendance of another person. They do not assert that the Veteran has anatomical loss or loss of use of both feet, or one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less, or is permanently bedridden.

In this regard, a veteran will be considered in need of regular aid and attendance if he or she is: (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to five degrees or less; (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.351(c)

Factual need for aid and attendance is based on the following criteria: the inability of the veteran to dress or undress himself or herself, or to keep himself or herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); the inability of a veteran to feed himself or herself through the loss of coordination of upper extremities or through extreme weakness; the inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a veteran from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a).

It is not required that all of the disabling conditions enumerated in the provisions of 38 C.F.R. § 3.352(a) be found to exist to establish eligibility for aid and attendance, but such eligibility requires at least one of the enumerated factors be present. The particular personal function which a veteran was unable to perform should be considered in connection with his or her condition as a whole and it is only necessary that the evidence establishes that a veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Turco v. Brown, 9 Vet. App. 222 (1996).

For the entire appeal period stemming from his April 25, 2017, claim, the Veteran is service-connected for somatic symptom disorder, polycythemia vera, Peyronie's disease, diabetes mellitus, type II, cholecystectomy with hepatic steatosis, status post umbilical hernia, scar status post hernia surgery, bilateral lower extremity diabetic peripheral neuropathy affecting the sciatic nerves (as of October 6, 2017), bilateral lower extremity diabetic peripheral neuropathy affecting the femoral nerves (as of April 13, 2023), and bilateral upper extremity diabetic peripheral neuropathy (as of April 13, 2023). The Veteran is also in receipt of a TDIU and SMC at the (k) and (s) levels
, the Veteran is service-connected for somatic symptom disorder, polycythemia vera, Peyronie's disease, diabetes mellitus, type II, cholecystectomy with hepatic steatosis, status post umbilical hernia, scar status post hernia surgery, bilateral lower extremity diabetic peripheral neuropathy affecting the sciatic nerves (as of October 6, 2017), bilateral lower extremity diabetic peripheral neuropathy affecting the femoral nerves (as of April 13, 2023), and bilateral upper extremity diabetic peripheral neuropathy (as of April 13, 2023). The Veteran is also in receipt of a TDIU and SMC at the (k) and (s) levels.

Notably, the record demonstrates that, in June 2019, the Veteran and his son (the appointed primary family caregiver) inquired about the Comprehensive Assistance to Family Caregiver Program and submitted an application; however, later the same month it was determined that they were not eligible to receive such benefits. At such time, the Veteran was informed that he could explore an application to receive aid and attendance if he required personal care for daily living; however, he did not do so. Rather, in September 2021, the Veteran and his son submitted another application for the Program of Comprehensive Assistance for Family Caregivers; however, they withdrew such application a few days later. Additionally, VA treatment records dated in June 2017 and May 2021 reflect that the Veteran was independent with his activities of daily living and did not need support.

Nonetheless, in February 2022, the Veteran, through his representative, first reported his need for regular aid and attendance due to his service-connected psychiatric disability. Specifically, in a February 2022 written statement, the Veteran's son, who serves as his primary caretaker, indicated that he moved in with the Veteran in 2013 to assist him with his activities of daily living. Here, G.E. reported that the Veteran struggled with memory deficits and with completing multi-step tasks, so he cooked most of his meals, took care of the household chores, drove him wherever he needed to go (to include his doctor appointments and the grocery store), helped him shop for groceries, scheduled his doctor appointments, and reminded him to take his medication twice a day. He further reported that he had to monitor what the Veteran ate to prevent health problems with his diabetes.

Additionally, in a February 2024 evaluation report, a physician assistant, L.B., determined that, after a review of the pertinent records, the Veteran's medical history, and the medical literature, it was at least as likely as not that the Veteran required regular aid and attendance as of January 2020 due to his service-connected somatic symptom disorder and polycythemia vera. In this regard, she reported that, as a result of such service-connected disabilities, he had been unable to perform activities of daily living, including maintenance of personal hygiene and keeping himself ordinarily clean and presentable, and has required assistance on a regular basis to protect himself from hazards or dangers incident to his daily environment due to his imbalance and memory impairment. Here, L.B. noted that the Veteran's neglect of personal appearance and hygiene, as well as an intermittent inability to perform activities of daily living, was demonstrated in the January 21, 2020, and October 2021 VA mental disorders examination reports. She further noted that in March 2021, the Veteran reported that his polycythemia vera made it hard to walk and keep his balance; his depression kept him from leaving the house unless necessary; and he had a lot of outbursts when in public. Additionally, L.B. indicated that in the February 2022 written statement from the Veteran's son, he reported that he had assisted the Veteran with his activities of daily living since 2013. She further indicated that the Veteran's medical records, previous VA examination reports, personal statements, and his son's statement showed a long history of neglect of hygiene and an inability to perform activities of daily living. L.B. concluded that it was well known in the medical community, and discussed in medical literature, that mental health disorders could significantly interfere with activities of daily living, as has been the case with the Veteran.

Based on the evidence described above and, in particular, L.B.'s February 2024 evaluation report reflecting that the Veteran met the criteria for SMC as of January 2020, the Board finds that, as of January 21, 2020, he has required the regular aid and attendance of another person as a result of his service-connected disabilities. Therefore, as of such date, the Board finds that the criteria for SMC based on the need for regular aid and attendance have been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. However, the Board finds that, prior to such date, the evidence does not demonstrate that the Veteran's service-connected disabilities were so severe that he required the regular aid and attendance of another person. While the record reflects that, prior to January 2020, the Veteran had difficulties with memory and disorientation, and his son had assisted him with activities of daily living since 2013, the Board finds there is no evidence to suggest that such assistance was medically necessary or that the Veteran was precluded from performing activities of daily living by himself, and without assistance, due to his service-connected disabilities. Notably, L.B., a medical professional, considered the Veteran's symptoms since as early as August 2016 but determined that his service-connected disabilities have at least as likely as not been of such significance that he needed regular aid and attendance only as of January 2020. Thus, while the Board has considered the applicability of the benefit of the doubt doctrine, the weight of the probative evidence is against the Veteran's claim for SMC based on the need for aid and attendance of another person prior to January 21, 2020. Thus, such doctrine is inapplicable in such regard, and such aspect of his claim must be denied. Id.

M. M. Celli

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Koria B. Stanton, 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.

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