DIABETES MELLITUS

REBECCA N. POULSON · 2026 · Case ID: A26039932

MIXED

Summary

The veteran, who served from November 1972 to November 1975, appeals decisions denying increased evaluations for diabetes mellitus and diabetic neuropathy, as well as earlier effective dates for these conditions and other benefits. The Board granted earlier effective dates for increased ratings of 30% for bilateral femoral nerve neuropathy and separate ratings for bilateral sciatic nerve neuropathy, effective February 25, 2019. However, the Board denied higher evaluations for these neuropathies, finding that the evidence did not support complete paralysis or marked muscle atrophy. The Board also denied an increased evaluation for diabetes mellitus beyond the 40% rating already granted, finding insufficient evidence of hospitalizations for ketoacidosis or hypoglycemia. Service connection for depressive disorder was granted, with the Board adopting the favorable finding from a subsequent VA rating decision that it was related to service-connected disabilities. The Board denied earlier effective dates for TDIU and DEA benefits, as well as for diabetic nephropathy, finding the claim date for these issues to be February 25, 2019, and no entitlement arose earlier. The Board also denied a challenge to the competency of a VA examiner, finding no specific challenge raised.

Rationale

Insufficient evidence of hospitalizations for ketoacidosis/hypoglycemia; Conflicting examiner findings on hospitalizations; Veteran's subjective reports not sufficient for higher rating

Special Benefit

SMC - AID & ATTENDANCE; TDIU

Docket No.

200824-105704

Full Decision Text

Citation Nr: A26039932
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 200824-105704
DATE: April 29, 2026

ORDER

An initial evaluation in excess of 40 percent for diabetes mellitus is denied.

An effective date of February 25, 2019, but no earlier, for an award of an increased evaluation from 20 to 30 percent for diabetic peripheral neuropathy affecting the left femoral nerve is granted.

An initial evaluation in excess of 30 percent for diabetic neuropathy affecting the left femoral nerve is denied.

An effective date of February 25, 2019, but no earlier, for an award of an increased evaluation from 20 to 30 percent for diabetic peripheral neuropathy affecting the right femoral nerve is granted.

An initial evaluation in excess of 30 percent for diabetic neuropathy affecting the right femoral nerve is denied.

An effective date of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting the left sciatic nerve is granted.

An initial evaluation in excess of 40 percent for diabetic neuropathy affecting the left sciatic nerve is denied.

An effective date of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting the right sciatic nerve is granted.

An initial evaluation in excess of 40 percent for diabetic neuropathy affecting the right sciatic nerve is denied.

An effective date of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting all left radicular nerve groups is granted.

An initial evaluation of 60 percent, but not in excess thereof, for diabetic neuropathy affecting all left radicular nerve groups is granted.

An effective date of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting all right radicular nerve groups is granted.

An initial evaluation of 70 percent, but not in excess thereof, for diabetic neuropathy affecting all right radicular nerve groups is granted.

An effective date of February 25, 2019, but no earlier, for an award of special monthly compensation (SMC) based on the need for aid and attendance is granted.

An effective date earlier than February 25, 2019 for an award of a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is denied.

An effective date earlier than February 25, 2019 for an award of basic eligibility to dependents' educational assistance (DEA) benefits is denied.

An effective date earlier than February 25, 2019 for an award of service connection for diabetic nephropathy with renal insufficiency is denied.

Service connection for depressive disorder is granted.

FINDINGS OF FACT

1. The Veteran's diabetes mellitus is not productive of episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider.

2. The Veteran's diabetic peripheral neuropathy was productive of severe incomplete paralysis of the left femoral nerve as of his February 25, 2019 claim date.

3. The Veteran's diabetic peripheral neuropathy of the left femoral nerve manifests more closely to severe symptoms.

4. The Veteran's diabetic peripheral neuropathy was productive of severe incomplete paralysis of the right femoral nerve as of his February 25, 2019 claim date.

5. The Veteran's diabetic peripheral neuropathy of the right femoral nerve manifests more closely to severe symptoms.

6. The Veteran's diabetic peripheral neuropathy was productive of moderately severe incomplete paralysis of the left sciatic nerve as of his February 25, 2019 claim date.

7. The Veteran's diabetic peripheral neuropathy is not productive of complete paralysis of the left sciatic nerve or severe incomplete paralysis with marked muscle atrophy.

8. The Veteran's diabetic peripheral neuropathy was productive of moderately severe incomplete paralysis of the right sciatic nerve as of his February 25, 2019 claim date.

9. The Veteran's diabetic peripheral neuropathy is not productive of complete paralysis of the right sciatic nerve or severe incomplete paralysis with marked muscle atrophy.

10. The Veteran's diabetic peripheral neuropathy was productive of severe incomplete paralysis all left radicular nerve groups as of his February 25, 2019 claim date.

11. The Veteran's diabetic peripheral neuropathy is productive of severe incomplete paralysis but not complete paralysis of all left radicular nerve groups.

12. The Veteran's diabetic peripheral neuropathy was productive of severe incomplete paralysis all right radicular nerve groups as of his February 25, 2019 claim date.

13. The Veteran
atic nerve as of his February 25, 2019 claim date.

9. The Veteran's diabetic peripheral neuropathy is not productive of complete paralysis of the right sciatic nerve or severe incomplete paralysis with marked muscle atrophy.

10. The Veteran's diabetic peripheral neuropathy was productive of severe incomplete paralysis all left radicular nerve groups as of his February 25, 2019 claim date.

11. The Veteran's diabetic peripheral neuropathy is productive of severe incomplete paralysis but not complete paralysis of all left radicular nerve groups.

12. The Veteran's diabetic peripheral neuropathy was productive of severe incomplete paralysis all right radicular nerve groups as of his February 25, 2019 claim date.

13. The Veteran's diabetic peripheral neuropathy is productive of severe incomplete paralysis but not complete paralysis of all right radicular nerve groups.

14. The Veteran's service-connected disabilities rendered him so helpless as to be in need of regular aid and attendance as of his February 25, 2019 claim date.

15. Prior to February 25, 2019, the Veteran had not claimed a TDIU, nor did he have a pending increased rating claim currently before the Board.

16. Prior to February 25, 2019, the Veteran is not in receipt of a TDIU or a combined schedular rating of 100 percent.

17. VA did not receive from the Veteran a claim of service connection for diabetic nephropathy with renal insufficiency earlier than February 25, 2019.

18. An April 2024 rating decision granted service connection for depressive disorder based on a favorable finding that it is related to the Veteran's service-connected disabilities.

CONCLUSIONS OF LAW

1. The criteria for an initial evaluation in excess of 40 percent for diabetes mellitus are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2025).

2. The criteria for an effective of February 25, 2019, but no earlier, for an award of an increased evaluation from 20 to 30 percent for diabetic peripheral neuropathy affecting the left femoral nerve are met. 38 U.S.C. §§ 1155, 5110 (2018); 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8526 (2025).

3. The criteria for an initial evaluation in excess of 30 percent for diabetic neuropathy affecting the left femoral nerve are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2025).

4. The criteria for an effective of February 25, 2019, but no earlier, for an award of an increased evaluation from 20 to 30 percent for diabetic peripheral neuropathy affecting the right femoral nerve are met. 38 U.S.C. §§ 1155, 5110 (2018); 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8526 (2025).

5. The criteria for an initial evaluation in excess of 30 percent for diabetic neuropathy affecting the right femoral nerve are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2025).

6. The criteria for an effective of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting the left sciatic nerve are met. 38 U.S.C. §§ 1155, 5110 (2018); 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8520 (2025).

7. The criteria for an initial evaluation in excess of 40 percent for diabetic neuropathy affecting the left sciatic nerve are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2025).

8. The criteria for an effective of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting the right sciatic nerve are met. 38 U.S.C. §§ 1155, 5110 (2018); 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8520 (2025).

9. The criteria for an initial evaluation in excess of 40 percent for diabetic neuropathy affecting the right sci
not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2025).

9. The criteria for an initial evaluation in excess of 40 percent for diabetic neuropathy affecting the right sciatic nerve are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2025).

10. The criteria for an effective of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting all left radicular nerve groups are met. 38 U.S.C. §§ 1155, 5110 (2018); 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8513 (2025).

11. The criteria for an initial evaluation of 60 percent, but not in excess thereof, for diabetic neuropathy affecting all left radicular nerve groups, are met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.124a, Diagnostic Code 8513 (2025).

12. The criteria for an effective of February 25, 2019, but no earlier, for an award of service connection for diabetic peripheral neuropathy affecting all right radicular nerve groups are met. 38 U.S.C. §§ 1155, 5110 (2018); 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8513 (2025).

13. The criteria for an initial evaluation of 70 percent, but not in excess thereof, for diabetic neuropathy affecting all right radicular nerve groups, are met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.124a, Diagnostic Code 8513 (2025).

14. The criteria for an effective of February 25, 2019, but no earlier, for an award of SMC based on the need for aid and attendance are met. 38 U.S.C. §§ 1114(l), 1155, 5110 (2018); 38 C.F.R. §§ 3.400, 3.350(b), 3.352(a) (2025).

15. The criteria for an effective earlier than February 25, 2019 for an award of a TDIU are not met. 38 U.S.C. § 5110 (2018); 38 C.F.R. § 3.400 (2025).

16. The criteria for an effective date earlier than February 25, 2019 for an award of basic eligibility for DEA benefits are not met. 38 U.S.C. §§ 3500, 3501, 3510, 5110 (2018); 38 C.F.R. §§ 3.400, 21.3021 (2024).

17. The criteria for an effective date earlier than February 25, 2019, for an award of service connection for diabetic nephropathy with renal insufficiency are not met. 38 U.S.C. § 5110 (2018); 38 C.F.R. § 3.400 (2025).

18. The criteria for service connection for depressive disorder are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2025).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from November 1972 to November 1975.

This appeal is before the Board of Veterans' Appeals (Board) from January 2020 and August 2020 rating decisions of the agency of original jurisdiction (AOJ), a Department of Veterans Affairs (VA) Regional Office (RO).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from November 1972 to November 1975.

In his August 2020 notice of disagreement, the Veteran elected the Hearing docket. In April 2024, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. Therefore, the Board may only consider the evidence of record at the time of the applicable AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the applicable decision on appeal and prior to the April 2024 Board hearing, or (2) more than 90 days following the April 2024 hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

The Veteran submitted evidence outside the window described above. If he 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, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a supplemental claim are included with this decision.

The Veteran's August 2020 notice of disagreement also purported to appeal additional issues from a January 2020 rating decision, specifically entitlement to an increased evaluation for diabetic nephropathy with renal cysts and service connection for heart disease. The January 2020 rating decision had already been subject to higher-level review (HLR), and the May 2020 HLR decision had been appealed by a June 2020 notice of disagreement. The Board adjudicated these issues in a January 2022 Board decision, and no testimony or evidence was received regarding these issues at the Veteran's April 2024 hearing or within 90 days thereafter. As the record pertinent to these issues is thus identical to the record for the January 2022 Board decision, the Board finds this appeal to be duplicative as to these issues and they will not be addressed further herein.

The file contains a December 2020 correspondence from the Veteran's attorney in which she appears to challenge the competency of an unidentified VA examiner. It is presumed that VA examiners are competent unless an appellant expressly challenges an examiner's competency. See Fears v. Wilkie, 31 Vet. App. 308 (2019). The Board acknowledges that once a request is made for information as to the competency of an examiner, a claimant has the right, absent unusual circumstances, to the curriculum vitae and other information about qualifications of the medical examiner, as required by VA's duty to assist. Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019). Here, however, the Veteran has been afforded many VA examinations and the Veteran's representative has not identified any specific examination or examiner for which she is requesting records. Moreover, neither the Veteran nor his representative have specifically challenged the qualifications of any examiner. Under these circumstances, the Board finds that the Veteran's representative has not "raise[d] a challenge to the competence of the medical examiner" warranting remand pursuant to Francway. Further, because the challenge was received after the rating decision on appeal, the failure to provide the VA examiner's qualifications to the Veteran does not represent a pre-decisional duty to assist error. Thus, no further action is warranted.

Earlier Effective Dates and Increased Ratings

Generally, the effective date of an award of an increased rating is the date of receipt of a claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. If the earliest date that the claimed increase in disability had occurred was factually ascertainable based on all evidence of record within one year prior to the receipt of claim, the effective date is the date such increase occurred. 38 C.F.R. § 3.400
to provide the VA examiner's qualifications to the Veteran does not represent a pre-decisional duty to assist error. Thus, no further action is warranted.

Earlier Effective Dates and Increased Ratings

If a claimant submits an?intent to file?a claim, VA will recognize the receipt date of the intent to file a claim as the date of claim so long as VA receives the successfully completed claim form within a year.? An?intent to file?a claim can be submitted in one of the following three ways: (1) saved electronic application; (2) written intent on prescribed intent to file a claim form; or (3) an oral intent communication to designated VA personnel and recorded in writing.? 38?C.F.R. §?3.155(b).? On its face, the regulation excludes supplemental claims from taking the claim date of an intent to file, but this exclusion was struck down by Military-Veterans' Advocacy v. Sec'y of Veterans Affairs, 7 F.4th 1110, 1117 (Fed. Cir. 2021).

A claim date may be maintained by?continuously pursuing?a claim or issue via supplemental claim, request for HLR, appeal to the Board, or appeal to the United States Court of Appeals for Veterans Claims (CAVC), provided such options are timely exercised within one year of the issuance of the decision.? 38 C.F.R. § 3.2500. For supplemental claims received more than one year after the date on which the AOJ issues notice of a decision, the effective date will not be earlier than the date of receipt of the supplemental claim.? 38 C.F.R. §?3.2500(h)(2).

Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the claimant's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10.

When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The claimant's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).

With regard to the Veteran's neuropathy claims, the Board notes that "VA's Adjudication Procedures Manual 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. 1, 17-18 (2021) (citing Healy v. McDonough, 33 Vet. App. 321 (2021) and Overton v. Wilkie, 30 Vet. App. 257, 264 (2018)). The following relevant standards are provided in the M21-1, Part V, Subpart iii, Chapter 12, Section A.2.c:

"Mild" is the default evaluation assigned based on the symptoms, however slight, as long as they were sufficient to support a diagnosis of the peripheral nerve impairment. In general look for a 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 Overton v. Wilkie, 30 Vet. App. 257, 264 (2018)). The following relevant standards are provided in the M21-1, Part V, Subpart iii, Chapter 12, Section A.2.c:

"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 sensory impairment) graded as medically moderate.

"Moderately-severe" is only applicable for involvement of the sciatic nerve and is the maximum rating for sciatic nerve neuritis not characterized by organic changes specified in 38 C.F.R. § 4.123. Motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability is expected. Atrophy may be present.

"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 longstanding 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. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain should be rated as high as severe incomplete paralysis of the nerve.

Rather than applying a mechanical formula, VA must evaluate all evidence so that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6.

1. Entitlement to an initial evaluation in excess of 40 percent for diabetes mellitus

The Veteran claims an increased evaluation for his diabetes mellitus.

Service connection for diabetes mellitus was initially granted in a May 2019 rating decision which assigned a 20 percent rating effective March 15, 2019. In June 2019, the Veteran submitted a request for HLR. A July 2019 letter declined to accept the request, stating that the issue was already on appeal. It is unclear what the letter was referring to. The Veteran underwent an October 2019 VA examination for diabetes in connection with his June 2019 TDIU claim. In March 2020, he submitted a new claim for an increased rating. An April 2020 rating decision continued his 20 percent rating. The Veteran submitted a June 2020 notice of disagreement. As additional evidence was received in connection with his neuropathy claims, the 20 percent rating was again continued by the August 2020 rating decision on appeal. The Veteran again disagreed with the continued 20 percent rating in his August 2020 notice of disagreement.

The Board granted an initial evaluation of 40 percent for diabetes mellitus in its January 2022 decision, implemented by a February 2022 rating decision. In compliance with a separate March 2023 Board decision remanding entitlement to a TDIU, a June 2023 rating decision granted an earlier effective date of February 25, 2019. The issue has thus been recharacterized as entitlement to an initial evaluation in excess of 40 percent. While the Board has already addressed entitlement to an increased rating for diabetes mellitus in its January 2022 decision, that decision was restricted to evidence in the record as of April 2020. As this appeal allows the Board to consider evidence up to August 2020, the Board will again adjudicate this claim. For this issue, the Board may only consider the evidence of record at the
2 rating decision. In compliance with a separate March 2023 Board decision remanding entitlement to a TDIU, a June 2023 rating decision granted an earlier effective date of February 25, 2019. The issue has thus been recharacterized as entitlement to an initial evaluation in excess of 40 percent. While the Board has already addressed entitlement to an increased rating for diabetes mellitus in its January 2022 decision, that decision was restricted to evidence in the record as of April 2020. As this appeal allows the Board to consider evidence up to August 2020, the Board will again adjudicate this claim. For this issue, the Board may only consider the evidence of record at the time of the August 2020 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

Diabetes mellitus is evaluated under 38 C.F.R. § 4.119, Diagnostic Code 7913. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted 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.

The criteria for rating diabetes are "successive." Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007). "Successive" criteria exist where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008).

VA treatment records reflect that at a June 2018 endocrinology consultation the Veteran was diagnosed with diabetes complicated by neuropathy and nonproliferative diabetic retinopathy. Diabetes was treated with insulin. In January 2019 he presented to the emergency room with elevated blood sugar after drinking an entire bottle of apple juice prior to a scheduled partial gastrectomy. His surgery was postponed until March. In April 2019 he reported that while cooking he experienced an episode of dizziness, sweating, and inability to stand. The episode resolved without intervention.

The Veteran underwent a VA examination in May 2019. He was diagnosed with diabetes mellitus managed by restricted diet, oral hypoglycemic agent, and multiple daily insulin injections. The examiner found that regulation of activities was a part of his management, explaining that he must avoid overexerting himself with physical activities to prevent hypoglycemic episodes. He required care for episodes of ketoacidosis or hypoglycemia less than twice per month. There were no hospitalizations due to ketoacidosis or hypoglycemia. There was no progressive unintentional weight loss or loss of strength. The examiner noted complications of diabetic neuropathy. Functional impact consisted of the need to avoid tasks requiring prolonged standing, walking, or extensive physical strength and energy.

The Veteran underwent another VA examination in October 2019. He was diagnosed with diabetes mellitus managed by restricted diet, oral hypoglycemic agent, and multiple daily insulin injections. The examiner found that regulation of activities was a part of his management, explaining that he was cautious of activities due to labile glucose levels, with frequent episodes of hypoglycemia or hyperglycemia. He required care for episodes of ketoacidosis or hypoglycemia less than twice per month. The examiner noted two ketoacidosis hospitalizations over the prior 12 months. There was no progressive unintentional weight loss or loss of strength. The examiner noted complications of diabetic neuropathy.

The Veteran underwent another VA examination in March 2020. He was diagnosed with diabetes mellitus managed by oral hypoglycemic agent and multiple daily insulin injections. The examiner found that regulation of activities was not required as part of his
was a part of his management, explaining that he was cautious of activities due to labile glucose levels, with frequent episodes of hypoglycemia or hyperglycemia. He required care for episodes of ketoacidosis or hypoglycemia less than twice per month. The examiner noted two ketoacidosis hospitalizations over the prior 12 months. There was no progressive unintentional weight loss or loss of strength. The examiner noted complications of diabetic neuropathy.

The Veteran underwent another VA examination in March 2020. He was diagnosed with diabetes mellitus managed by oral hypoglycemic agent and multiple daily insulin injections. The examiner found that regulation of activities was not required as part of his management. He required care for episodes of ketoacidosis or hypoglycemia less than twice per month. There were no hospitalizations over the prior 12 months for ketoacidosis or hypoglycemia. There was no progressive unintentional weight loss or loss of strength. The examiner noted complications of diabetic neuropathy, nephropathy, and retinopathy.

VA treatment records reflect that in August 2020 the Veteran was hospitalized for hyperglycemia with a urinary tract infection. He was treated and discharged after one day.

At his April 2024 Board hearing, the Veteran stated that he got all his medical treatment from VA facilities.

The Board finds that an evaluation in excess of 40 percent is not warranted for the Veteran's diabetes mellitus. Higher ratings are available for episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. The evidence persuasively weighs against such findings. While the October 2019 VA examiner noted two hospitalizations for ketoacidosis, this finding is contradicted by the findings of the other examiners and the Veteran's VA treatment records. The May 2019 and March 2020 VA examiners both found no such hospitalizations. Moreover, while his treatment records indicate hospitalizations for other reasons - including pancreatitis, a partial gastrectomy, and a hyperglycemic episode associated with a urinary tract infection - there is nothing to indicate any hospitalizations for episodes of ketoacidosis or hypoglycemia. Neither the Veteran nor his representative have argued that the evidence warrants a higher rating. Indeed, in May 2021 his representative argued that the evidence warranted a 40 percent rating, which has since been granted. For these reasons, the Board finds that an evaluation in excess of 40 percent is not warranted for the Veteran's diabetes mellitus at any time during the rating period.

2. Entitlement to an effective date earlier than June 14, 2019 for an award of an increased evaluation from 20 to 30 percent for diabetic peripheral neuropathy affecting the left femoral nerve

3. Entitlement to an initial evaluation in excess of 30 percent for diabetic neuropathy affecting the left femoral nerve

4. Entitlement to an effective date earlier than June 14, 2019 for an award of an increased evaluation from 20 to 30 percent for diabetic peripheral neuropathy affecting the right femoral nerve

5. Entitlement to an initial evaluation in excess of 30 percent for diabetic neuropathy affecting the right femoral nerve

6. Entitlement to an effective date earlier than June 14, 2019 for an award of service connection for diabetic peripheral neuropathy affecting the left sciatic nerve

7. Entitlement to an initial evaluation in excess of 40 percent for diabetic neuropathy affecting the left sciatic nerve

8. Entitlement to an effective date earlier than June 14, 2019 for an award of service connection for diabetic peripheral neuropathy affecting the right sciatic nerve

9. Entitlement to an initial evaluation in excess of 40 percent for diabetic neuropathy affecting the right sciatic nerve

The Veteran claims increased ratings and earlier effective dates for diabetic neuropathy in his bilateral lower extremities.

After submitting a February 25, 2019 claim of service connection for a kidney condition, the Veteran submitted a claim of service connection for diabetes on March 15, 2019. The May 2019 rating decision granting service connection for diabetes mellitus also granted service connection for diabetic neuropathy affecting the bilateral femoral nerves, assigning a 20 percent rating in each lower extremity effective March 15, 2019. In October 2019 he underwent a VA examination for diabetes in connection with a TDIU claim received on June 17, 2019, three days after a June 14, 2019 intent to file. In March 2020, he submitted a new claim for increased ratings. The August 2020 rating decision on appeal increased his femoral nerve ratings to
condition, the Veteran submitted a claim of service connection for diabetes on March 15, 2019. The May 2019 rating decision granting service connection for diabetes mellitus also granted service connection for diabetic neuropathy affecting the bilateral femoral nerves, assigning a 20 percent rating in each lower extremity effective March 15, 2019. In October 2019 he underwent a VA examination for diabetes in connection with a TDIU claim received on June 17, 2019, three days after a June 14, 2019 intent to file. In March 2020, he submitted a new claim for increased ratings. The August 2020 rating decision on appeal increased his femoral nerve ratings to 30 percent each and assigned two 40 percent ratings for the bilateral sciatic nerves, all effective June 14, 2019. In compliance with a separate March 2023 Board decision remanding entitlement to a TDIU, a June 2023 rating decision granted an earlier effective date of February 25, 2019 for the initial 20 percent ratings for neuropathy affecting the femoral nerves, based on a finding that the claim of service connection for a kidney condition secondary to diabetes constituted a claim for diabetes itself.

For these issues, the Board may only consider the evidence of record at the time of the August 2020 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

The Board finds that the Veteran's claim date for these issues is February 25, 2019, the date VA received the initial claim of service connection for his diabetic nephropathy. The AOJ has already determined that this claim constituted a claim for diabetes mellitus. As this claim resulted in the initial grant of service connection for diabetic neuropathy, his claim for diabetes encompassed his claim for diabetic neuropathy. Moreover, his June 2019 claim for a TDIU can be considered a supplemental claim for an increased rating for diabetes and the associated neuropathy. See?Chisholm?v. Collins, 38 Vet. App. 140 (2025). While the TDIU application mentioned diabetes without expressly referring to neuropathy, such an inclusion can be inferred by the level of disability assigned to his neuropathy. Indeed, the AOJ has already considered the TDIU claim to encompass neuropathy, as that is the basis for his current June 14, 2019 effective date. This constitutes a favorable finding by the AOJ with no clear and unmistakable error. See 38?U.S.C. § 5104A; 38?C.F.R. § 3.104(c). Similarly, the AOJ's February 2022 increase of his diabetes rating effective March 15, 2019, subsequently amended as effective February 25, 2019, is a favorable finding that increasing his diabetes rating - and by extension is diabetic neuropathy ratings - was continuously pursued since the initial claim. As such, the Board finds that the Veteran's claim date for these issues is February 25, 2019. Earlier effective dates thus may be granted if entitlement to increased femoral ratings or separate sciatic ratings arose between that date and the current effective date of June 14, 2019.

The Veteran's diabetic neuropathy affecting the femoral nerves is rated as paralysis and evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8526. Under this code, an evaluation of 10 percent is warranted for mild incomplete paralysis, an evaluation of 20 percent is warranted for moderate incomplete paralysis, an evaluation of 30 percent is warranted for severe incomplete paralysis, and an evaluation of 40 percent is warranted for complete paralysis. Complete paralysis of the femoral nerve is productive of paralysis of the quadriceps extensor muscles.

The Veteran's diabetic neuropathy affecting the sciatic nerves is rated as paralysis and evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under this code, an evaluation of 10 percent is warranted for mild incomplete paralysis, an evaluation of 20 percent is warranted for moderate incomplete paralysis, an evaluation of 40 percent is warranted for moderately severe incomplete paralysis, an evaluation of 60 percent is warranted for severe incomplete paralysis with marked muscular atrophy, and an evaluation of 80 percent is warranted for complete paralysis. Complete paralysis of the sciatic nerve causes the foot to dangle and drop, with no active movement possible of the muscles below the knee, and with flexion of the knee weakened or (very rarely) lost.

When involvement is wholly sensory, peripheral nerve ratings should be for the
.F.R. § 4.124a, Diagnostic Code 8520. Under this code, an evaluation of 10 percent is warranted for mild incomplete paralysis, an evaluation of 20 percent is warranted for moderate incomplete paralysis, an evaluation of 40 percent is warranted for moderately severe incomplete paralysis, an evaluation of 60 percent is warranted for severe incomplete paralysis with marked muscular atrophy, and an evaluation of 80 percent is warranted for complete paralysis. Complete paralysis of the sciatic nerve causes the foot to dangle and drop, with no active movement possible of the muscles below the knee, and with flexion of the knee weakened or (very rarely) lost.

When involvement is wholly sensory, peripheral nerve ratings should be for the mild, or at most, the moderate degree. In rating the peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120.

The Board recognizes the holding in Banschbach v. McDonough, 37 Vet. App. 422 (2024), finding that 38 C.F.R. § 4.124a does not necessarily prohibit the assignment of separate compensable ratings for paralysis, neuritis, and neuralgia. However, the record before the Board does not specifically note findings of neuritis or neuralgia, only references to nerve impairment. Accordingly, no further consideration of separate ratings for neuritis under Diagnostic Codes 8620 and 8626 or neuralgia under Diagnostic Codes 8720 and 8726 is required.

VA treatment records reflect that at a June 2018 endocrinology consultation, the Veteran reported numbness and tingling in his lower extremities and exhibited decreased protective sense and pulse with diminished sensation and strength. At a July 2018 foot screen he reported one fall in the prior three months. Sensation was absent in 13 of 20 points tested in the feet. In August 2018 he reported pain all over the feet and legs. He was diagnosed with neuropathy. At a September 2018 physical therapy session, he exhibited 4/5 strength in the lower extremities. He was issued a straight cane and diabetic shoes with inserts. In November 2018 he reported that his primary issue with his feet was constant pain. He was diagnosed with insensate feet. In February 2019 he rated his foot pain at 10/10. He underwent physical therapy, and in March 2019 he rated his pain at 8/10 and 9/10. In April 2019 his treating physician noted that strength and sensitivity to light touch were grossly intact in all extremities.

The Veteran underwent a VA examination in May 2019. He reported episodes of numbness, tingling, and pain at random in the bilateral lower extremities including the feet and toes. He described cramps and muscular weakness. The examiner characterized his reported symptoms as moderate paresthesia, numbness, and intermittent pain. Muscle strength was 4/5 without atrophy throughout both lower extremities. Reflexes were decreased. There were no trophic changes. Light touch sensation was decreased throughout the extremities, from the knees/thighs to the feet/toes. Vibration sensation and cold sensation were absent. Position sense was normal. He was diagnosed with diabetic peripheral neuropathy affecting the bilateral lower extremities productive of moderate incomplete paralysis of the bilateral femoral nerves.

The Veteran underwent another VA examination in October 2019. He reported episodes of peripheral neuropathy present in both feet and occasionally to his left anterior thigh. The examiner characterized his reported symptoms as moderate paresthesia and numbness. Muscle strength was full without atrophy. Reflexes were decreased. Light touch sensation was decreased. Vibration sensation, cold sensation, and position sense were not tested. There were no trophic changes. He was diagnosed with diabetic peripheral neuropathy affecting the bilateral lower extremities productive of mild incomplete paralysis of the bilateral sciatic nerves.

VA treatment records reflect that in December 2019 the Veteran reported increased foot pain. Sensation was intact on examination. At a January 2020 podiatry consultation, he was diagnosed with degenerative changes and pes planus in addition to his diabetic pain.

The Veteran underwent another VA examination in March 2020. He reported an inability to feel his feet or keep his balance without a walker. He was unable to stand more than five minutes at a time due to foot pain, affecting his activities of daily living. He described weekly falls. The examiner characterized his reported symptoms as moderate paresthesia, numbness, and constant pain. Muscle strength was 4/5 without atrophy throughout both lower extremities. Reflexes were decreased. Light touch sensation, vibration sensation, and cold sensation were decreased. Position sense was normal. Trophic changes included smooth skin and loss of hair. He was diagnosed with diabetic peripheral neuropathy affecting the bilateral lower extremities productive of moderately severe incomplete paralysis of the bilateral sciatic and femoral nerves.

VA treatment records reflect that in May 2020 the Veteran reported difficulty during gait, especially for longer distances. He had a rollator but had difficulty getting it out of his car. He also had a cane he used at home. He was instructed in the safe and proper use of a scooter.

In a May 2021 post-Board-hearing memorandum associated with the appeal arising from his June 2020 notice of disagreement, the Veteran's representative argued that his neuropathy should be rated at 40 percent with no further specification regarding the nerves or extremities.

At his April 2024 hearing, the Veteran reported that he did not have feeling in his toes, in the bottom of his feet, and up around his ankles. He stated that he will fall when he tries to walk. He reported pain and numbness above his knees and into his hips. He stated that his left leg was the worse leg. He described use of a wheelchair. He described his legs as severely unstable with pain and itching. He stated that he had had these symptoms since 2016.

The Board finds that effective dates of February 25, 2019, but no earlier, are warranted for the Veteran's 30 percent ratings for his femoral nerve neuropathy and his separate ratings for his sciatic nerve neuropathy. While the May 2019 VA examination noted no more than moderate incomplete paralysis of the femoral nerves, this finding fails to address the Veteran's decreased light touch sensation in his feet and toes, along with his subjective reports of numbness in his feet and toes. Indeed, throughout the appeal period, examination reports and treatment records show the Veteran's primary lower extremity complaints were focused on his feet and toes, affected by the sciatic nerves. The inconsistency of the examiner's findings coupled with the Veteran's credible hearing testimony that he has experienced his severe symptoms since 2016 weigh in favor of entitlement to his current ratings arising as of his February 25, 2019 claim date. Effective dates are not available prior to his February 25, 2019 claim date because no claim of service connection for diabetes or neuropathy was received by VA prior to this date. For these reasons, the Board finds that an effective dates of February 25, 2019, but no earlier, are warranted for the Veteran's 30 percent ratings for his femoral nerve neuropathy and his separate ratings for his sciatic nerve neuropathy.

The Board further finds that evaluations in excess of 30 percent are not warranted for the Veteran's diabetic neuropathy affecting his femoral nerves. Higher ratings are available for complete paralysis of the femoral nerve. The evidence persuasively weighs against such findings. While his statements, examination reports, and treatment records all indicate significant nerve impairment in the lower extremities, there is nothing to suggest complete paralysis of the quadriceps muscles. The Veteran has an inability to walk without assistance and has stated that he regularly falls, but he is nonetheless capable of standing up. Notably, the severe incomplete paralysis for which he is already compensated is defined in the M21-1 as impairment reflecting a very high level of limitation or disability. The examiners expressly indicated that complete paralysis, or paralysis of the quadriceps extensor muscle, is not present. As such, absent a showing of actual paralysis, his symptoms to not warrant a higher evaluation. For these reasons, the Board finds that evaluations in excess of 30 percent are not warranted for the Veteran's diabetic neuropathy affecting his femoral nerves.

Finally, the Board finds that evaluations in excess of 40 percent are not warranted for the Veteran's diabetic neuropathy affecting his sciatic nerves
he regularly falls, but he is nonetheless capable of standing up. Notably, the severe incomplete paralysis for which he is already compensated is defined in the M21-1 as impairment reflecting a very high level of limitation or disability. The examiners expressly indicated that complete paralysis, or paralysis of the quadriceps extensor muscle, is not present. As such, absent a showing of actual paralysis, his symptoms to not warrant a higher evaluation. For these reasons, the Board finds that evaluations in excess of 30 percent are not warranted for the Veteran's diabetic neuropathy affecting his femoral nerves.

Finally, the Board finds that evaluations in excess of 40 percent are not warranted for the Veteran's diabetic neuropathy affecting his sciatic nerves. Higher ratings are available for complete paralysis of the sciatic nerve or for severe incomplete paralysis with marked muscle atrophy. The evidence persuasively weighs against such findings. Despite his significant functional impairment, his VA examiners have consistently found no muscle atrophy, let alone the marked muscle atrophy required for an increased rating. There is no evidence to contradict the VA examiners' findings in his treatment records, and the Veteran has not presented any other evidence to establish marked muscle atrophy or complete paralysis of the sciatic nerves. For these reasons, the Board finds that evaluations in excess of 40 percent are not warranted for the Veteran's diabetic neuropathy affecting his sciatic nerves.

10. Entitlement to an effective date earlier than June 14, 2019 for an award of service connection for diabetic peripheral neuropathy affecting all left radicular nerve groups

11. Entitlement to an initial evaluation in excess of 30 percent for diabetic neuropathy affecting all left radicular nerve groups

12. Entitlement to an effective date earlier than June 14, 2019 for an award of service connection for diabetic peripheral neuropathy affecting all right radicular nerve groups

13. Entitlement to an initial evaluation in excess of 40 percent for diabetic neuropathy affecting all right radicular nerve groups

The Veteran claims increased ratings and earlier effective dates for diabetic neuropathy in his bilateral upper extremities.

The Board finds that the Veteran's claim date for these issues is February 25, 2019, the date VA received the initial claim of service connection for his diabetic nephropathy. The AOJ has already determined that this claim constituted a claim for diabetes mellitus. As this claim resulted in the initial grant of service connection for diabetic neuropathy, his claim for diabetes encompassed his claim for diabetic neuropathy. Moreover, his June 2019 claim for a TDIU can be considered a supplemental claim for an increased rating for diabetes and the associated neuropathy. See?Chisholm?v. Collins, 38 Vet. App. 140 (2025). While the TDIU application mentioned diabetes without expressly referring to neuropathy, such an inclusion can be inferred by the level of disability assigned to his neuropathy. Indeed, the AOJ has already considered the TDIU claim to encompass neuropathy, as that is the basis for his current June 14, 2019 effective date. This constitutes a favorable finding by the AOJ with no clear and unmistakable error. See 38?U
. Moreover, his June 2019 claim for a TDIU can be considered a supplemental claim for an increased rating for diabetes and the associated neuropathy. See?Chisholm?v. Collins, 38 Vet. App. 140 (2025). While the TDIU application mentioned diabetes without expressly referring to neuropathy, such an inclusion can be inferred by the level of disability assigned to his neuropathy. Indeed, the AOJ has already considered the TDIU claim to encompass neuropathy, as that is the basis for his current June 14, 2019 effective date. This constitutes a favorable finding by the AOJ with no clear and unmistakable error. See 38?U.S.C. § 5104A; 38?C.F.R. § 3.104(c). Similarly, the AOJ's February 2022 increase of his diabetes rating effective March 15, 2019, subsequently amended as effective February 25, 2019, is a favorable finding that increasing his diabetes rating - and by extension is diabetic neuropathy ratings - was continuously pursued since the initial claim. As such, the Board finds that the Veteran's claim date for these issues is February 25, 2019. Earlier effective dates thus may be granted if entitlement to separate ratings for the upper extremities arose between that date and the current effective date of June 14, 2019.

The Veteran's diabetic neuropathy affecting all radicular nerve groups in the bilateral upper extremities is rated as paralysis and evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8513. His VA examinations establish that he is right-handed. Under this code, in the nondominant extremity an evaluation of 20 percent is warranted for mild incomplete paralysis, an evaluation of 30 percent is warranted for moderate incomplete paralysis, an evaluation of 60 percent is warranted for severe incomplete paralysis, and an evaluation of 80 percent is warranted for complete paralysis. Ratings for the dominant extremity are to be increased by 10 percent at each level except mild, which is equal to the rating in the nondominant extremity. When involvement is wholly sensory, peripheral nerve ratings should be for the mild, or at most, the moderate degree. In rating the peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120.

The Board recognizes the holding in Banschbach v. McDonough, 37 Vet. App. 422 (2024), finding that 38 C.F.R. § 4.124a does not necessarily prohibit the assignment of separate compensable ratings for paralysis, neuritis, and neuralgia. However, the record before the Board does not specifically note findings of neuritis or neuralgia, only references to nerve impairment. Accordingly, no further consideration of separate ratings for neuritis under Diagnostic Code 8613 or neuralgia under Diagnostic Code 8713 is required.

VA treatment records reflect that in April 2019 the Veteran's treating physician noted that strength and sensitivity to light touch were grossly intact in all extremities.

The Veteran underwent VA examinations for diabetic neuropathy in May 2019 and October 2019. No upper extremity symptoms were noted. Muscle strength in the upper extremities was full without atrophy. Reflexes were normal. There were no trophic changes. Sensation tests were normal. No upper extremity neuropathy was diagnosed.

The Veteran underwent another VA examination in March 2020. He reported pain, numbness, tingling, and swelling in his arms and hands. He described daily partial numbness, tingling, and pain in his fingers. He stated he was unable to grip or grasp cups or utensils. He was unable to conduct daily chores or grooming activities. The examiner characterized his reported symptoms as moderate paresthesia, numbness, and constant pain. Muscle strength was 2/5 in grip and otherwise 4/5 without atrophy throughout both upper extremities. Reflexes were decreased. Light touch sensation, vibration sensation, and cold sensation were decreased. Position sense was normal. Trophic changes included smooth skin and loss of hair. He was diagnosed with diabetic peripheral neuropathy affecting the bilateral upper extremities productive of mild incomplete paralysis of the bilateral radial and median nerves and the right ulnar nerve and productive of moderate incomplete paralysis of the left ulnar nerve. In an August 2020 addendum, the examiner corrected that all upper extremity nerves exhibited moderate incomplete paralysis and that the examiner would have indicated moderately severe incomplete paralysis, but such was not an
Muscle strength was 2/5 in grip and otherwise 4/5 without atrophy throughout both upper extremities. Reflexes were decreased. Light touch sensation, vibration sensation, and cold sensation were decreased. Position sense was normal. Trophic changes included smooth skin and loss of hair. He was diagnosed with diabetic peripheral neuropathy affecting the bilateral upper extremities productive of mild incomplete paralysis of the bilateral radial and median nerves and the right ulnar nerve and productive of moderate incomplete paralysis of the left ulnar nerve. In an August 2020 addendum, the examiner corrected that all upper extremity nerves exhibited moderate incomplete paralysis and that the examiner would have indicated moderately severe incomplete paralysis, but such was not an option. The examiner erroneously stated that severe would indicate no use at all of the upper extremities.

VA treatment records reflect that in April 2020 the Veteran reported that his neuropathy had moved to his hands, fingers, and wrists.

At his April 2024 hearing, the Veteran reported complete numbness in his right fingertips when he wakes up, with tingling throughout his right arm. He reported feeling numbness from his left forearm to his elbow. He described times when he cannot feel a cup that he is holding. He stated that his left arm was just as bad as his right arm, in terms of function. He described sometimes being unable to feel things when he grabs them, though he demonstrated an ability to grab. He stated that he was able to drive only short distances and did not drive himself out of town. He stated that his problems with his arms tingling began when he first was diagnosed with diabetes.

In a July 2024 post-hearing memorandum, the Veteran's representative argued that the evidence warranted a 60 percent rating for left upper extremity neuropathy and a 70 percent rating for right upper extremity neuropathy.

The Board finds that effective dates of February 25, 2019, but no earlier, are warranted for the Veteran's separate ratings for his diabetic neuropathy in the upper extremities. While the May 2019 VA examination noted no symptoms in his upper extremities, neither did the October 2019 VA examination, conducted after his current effective date of June 14, 2019. If the conspicuous absence of any mention of his upper extremities in the October 2019 VA examination report does not prevent effective dates in June 2019, then there is no reason that an identical absence in the May 2019 examination report should prevent effective dates in February 2019. Rather, the Veteran's credible hearing testimony that he has experienced his severe symptoms since 2016 weigh in favor of entitlement to his current ratings arising as of his February 25, 2019 claim date, with impairment not adequately examined until his March 2020 VA examination. Effective dates are not available prior to his February 25, 2019 claim date because no claim of service connection for diabetes or neuropathy was received by VA prior to this date. For these reasons, the Board finds that an effective dates of February 25, 2019, but no earlier, are warranted for the Veteran's separate ratings for his diabetic neuropathy in the upper extremities.

The Board further finds that evaluations of 60 percent in the left upper extremity and 70 percent in the right upper extremity are warranted for the Veteran's diabetic neuropathy affecting all radicular nerve groups. Such ratings are warranted for severe incomplete paralysis. The evidence is at least in equipoise as to such findings. The diminished reflexes, decreased sensation, and muscle strength significantly diminished to 2/5 in grip meet VA's definition of severe incomplete paralysis and are consistent with the findings discussed below that this functional impairment renders him in need of aid and attendance. While the earlier VA examinations do not reflect impairment of such severity, they contain no express reference to his upper extremities beyond the checking of boxes to the point that it is unclear if his upper extremities were actually examined. As such, the March 2020 VA examination report is the most probative for the entirety of the appeal period. While the examiner initially found only mild incomplete paralysis, the examiner amended this finding to moderate incomplete paralysis and erroneously stated that severe was not appropriate because it would be the equivalent of loss of use. As discussed above, that is not VA's definition of severe incomplete paralysis but rather falls under the possible meanings of complete paralysis, a higher rating. The findings of the March 2020 examiner are thus consistent with a finding of severe incomplete paralysis
of such severity, they contain no express reference to his upper extremities beyond the checking of boxes to the point that it is unclear if his upper extremities were actually examined. As such, the March 2020 VA examination report is the most probative for the entirety of the appeal period. While the examiner initially found only mild incomplete paralysis, the examiner amended this finding to moderate incomplete paralysis and erroneously stated that severe was not appropriate because it would be the equivalent of loss of use. As discussed above, that is not VA's definition of severe incomplete paralysis but rather falls under the possible meanings of complete paralysis, a higher rating. The findings of the March 2020 examiner are thus consistent with a finding of severe incomplete paralysis as defined by the M21-1. For these reasons, the Board finds that that evaluations of 60 percent in the left upper extremity and 70 percent in the right upper extremity are warranted for the Veteran's diabetic neuropathy affecting all radicular nerve groups.

Finally, the Board finds that evaluations in excess of 60 percent in the left upper extremity and 70 percent in the right upper extremity are not warranted for the Veteran's diabetic neuropathy affecting all radicular nerve groups. Higher ratings are available for complete paralysis of all radicular groups. The evidence persuasively weighs against such findings. Despite the significant impairment exhibited by the Veteran, complete paralysis has not been established. The March 2020 VA examiner did not find severe incomplete paralysis due to the apparent misunderstanding that it was the equivalent of complete paralysis. Moreover, at his April 2024 hearing, the Veteran stated and demonstrated an ability to pick items up, though his numbness prevented him from using them well. Similarly, he stated that he was able to drive short distances. Such abilities are inconsistent with complete paralysis. For these reasons, the Board finds that evaluations in excess of 60 percent in the left upper extremity and 70 percent in the right upper extremity are not warranted for the Veteran's diabetic neuropathy affecting all radicular nerve groups.

14. Entitlement to an effective date earlier than June 14, 2019 for an award of SMC based on the need for aid and attendance

The Veteran claims an earlier effective date for his award of SMC based on the need for aid and attendance.

SMC was granted by the August 2020 rating decision on appeal effective June 14, 2019, the date he submitted his claim for a TDIU. The Veteran's claim for SMC attaches to his underlying increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). As such, he is entitled to a claim date no earlier than February 25, 2019 based on his pending appeal for an increased rating for diabetes mellitus and associated neuropathies. The Board must therefore determine if entitlement arose prior to June 14, 2019.

For this issue, the Board may only consider the evidence of record at the time of the August 2020 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

SMC provided by 38 U.S.C. § 1114(l) is payable for being so helpless as to be in need of regular aid and attendance due to service-connected disability or disabilities. 38 C.F.R. § 3.350(b). The following is accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress oneself, or to keep oneself ordinarily clean and presentable; inability to attend to the wants of nature; and incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. It is not required that all of these disabling conditions be found to exist before a favorable rating may be made. The particular personal functions which a veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that a veteran is so helpless as to be in need of regular aid and attendance are based on the actual requirement of personal assistance from others. 38 C.F.R. § 3.352(a).

The Veteran underwent a VA examination in March 2020. His activities were limited by diabetic peripheral neuropathy, chronic obstructive pulmonary disease (COPD), shortness of breath on exertion, back pain, and severe numbness, tingling, and
which a veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that a veteran is so helpless as to be in need of regular aid and attendance are based on the actual requirement of personal assistance from others. 38 C.F.R. § 3.352(a).

The Veteran underwent a VA examination in March 2020. His activities were limited by diabetic peripheral neuropathy, chronic obstructive pulmonary disease (COPD), shortness of breath on exertion, back pain, and severe numbness, tingling, and pain in the shoulders, arms, hands, legs, and feet. He was able to feed himself but not able to prepare his own meals due to his inability to stand. He needed assistance with his insulin injections. He was not blind and did not require nursing home care or medication management. He was able to manage his own benefit payments. He was unable to grip or grasp a cup, fork, knife, spoon, steering wheel, mop, or broom. He could not vacuum, sweep, mop, change the sheets, button shirts or pants, shave, or do any other household chore. He could not bend over to pick things off the floor. He could not use a laundry machine. He could not keep his balance without a walker. He reported weekly falls. He did not leave the house except for medical appointments.

At his April 2024 Board hearing, the Veteran's representative argued for an effective date of February 25, 2019. He stated that he had had in home assistance since 2002. The representative again argued for an effective date of February 25, 2019 in a July 2024 post-hearing memorandum.

The Board finds that an effective date of February 25, 2019, but no earlier, is warranted for the Veteran's SMC based on the need for aid and attendance. His current effective date of June 14, 2019 was granted based on a claim for a TDIU received on that date. He has since been granted an earlier effective date of February 25, 2019 for his TDIU, and the Board herein grants the same date for his multiple increased ratings on appeal. Moreover, he was not provided a VA examination to address aid and attendance prior to March 2020, and as such there is no evidence to contradict application of its findings to the period between February 25, 2019 and June 14, 2019. An effective date earlier than February 25, 2019 is not available, because that is the claim date for his underlying service connection claims. Moreover, neither the Veteran nor his representative have argued or provided evidence in support of an earlier claim date or effective date for SMC. For these reasons, the Board finds that an effective date of February 25, 2019, but no earlier, is warranted for the Veteran's SMC based on the need for aid and attendance.

15. Entitlement to an effective date earlier than February 25, 2019 for an award of a TDIU

The Veteran appealed for an earlier effective date for his TDIU.

The Veteran submitted a claim for TDIU among other issues in June 2019. His claim was initially denied in a January 2020 rating decision. He requested HLR in January 2020. A May 2020 HLR decision again denied TDIU. The Veteran disagreed with this denial in a June 2020 notice of disagreement.

After the August 2020 rating decision on appeal denied increased ratings for diabetes and its associated neuropathies, the Veteran again appealed for a TDIU in his August 2020 notice of disagreement. This issue attaches to the increased ratings claims under Rice v. Shinseki, 22 Vet. App. 447, 453 (2009).

At a February 2021 Board hearing arising from his June 2020 notice of disagreement, the Veteran's representative argued for an effective date of February 25, 2019 for a TDIU.

In a January 2022 decision addressing the June 2020 notice of disagreement, the Board denied a TDIU. The Veteran appealed this denial to CAVC, which vacated the denial in an October 2022 order granting a joint motion for partial remand (JMPR). In compliance with JMPR, the Board remanded the issue of entitlement to a TDIU in March 2023. A June 2023 rating decision granted a TDIU effective February 25, 2019
At a February 2021 Board hearing arising from his June 2020 notice of disagreement, the Veteran's representative argued for an effective date of February 25, 2019 for a TDIU.

At his April 2024 Board hearing, the Veteran's representative argued for an effective date of February 25, 2019 for his TDIU, apparently unaware that such an effective date had already been assigned. The representative again argued for an effective date of February 25, 2019 in a July 2024 post-hearing memorandum.

While the Board has already addressed entitlement to an increased rating for diabetes mellitus in its January 2022 decision, that decision was restricted to evidence in the record as of April 2020. As this appeal allows the Board to consider evidence up to August 2020, the Board will again adjudicate this claim. As such, for this issue, the Board may only consider the evidence of record at the time of the August 2020 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

The Board finds that an effective date earlier than February 25, 2019 is not warranted for the Veteran's award of a TDIU. This issue is before the Board as part and parcel of the increased rating claims for diabetes and its complications, and as such it shares the same claim date of February 25, 2019. He did not claim a TDIU before this date. Moreover, neither the Veteran nor his representative have presented argument or evidence for an earlier effective date for a TDIU. For these reasons, the Board finds that an effective date earlier than February 25, 2019 is not warranted for the Veteran's award of a TDIU.

16. Entitlement to an effective date earlier than February 25, 2019 for an award of basic eligibility to DEA benefits

The Veteran claims an earlier effective date for his award of basic eligibility for DEA benefits. For this issue, the Board may only consider the evidence of record at the time of the August 2020 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

Educational assistance under Chapter 35 is generally payable to a dependent of a claimant who has a total disability permanent in nature resulting from a service-connected disability. 38 C.F.R. § 21.3021. The Veteran is currently eligible for DEA benefits effective February 25, 2019. His current effective date was assigned by a June 2023 rating decision in conjunction with his TDIU.

The Board finds that basic eligibility for DEA benefits is not warranted prior to February 25, 2019. The Veteran is not in receipt of a combined schedular rating of 100 percent or a TDIU prior to this date. Neither he nor his representative have presented evidence or argument that an earlier effective date should be awarded absent a TDIU or combined schedular rating of 100 percent. For these reasons, the Board finds that basic eligibility for DEA benefits is not warranted prior to February 25, 2019.

17. Entitlement to an effective date earlier than February 25, 2019 for an award of service connection for diabetic nephropathy with renal insufficiency

The Veteran claims an earlier effective date for his award of service connection for diabetic nephropathy with renal insufficiency.

The Veteran's initial claim of service connection for a kidney condition was received by VA on February 25, 2019. Service connection for renal insufficiency with renal cysts was granted in a January 2020 rating decision which assigned a noncompensable rating effective February 25, 2019. In January 2020, the Veteran submitted a request for HLR of the assigned rating only. A May 2020 HLR decision increased his initial rating to 30 percent. The Veteran submitted a June 2020 notice of disagreement which expressed disagreement with the assigned rating only. A January 2022 Board decision denied an increased rating. The Veteran appealed this denial to CAVC, which vacated the denial in an October 2022 order granting a joint motion for partial remand (JMPR). The Board addressed the concerns of the JMPR and denied the issue again in a March 2023 decision.

The August 2020 notice of disagreement giving rise to this appeal expressed disagreement with the January 2020 rating decision's assigned rating and effective date. As discussed above, the Board finds that the increased rating appeal is duplicative of the appeal decided in the January 2022 and March 2023 Board decisions, and as such it is not addressed herein. The earlier effective date appeal, however, has never been addressed by the Board, and as such must be addressed in this decision. For this issue, the Board may only consider the evidence of record at the time of the January 2020 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

Generally, the effective date of an award of a service connection claim is the date of receipt of a claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Under regulations applicable prior to March 24, 2015, any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. An informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a) (2014).

The Board finds that an effective date earlier than February 25, 2019 is not warranted for the Veteran's award of service connection for diabetic nephropathy with renal insufficiency. VA did not receive any claim of service connection for this disability prior to this date. Moreover, neither the Veteran nor his representative have offered evidence or argument that an earlier claim was received or that an earlier effective date is warranted absent such a claim. For these reasons, the Board finds that an effective date earlier than February 25, 2019 is not warranted for the Veteran's award of service connection for diabetic nephropathy with renal insufficiency.

18. Entitlement to service connection for depressive disorder

The Veteran seeks service connection for depression.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Service connection may be awarded on a secondary basis if a claimant suffers a disability that is "proximately due to or the result of a service-connected disease or injury." See 38 C.F.R. § 3.310(a); but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023). For "aggravation of non-service-connected disabilities" it is enough to show that a non-service-connected disability would have been less severe but-for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability.

In determining whether service connection is warranted
awarded on a secondary basis if a claimant suffers a disability that is "proximately due to or the result of a service-connected disease or injury." See 38 C.F.R. § 3.310(a); but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023). For "aggravation of non-service-connected disabilities" it is enough to show that a non-service-connected disability would have been less severe but-for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability.

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether the evidence is persuasively against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant.

Service connection for posttraumatic stress disorder (PTSD) was initially denied in a March 2017 legacy rating decision. The Veteran did not appeal this decision, and no new and material evidence was received within one year of its issuance. The decision therefore became final.

In June 2019, the Veteran submitted a claim of service connection for depression, which was denied in a January 2020 rating decision. The Veteran submitted a request for HLR in January 2020. Service connection was again denied by a May 2020 HLR decision. The Veteran's June 2020 notice of disagreement initiated an appeal as to this issue. The issue was again appealed in the August 2020 notice of disagreement giving rise to this appeal, which expressed disagreement with the January 2020 rating decision denying service connection. In January 2022, the Board denied service connection for depression.

When the August 2020 notice of disagreement was received by the Board, this issue was duplicative of the issue appealed in the June 2020 notice of disagreement. However, unlike the issues of entitlement to service connection for a heart disability and an increased rating for diabetic nephropathy, the procedural posture of this issue has since changed. Specifically, in December 2022, within one year of the January 2022 Board decision, the Veteran submitted a supplemental claim of service connection for depression. An April 2024 rating decision subsequently granted service connection for depressive disorder, assigning a 50 percent evaluation effective December 8, 2022, the date of receipt of the supplemental claim. This decision contained favorable findings that the Veteran's depressive disorder was related to his service-connected disabilities, including diabetes, neuropathy, nephropathy, and liver disabilities.

For this issue, the Board may only consider the evidence of record at the time of the January 2020 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the April 2024 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

Although service connection has been granted for depressive disorder, the Board finds that this issue is not moot because a grant of this appeal could result in an earlier effective date. See, e.g., Concepcion-Maldonado v. Collins, 38 Vet. App. 294 (2025); Johnson v. Collins, 38 Vet. App. 151 (2025). While the Board may not consider all the evidence before the AOJ in its April 2024 rating decision, the favorable findings therein are binding on this decision. 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). As such, the Board finds that the Veteran's depressive disorder is related to his service-connected disabilities, and service connection is therefore granted.

Rebecca N. Poulson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J. Gallagher, 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.

's depressive disorder is related to his service-connected disabilities, and service connection is therefore granted.

Rebecca N. Poulson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J. Gallagher, Counsel

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