DIABETES MELLITUS

Summary

The veteran, who served from July 1970 to February 1972, appeals the denial of an increased rating for diabetes mellitus type II and diabetic retinopathy. The veteran sought a rating higher than 20 percent for diabetes, arguing it restricted his activities. However, the Board found that while the veteran used an insulin pump and followed a restricted diet, his diabetes did not inherently restrict his activities; rather, exercise was encouraged. The Board noted the absence of ketoacidosis episodes, hypoglycemic reactions, or progressive weight loss, and that complications like erectile dysfunction were not substantiated. The veteran's fatigue after mowing the lawn was attributed to his 30 percent rating for coronary artery disease. For diabetic retinopathy, the veteran sought a higher rating, citing incapacitating episodes and injections. The Board found no visual field defects or decreased visual acuity warranting a higher rating, except for the period between April 22, 2021, and September 21, 2021. During this five-month period, the veteran received multiple injections for retinopathy, supporting a 20 percent rating. Service connection for diabetes remains at 20 percent, and diabetic retinopathy is rated at 20 percent for the specified period, with denial for other periods.

Rationale

Diabetes does not restrict activities; exercise is encouraged.; No ketoacidosis, hypoglycemic reactions, or progressive weight loss.; Erectile dysfunction complication not substantiated.

Full Decision Text

Citation Nr: A26038893
Decision Date: 04/27/26	Archive Date: 04/27/26

DOCKET NO. 250716-565934
DATE: April 27, 2026

ORDER

Entitlement to an initial rating in excess of 20 percent for diabetes mellitus type II (diabetes) is denied.

Prior to April 22, 2021 and since September 21, 2021, entitlement to an initial compensable rating for diabetic retinopathy is denied. 

From April 22, 2021 to September 21, 2021, an initial 20 percent rating for diabetic retinopathy is granted; subject to the laws and regulations governing the payment of monetary benefits.

FINDINGS OF FACT

1. The Veteran's diabetes is managed by medication, diet, and daily insulin use, but not regulation of activities or other more severe symptoms.

2. From April 22, 2021 to September 21, 2021, the Veteran received several injections for his retinopathy; however, there were no other incapacitating episodes, decreased visual acuity, contracted visual field, or impaired eye muscle function, and the Veteran has posterior chamber intraocular lenses (PCIOL) after his cataract's surgeries.

CONCLUSIONS OF LAW

1. The criteria for an initial rating in excess of 20 percent for diabetes have not been met.  38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?3.102, 4.3, 4.7, 4.119, Diagnostic Code (DC) 7913.

2. Prior to April 22, 2021 and since September 21, 2021, the criteria for an initial compensable rating for diabetic retinopathy have not been met.  38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?3.102, 4.3, 4.7, 4.79, DC 6040.

3. From April 22, 2021 to September 21, 2021, the criteria for an initial 20 percent rating, but no higher, for diabetic retinopathy have been met.  38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?3.102, 4.3, 4.7, 4.79, DC 6040.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from July 1970 to February 1972.

In a March 2021 rating decision, service connection for diabetes, rated 20 percent disabling effective February 28, 2020, was granted.  In an October 2024 rating decision, service connection for diabetic retinopathy, rated noncompensably disabling effective February 28, 2020, was granted.  The Veteran has continuously pursued the ratings for diabetes and diabetic retinopathy since these rating decisions were issued.  38 C.F.R. § 3.2500(b).  In November 2024, the Veteran filed a Higher-Level Review Request seeking higher ratings for diabetes and diabetic retinopathy.  A duty to assist error was found in March 2025, and the ratings for diabetes and diabetic retinopathy were continued in a June 2025 rating decision.  In July 2025, the Veteran filed a VA Form 10182 to initiate an appeal on the Board's Hearing Docket.  In December 2025, the Veteran testified at a Board hearing.  Thus, the Board will review the evidence of record at the time of the June 2025 rating decision on appeal as well as any evidence received at or within 90 days after the Board hearing.  38 C.F.R. §§ 20.300, 20.302; see also 38 C.F.R. § 3.2502. 

Increased Rating

Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations.?38?U.S.C. §?1155.?Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38?C.F.R. §?4.1.? 

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 
 on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations.?38?U.S.C. §?1155.?Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38?C.F.R. §?4.1.? 

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38?C.F.R. §?4.7.?When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38?U.S.C. §?5107(b); 38?C.F.R. §§?3.102, 4.3.? 

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

1. Entitlement to an initial rating in excess of 20 percent for diabetes

The Veteran is claiming that his 20 percent rating for diabetes does not reflect the severity of his symptoms and, in particular, the regulation of activities.

Under DC 7913, the rating criteria 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 (defined within the DC as avoidance of strenuous occupational and recreational activities); a 60 percent rating is warranted for diabetes mellitus requiring one or more daily injection of 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; and 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. 38?C.F.R. §?4.119.? 

Because the criteria are joined by an "and," a claimant is required to demonstrate that all the criteria listed for a 40 percent rating are met. ?Camacho?v. Nicholson, 21?Vet. App.?360, 366-67 (2007).  The DC for diabetes is successive because each higher rating requires the elements of the lower evaluation. Id. at 366. The phrase "regulation of activities" is defined in DC 7913 as "avoidance of strenuous occupational and recreational activities." Medical evidence is required to support the "regulation of activities" criterion.?38?C.F.R. §?4.119, DC 7913;?Camacho,?21 Vet. App. at 364.? 

The rating period on appeal begins with the effective date of service connection, February 28, 2020 and ends with the issuance of the June 2025 decision on appeal.

In March 2020, the Veteran submitted a Diabetes Mellitus Disability Benefits Questionnaire (DBQ).  The Veteran's diabetes was treated with an insulin pump.  The Veteran did not require regulation of activities as part of his medical treatment for diabetes.  There were no episodes of diabetic care for ketoacidosis or hypoglycemic reactions or hospitalizations in the past 12 months.  There was no progressive loss of weight or strength.  Complications of diabetes were noted as diabetic retinopathy, erectile dysfunction, cardiac conditions, and hypertension.

The Veteran was afforded a VA examination of his diabetes in December 2020, at which time the Veteran was taking more than one injection of insulin per day.  The Veteran did not require regulation of activities as part of his medical treatment for diabetes.  There were no episodes of diabetic care for ketoacidosis or hypoglycemic reactions or hospitalizations in the past 12 months. 
 part of his medical treatment for diabetes.  There were no episodes of diabetic care for ketoacidosis or hypoglycemic reactions or hospitalizations in the past 12 months.  There was no progressive loss of weight or strength.  Complications of diabetes were noted as diabetic retinopathy, erectile dysfunction, cardiac conditions, and hypertension.

The Veteran was afforded a VA examination of his diabetes in December 2020, at which time the Veteran was taking more than one injection of insulin per day.  The Veteran did not require regulation of activities as part of his medical treatment for diabetes.  There were no episodes of diabetic care for ketoacidosis or hypoglycemic reactions or hospitalizations in the past 12 months.  No progressive loss of weight or strength was reported.  Only diabetic retinopathy was noted as a diabetic complication.  

In a March 2022 medical opinion, an examiner clarified that the March 2020 DBQ was wrong to list erectile dysfunction as a complication of diabetes because the Veteran did not have a diagnosis of erectile dysfunction.

In April 2022, Dr. K.W., the Veteran's doctor, noted that the Veteran's diabetes was being treated with a strict diet, exercise, insulin therapy, and other pharmacological interventions.

In April 2023, the Veteran testified at a Board hearing about his diabetes in conjunction with a prior appeal.  The Veteran managed his diabetes with an insulin pump, a blood glucose monitor, exercising, and diet.  However, the Veteran noted that exercising made him very tired.  For instance, if he mows the lawn, at the end of the day he will be worn out.  The Veteran also testified that he occasionally felt a pinprick-type feeling in his hands and feet and that he cannot stay on his feet for a long period of time.

The Veteran was afforded another VA examination of his diabetes in August 2024.  He treated his diabetes with an insulin pump and Ozempic.  It was noted that the Veteran walked five days per week for 30 minutes to help regulate his blood sugar.  There were no episodes of diabetic care for ketoacidosis or hypoglycemic reactions or hospitalizations in the past 12 months.  No progressive loss of weight or strength was reported.  Only diabetic retinopathy was noted as a diabetic complication.  

The Veteran was afforded another examination of his diabetes in March 2025, at which time the Veteran's diabetes was managed by diet, prescribed oral hypoglycemic agents, and an insulin pump.  The Veteran did not require regulation of activities as part of his medical treatment for diabetes.  There were no episodes of diabetic care for ketoacidosis or hypoglycemic reactions or hospitalizations in the past 12 months.  No progressive loss of weight or strength was reported.  Only diabetic retinopathy was noted as a diabetic complication.  

At the Board hearing, the Veteran testified that he takes Jardiance and Ozempic for his diabetes.  He also has an insulin pump and maintained a restricted diet.  He stated that he could not walk because his feet were bothering him, so he does chair yoga 15-30 minutes five or six times per week.  The Veteran attributed his difficulty with walking to being overweight and pain in his bones and muscles rather than neurological symptoms from diabetes.

The Board finds that a rating in excess of 20 percent for diabetes is not warranted.  The Veteran's diabetes is regulated by oral medication, Ozempic, diet, and the use of an insulin pump.  The use of an insulin pump itself indicates the use of an insulin injection at least once daily.  The Veteran has reported what he described as regulation of activities.  However, the Veteran's diabetes itself does not restrict his activities.  Rather, the Veteran has been encouraged to exercise to treat his diabetes.  As a result, as of August 2024, he was walking for 30 minutes five times per week.  As he experienced more pain in his feet, he began doing chair yoga five to six times per week for 15-30 minutes.  Thus, the Veteran does not require regulation of activities to treat his diabetes.  See Camacho, supra (defining the regulation of activities as avoidance of strenuous activity, not encouragement to exercise to control diabetic symptoms).  There also has been no treatment by a diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions or progressive loss of weight or strength.  Other than diabetic retinopathy, the Veteran does not have any nonservice-connected complications of diabetes.  38 C.F.R. § 4.119, DC 7913, Note (1) (directing VA to rate separately compensable complications of diabetes unless used to support a 100 percent evaluation).  At the April 2023 Board hearing, the Veteran noted an occasional
 regulation of activities to treat his diabetes.  See Camacho, supra (defining the regulation of activities as avoidance of strenuous activity, not encouragement to exercise to control diabetic symptoms).  There also has been no treatment by a diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions or progressive loss of weight or strength.  Other than diabetic retinopathy, the Veteran does not have any nonservice-connected complications of diabetes.  38 C.F.R. § 4.119, DC 7913, Note (1) (directing VA to rate separately compensable complications of diabetes unless used to support a 100 percent evaluation).  At the April 2023 Board hearing, the Veteran noted an occasional pinprick feeling in his feet and hands.  However, the Veteran has not been diagnosed with diabetic neuropathy, and at the December 2025 Board hearing, the Veteran attributed his current foot pain to aging, being overweight, and pressure on his bones and muscles rather than his diabetes.  The Veteran is also service connected for coronary artery disease (CAD).  At a February 2021 VA examination, it was noted that the Veteran would experience dyspnea and fatigue on exertion of 5-7 metabolic equivalents, which according to the examination report is consistent with mowing the lawn with a push mower.  Thus, the Veteran being fatigued at the end of the day after mowing the lawn is contemplated by his 30 percent rating for CAD.  See 38 C.F.R. § 4.104, General Rating Formula for Diseases of the Heart.  The Veteran is also service connected for hypertension.  While the March 2020 DBQ noted erectile dysfunction as a complication of diabetes, there is no other indication in the record that the Veteran has erectile dysfunction, and the Board would expect that treatment for erectile dysfunction would be noted in the Veteran's treatment records for diabetes if he had erectile dysfunction as a complication of diabetes.  Therefore, a rating in excess of 20 percent for diabetes is denied.

2. Entitlement to an initial compensable rating for diabetic retinopathy

The Veteran maintains that his initial compensable rating for diabetic retinopathy does not reflect the severity of his symptoms, especially given that he had to have eye injections to treat his retinopathy.

The General Rating Formula for Diseases of the Eye instructs to evaluate based on either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation.?38 C.F.R. § 4.79, General Rating Formula for Diseases of the Eye. An incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Id., Note (1). Examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Id., Note (2). The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function.? 38 C.F.R. § 4.75(a). To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, visual acuity and visual field defects are evaluated separately, and then combined under the provisions of 38 C.F.R. §?4.25.

In this case, as explained below, there has been no visual field defect and the Veteran's corrected distance and near vision is 20/40 or better bilaterally.  See 38 C.F.R. § 4.76 (directing VA to rate based on corrected visual acuity); 38 C.F.R. § 4.79, DCs 6063-6066 (providing for compensable ratings only where corrected vision in one eye is 20/50 or worse and in the other eye is 20/40 or worse).  

Thus, relevant to this case is the General Rating Formula for Diseases of the Eye, under which a 10 percent rating is warranted for documented incapacitating episodes requiring at least one but less than three treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted for documented incapacitating episodes requiring at least three but less than five treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted for documented incapacitating episodes requiring at least five but less than seven treatment visits for an eye condition during the past 12 months, and a 60 percent rating is warranted for documented incapacitating episodes requiring at least seven treatment visits for an eye condition during the past 12 months.  38 C.F.R. § 4.79.

The Veteran also had cataracts in the past, which as a part of surgery the
itating episodes requiring at least one but less than three treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted for documented incapacitating episodes requiring at least three but less than five treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted for documented incapacitating episodes requiring at least five but less than seven treatment visits for an eye condition during the past 12 months, and a 60 percent rating is warranted for documented incapacitating episodes requiring at least seven treatment visits for an eye condition during the past 12 months.  38 C.F.R. § 4.79.

The Veteran also had cataracts in the past, which as a part of surgery the PCIOLs were placed.  Under DC 6027, the cataracts would be rated under the General Rating Formula for Diseases of the Eye in this case.  Id.

Private treatment records dated from April 22, 2021 to September 22, 2021 show that the Veteran was receiving Avastin injections in his eyes to relieve his retinopathy.  Records demonstrate that he had at least three injections during this period.  Records also show that the Veteran had pseudophakia with PCIOLs.  No decrease in corrected visual acuity or visual field impairment was noted.  

The Veteran was afforded a VA examination of his eyes in September 2023. The Veteran reported that he had eye injections in his left eye. Corrected vision was to 20/20 or better, with the Veteran's vision described as "excellent."  It was noted that the Veteran had pseudophakia with PCIOLs for cataracts.  No additional functional impairment was noted.

In August 2024, the Veteran was afforded another VA examination of his eyes.  Diagnosis of diabetic retinopathy and pseudophakia with prior cataracts were noted.  The Veteran indicated that he had last received eye injections for retinopathy in 2022.  Corrected distance and near vision was to 20/20 or better in the right eye and corrected and near vision was to 20/40 in the left eye.  Decreased vision was due to retinopathy.  

In November 2024, the Veteran reported receiving four shots in his eyes over a six-month period and having blurry vision, floaters, and spots.

In March 2025, the Veteran reported that he was first treated for retinopathy in December 2020.  He started experiencing floaters and flashes in April 2021.  He began receiving eye injections on June 3, 2021.  Subsequent injections were received July 15, 2021, and September 21, 2021.  The Veteran received follow-up care in March 2022 and December 2022.  He now sees his eye doctor every six months, though there is no indication of further injections after September 21, 2021.

The Veteran was afforded another VA examination of his eyes in March 2025.  Corrected near and distance vision was to 20/20 or better.  Dot hemorrhages, described as diabetic retinopathy, were found in each eye.  No contraction of visual fields or decrease in corrected vision was noted.  

At the December 2025 Board hearing, the Veteran testified that he began seeing an eye doctor because his vision became blurrier.  This was due to a build-up of pressure on the eye vessels, which was due to his retinopathy.  He received eye injections for about six months to correct his vision.  By the fourth shot, the pressure was back to normal.  The Veteran noted that, when his vision was affected during this period, he had to get a bigger computer screen for work and take breaks because his eyes got tired.  He has not had any issues with his eyes since the last of the shots.

The Board finds that prior to April 22, 2021 and since September 21, 2021, a compensable rating for retinopathy is not warranted.  As noted above, there has been no reported contraction of visual field.  The Veteran's corrected distance and near vision has generally been to 20/20 or better. At the November 2024 examination, the Veteran's corrected left eye distance and near vision was 20/40.  However, a compensable rating for decreased visual acuity is not warranted because the Veteran's right eye corrected distance and near vision was to 20/20 or better.  The Veteran in his March 2025 statement reported that he did not begin experiencing floaters or blurred vision due to retinopathy prior to April 22, 2021.  Further, at the Board hearing, the Veteran reported that his retinopathy problems resolved with the last injection which he received September 21,
 contraction of visual field.  The Veteran's corrected distance and near vision has generally been to 20/20 or better. At the November 2024 examination, the Veteran's corrected left eye distance and near vision was 20/40.  However, a compensable rating for decreased visual acuity is not warranted because the Veteran's right eye corrected distance and near vision was to 20/20 or better.  The Veteran in his March 2025 statement reported that he did not begin experiencing floaters or blurred vision due to retinopathy prior to April 22, 2021.  Further, at the Board hearing, the Veteran reported that his retinopathy problems resolved with the last injection which he received September 21, 2021.  Therefore, a compensable rating for diabetic retinopathy prior to April 22, 2021 and since September 21, 2021 is denied.

From April 22, 2021 to September 21, 2021, the Board finds that a 20 percent rating, but no higher, is warranted for diabetic retinopathy.  The Veteran in his March 2025 statement reported first seeing a doctor due to seeing floaters and flashes related to retinopathy around April 22, 2021.  To treat his retinopathy, the Veteran received injections on June 3, 2021, July 15, 2021, and September 21, 2021.  No decrease in visual acuity or visual field was reported.  While the Veteran may have seen floaters and flashes prior to April 22, 2021, April 22, 2021 is the earliest ascertainable date in the record on which the Board can discern that his retinopathy symptoms began.  Per his Board hearing testimony, these symptoms resolved after three or four injection treatments with his eye doctor, the last of which was on September 21, 2021.  This five-month period from April to September 2021 is also consistent with the Veteran's November 2024 report that he received shots his his eye over a six-month period.  Thus, the Veteran had no more than four incapacitating episodes from April 22, 2021 to September 21, 2021, but none earlier than April 22, 2021, or prior to September 21, 2021.  Swain v. McDonald, 27 Vet. App. 219 (2015).  Thus, from April 22, 2021 to September 21, 2021, a 20 percent rating, but no higher, for diabetic retinopathy is granted.

 

 

C. CRAWFORD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. George

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.