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Updated Jun 06, 2024

In This Chapter
This chapter contains the following topics:
Topic
Topic Name
1
2
3
4

1.  Diabetes Mellitus

Introduction
This topic contains information about diabetes mellitus, including

Change Date
June 6, 2024

V.iii.11.1.a.  Definition: Diabetes Mellitus
Diabetes mellitus is a metabolic disorder in which the body is unable to use glucose (a type of sugar obtained from food) effectively.  Hyperglycemia, an abnormally high level of blood sugar, results.
Diabetes mellitus is not seriously disabling if, on a diet sufficient to maintain the weight and strength of the claimant, the
  • blood glucose can be kept within normal limits, and
  • urine is absent glucose.
As diabetes mellitus progresses
  • it becomes more difficult to control, even with insulin
  • complications develop which increase the degree of disability, and
  • increasing limitation of activity due to unstable blood sugar levels limits employability.

V.iii.11.1.b.  Symptoms of Diabetes Mellitus
The cardinal symptoms of uncontrolled diabetes mellitus are
  • polyuria (excessive urination)
  • polydipsia (excessive thirst)
  • polyphagia (excessive hunger)
  • weakness, and
  • loss of weight.
The presence of sugar in the urine is characteristic of, but not essential to, a diagnosis of diabetes mellitus.
Notes:
  • A diagnosis of diabetes mellitus cannot be made from glycosuria alone, as this may result from
    • a low renal threshold for sugar, or
    • excessive ingestion of sugar.
  • Persistent hyperglycemia, a blood sugar of 170 milligrams (mg) per 100 cubic centimeters (ccs) blood after 12-hour fast, and glycosuria may be related to
    • hyperthyroidism
    • dyspituitarism
    • pregnancy
    • apoplexy
    • cerebral trauma, or
    • severe infections.

V.iii.11.1.c.  Evaluating Diabetes Mellitus
Evaluations of diabetes mellitus are assigned under 38 CFR 4.119, diagnostic code (DC) 7913.  The diagnostic criteria take into account
  • the means necessary to control diabetes, specifically
    • restricted diet
    • oral hypoglycemic agent
    • one or more daily injection of insulin, and
    • regulation of activities
  • frequency of specific types of care for episodes of ketoacidosis or hypoglycemic reactions
    • hospitalizations, or
    • visits to a diabetic care provider
  • progressive loss of weight and strength, and
  • diabetic complications.
Note:  To treat diabetes mellitus, medical providers may prescribe non-insulin injectable medications, such as Ozempic, Victoza, Trulicity, or other generic versions.  These medications are distinctly different from injectable insulin.  Like oral hypoglycemic agents, non-insulin injectable medications help lower blood glucose levels.  For rating purposes, evaluate a prescription for a non-insulin injectable medication in the same manner as a prescription for an oral hypoglycemic agent.  Do not consider a non-insulin injectable medication as equivalent to treatment with insulin.
References:  For more information on

V.iii.11.1.d. Successive Criteria Requirement for the Next Higher Disability Evaluation
When determining the appropriate disability evaluation to assign for diabetes mellitus, note that the criteria are successive.  This means the Veteran can only be rated at the next higher disability evaluation when all criteria at the lower disability evaluation are met plus element(s) specific to the higher evaluation are satisfied.
References:  For more information on

V.iii.11.1.e. Information on Regulation of Activities
The term regulation of activities is defined parenthetically in 38 CFR 4.119, DC 7913 to mean the requirement of “avoidance of strenuous occupational and recreational activities.”  In turn, this must be understood as meaning that the avoidance is required to help control blood sugar.
Voluntary avoidance of strenuous activity by the Veteran, undertaken with the intention of avoiding hypoglycemic episodes, does not meet the regulatory criteria.  Evidence must document that the avoidance of strenuous activities is required/prescribed as part of medical management of the individual’s diabetes.
Prescribed or voluntary exercise also does not satisfy the regulation-of-activities criterion.
Notes:
  • Which specific activities are medically contraindicated as strenuous (what medical restrictions have been prescribed) is a factual medical question.
  • The Diabetes Mellitus Disability Benefits Questionnaire (DBQ) requires that the examiner address whether avoidance of strenuous occupational and recreational activities to avoid hypoglycemic episodes is required as part of medical management of diabetes mellitus, and if so, to provide examples.
  • The conclusion that “regulation of activities” is demonstrated is an adjudicative determination.
  • It is the Department of Veteran’s Affairs (VA’s) policy to concede that an individual’s diabetes mellitus requires insulin, restricted diet, and regulation of activities when the diabetes has caused episodes of ketoacidosis that have resulted in hospitalization.

V.iii.11.1.f.   Scope of Diabetes Mellitus Claims
As discussed in M21-1, Part V, Subpart ii, 3.A, determining what issues are within scope of a claim is a case-by-case determination based on a sympathetic reading of the evidence.
When reviewing claims for diabetes mellitus, including diabetic complications, consider whether the evidence establishes entitlement to
  • an increased evaluation for the
    • diabetes mellitus, and/or
    • service-connected (SC) complication(s), and/or
  • service connection (SC) for expressly claimed or newly discovered, unclaimed complications.
Notes:
  • As complications of diabetes mellitus are part of the evaluation criteria for the disease, entitlement to any additional benefits based on complications would be considered within scope of the claim.
  • Follow the guidance in M21-1, Part V, Subpart ii, 3.A.2.c for handling complications of an expressly claimed issue, including when to obtain adequate medical evidence, such as an examination.
References:  For more information on

V.iii.11.1.g. Requesting Examinations for Diabetes Mellitus or Diabetic Complications
Refer to the table below for general guidance on determining which examinations to request in claims for diabetes mellitus or diabetic complications.
If the claim wording is interpreted as requesting compensation for … Then request …
diabetes mellitus (initial SC or an increased evaluation) with or without complications specified
the Diabetes Mellitus Disability Benefits Questionnaire, when necessary to decide the claim.
Important:
  • If the Veteran explicitly claims a diabetic complication (new or increased evaluation), or is already SC for a complication(s), include a comment in the examination request to alert the examiner.
  • The Diabetes Mellitus Disability Benefits Questionnaire must address all diabetic complications present, to include completion of additional DBQs as appropriate.
  • If the examiner fails to address all diabetic complications and complete all necessary DBQs, the examination must be returned as insufficient.
a specified diabetic complication(s) (new or an increased evaluation)
the specific DBQ(s) associated with the claimed complication(s), when necessary to decide the claim.
Note:  Do not request the Diabetes Mellitus Disability Benefits Questionnaire.
Important:  Worsening of a diabetic complication could indicate a broader worsening of the diabetes generally.  When worsening in the diabetic process is shown, follow procedures for deciding all issues within scope of the claim as outlined in
 
References:  For more information on

V.iii.11.1.h. Failure to Report in Claims for Increase in Diabetes Mellitus
See the table below for guidance on the correct rating action to take when a claimant fails to report for a necessary VA examination in connection with a claim for increase for diabetes mellitus.
If the claim … Then …
is limited to an increase in one or more separately evaluated diabetic complications
deny an increase for the claimed complication(s) based on failure to report for the examination without good cause.
Exception:  If the other evidence of record is sufficient to address the evaluation criteria for the claimed complication(s), issue a grant or denial as supported by that evidence.
expressly refers to a reevaluation or increase for diabetes mellitus, whether or not it mentions complications
deny
  • an increase in the evaluation for the diabetic process, and
  • any expressly claimed diabetic complications.
Exception:  Evaluate the evidence of record in accordance with 38 CFR 3.326 to determine if it is otherwise adequate for rating purposes without a VA examination.  If it is, make a decision based on that evidence.
 
Reference:  For more information on failure to report for examinations in connection with a claim for an increased evaluation, see 38 CFR 3.655(b).

V.iii.11.1.i. Effective Dates for SC of Diabetes Mellitus
For SC of diabetes, the effective date is generally the later of the date of claim or date entitlement arose.  This includes the effective date for
  • any evaluation of the diabetic process, and
  • any separate evaluation of diabetic complications.
Important:  Consider entitlement to an earlier effective date, when applicable, under 38 CFR 3.114 and the Nehmer stipulation.
References:  For more information on

V.iii.11.1.j. Effective Dates for Claims for Increase of Diabetes Mellitus
Under 38 CFR 3.400(o), assign increased evaluations of diabetes mellitus from
  • the date an ascertainable increase in the disability occurred if a complete claim or intent to file a claim is received within one year from such date, otherwise
  • date of receipt of claim.
 Notes:
  • Prior to March 24, 2015, 38 CFR 3.157 was in effect.  Under that regulation, certain records showing treatment could be considered claims for increase.
  • Effective March 24, 2015, claims must be filed on standard forms and records are no longer treated as claims for increase.
  • Development of new diabetic complications is evidence of an ascertainable increase in the diabetic process.
References:  For more information on

2.  Complications of Diabetes Mellitus

Introduction
This topic contains information about complications of diabetes mellitus, including

Change Date

 November 29, 2016

V.iii.11.2.a. Common Complications of Diabetes Mellitus
As noted in M21-1, Part V, Subpart iii, 11.1.a, complications are disabilities of various body systems, including but not limited to the following, caused by progression of diabetes:
  • cardiovascular
  • neurological
  • ophthalmological
  • genitourinary
  • gynecological
  • musculoskeletal
  • immune, and
  • skin.
Notes:  Once diabetic complications begin, multiple complications are usually considered or involved.
Reference:  For more information on scope of claim and examination requirements in claims for diabetes mellitus, see M21-1, Part V, Subpart iii, 11.1.f and g.

V.iii.11.2.b. Evaluating Complications of Diabetes Mellitus
Per 38 CFR 4.119, DC 7913, evaluate compensable complications of diabetes mellitus separately unless they are a part of the criteria used to support a 100-percent evaluation.
Noncompensable complications are considered part of the diabetic process under 38 CFR 4.119, DC 7913.
Before conceding that a particular disability is a complication of diabetes, ensure that there is medical evidence of record supporting that determination.  In some cases, a particular disability of a body part of system could be a diabetic complication or it could be due to another cause.  For example, neurological symptoms in the lower extremities could represent the common complication diabetic peripheral neuropathy.  However, they could also be due to another etiology such as a spinal injury, peripheral vascular disease or multiple sclerosis.
References:  For more information on

V.iii.11.2.c. Effective Date for Diabetic Complications
Because diabetes mellitus is an endocrine disorder with potential multi-system effects, onset of diabetic complications represents medical progression or worsening of diabetes, and diabetic complications are contemplated in the evaluation criteria under 38 CFR 4.119, DC 7913, a claim asserting new complications of SC diabetes is a claim for increase rather than a claim for secondary SC.
Therefore, when assigning effective dates for new diabetic complications, consider effective date provisions applicable to increases, specifically
References:  For more information on

V.iii.11.2.d. Cardiovascular Complications of Diabetes Mellitus
Diabetic cardiovascular complications include, but are not limited to
  • hypertension
  • atherosclerosis (used interchangeably with arteriosclerotic heart disease (coronary artery disease))
  • peripheral arterial disease
  • peripheral vascular disease
  • cardiomyopathy
  • congestive heart failure, and
  • stroke (macrovascular complication).
References:  For more information on

V.iii.11.2.e. When Evidence Supports That Hypertension Is or Is Not a Complication of Diabetes Mellitus
Analyze the evidentiary record to determine if it contains evidence specifically addressing whether hypertension is or is not a complication of diabetes mellitus.
In the absence of record evidence specifically addressing the question of whether hypertension is related to diabetes mellitus
  • consider hypertension to be a complication of diabetes mellitus when onset of hypertension occurred after a diagnosis of diabetes mellitus with diabetic nephropathy (The onset of hypertension after diabetes mellitus without diabetic nephropathy is not sufficient.), and
  • do not consider hypertension to be a complication of diabetes mellitus when
    • onset of hypertension was before diabetes mellitus (with or without diabetic nephropathy), and
    • there has been no change in the treatment of hypertension or increase in blood pressure readings.
Important:
  • Evaluate the competency, credibility, and probative value of evidence in line with the principles in M21-1, Part V, Subpart ii, 1.A.
  • The analysis above should be used in determining whether or not to address unclaimed hypertension as a complication of diabetes mellitus and making a decision on the merits of the raised claim as detailed in M21-1, Part V, Subpart iii, 11.2.f.

V.iii.11.2.f.  Addressing Unclaimed Hypertension as a Complication of Diabetes Mellitus
Raise and decide whether hypertension is a complication of diabetes mellitus in the absence of an explicit claim only when the evidence supports a grant.  Do not raise and deny the matter of entitlement to hypertension as a complication of diabetes mellitus when it is not explicitly claimed.
Do not raise the issue simply because the record shows hypertension and diabetes mellitus (even if there is diabetic nephropathy).  This alone is not sufficient to support that hypertension is a complication of diabetes mellitus.
Important:  The policy stated in this block does not prohibit a determination of whether hypertension is a complication of diabetes mellitus when initial evaluation or reevaluation of diabetes mellitus is within the scope of the claim.  The scope and degree of severity of complications is part of any claim involving evaluation of diabetes mellitus.  However, the issue, unless explicitly claimed, should only be raised if SC may be awarded for hypertension as a complication of diabetes mellitus.

V.iii.11.2.g. Development on the Relationship Between Diabetes Mellitus and Hypertension
There are fact patterns where the evidence supports or does not support that hypertension is a complication of diabetes mellitus.
In the context of an explicit claim that hypertension is a complication of diabetes mellitus or in the context of evaluation of the extent of diabetes mellitus (to include whether there are complications of diabetes mellitus), a medical diagnosis or opinion may be necessary to determine whether hypertension is a complication of diabetes mellitus.
When there is an explicit claim as discussed above, obtain a medical diagnosis or opinion to determine if hypertension is a complication of diabetes mellitus in the following fact patterns:
  • medical evidence shows
    • hypertension was diagnosed before diabetes mellitus or before diabetic nephropathy, but
    • there has been a subsequent change in the treatment of hypertension and/or an increase in blood pressure readings thereafter (particularly if this occurred after the onset of diabetic nephropathy), or
  • medical evidence shows no clear indication as to
    • when hypertension was diagnosed, or
    • whether hypertension has worsened since the onset of diabetic nephropathy.
Important:  When there is not an explicit claim that hypertension is a complication of diabetes mellitus and when hypertension in an initial evaluation or reevaluation of diabetes mellitus is not within the scope of the claim, do not develop for a diagnosis or opinion on whether hypertension is a complication of diabetes mellitus.

V.iii.11.2.h. Neurological Complications of Diabetes Mellitus
Diabetic neurological complications affecting the nervous system stem from a disturbance of metabolism or ischemia (inadequate blood supply) to the nerves.  One of the most common disabilities is peripheral neuropathy.  Complications affecting the peripheral nerves can extend from the brain and spinal cord to the muscles, skin, and internal organs.  The table below contains a description of symptoms that can be caused by a peripheral nerve disability.
Symptoms of Peripheral Neuropathy
Description
paresthesias
  • numbness, and
  • tingling
hyperesthesias
increased sensitivity to touch
hypesthesia (or hypoesthesia)
decreased sensitivity to touch
loss of sensation
lack of feeling
pain
  • burning
  • lancinating, or
  • lightning sensations
dysesthesia
unusual and unpleasant sensation after normal stimulation
muscle weakness
lack of strength
 
Note:  Findings are typically in a stocking-glove distribution.
Reference:  For more information on evaluating peripheral nerve disorders, see

V.iii.11.2.i. Ophthalmological Complications of Diabetes Mellitus
Diabetic ophthalmological complications are largely due to blood vessel damage caused by high blood sugars such as leakage (hemorrhage) and/or blood vessel blockage.  The table below contains a description of diabetic eye complications.
Diabetic Eye Complications
Description
diabetic retinopathy
impairment or loss of vision due to damage affecting blood vessels of the retina
cataract
clouding or opaqueness of the lens of the eye
glaucoma
  • increased fluid pressure in the eye, and
  • causes loss of visual fields due to optic nerve damage
 
Reference:  For more information on ophthalmological complications, see

V.iii.11.2.j. Genitourinary Complications of Diabetes Mellitus

 Diabetic nephropathy is a common diabetic genitourinary complication of diabetes mellitus and may be rated based on criteria including
  • renal dysfunction, if renal function is affected
  • voiding dysfunction, if there is incontinence from autonomic nephropathy
  • urinary tract infection, if there is chronic pyelonephritis, as appropriate
  • kidney transplant
  • hemodialysis, or
  • nephrectomy.
Note:  Erectile dysfunction (impotence/retrograde ejaculation) is another common complication of diabetes mellitus.
Reference:  For more information on genitourinary complications and potential entitlement to special monthly compensation (SMC), see

V.iii.11.2.k. Musculoskeletal Complications of Diabetes Mellitus
Diabetic musculoskeletal complications affect the feet, ankles, bones, extremities, and overall gait.  The table below contains a description of diabetic musculoskeletal complications.
Diabetic Musculoskeletal Complications
Description
foot complications
affects muscles, joints, and bones
foot neuropathic ulcers
  • results from abnormal pressure and lack of sensitivity to pain
  • leads to callus formation, osteomyelitis, and/or gangrene
abnormalities of gait
sensory ataxia to include loss of balance and poor muscle coordination due to loss of position sense
Charcot joints (neuropathic osteoarthropathy)
  • degenerative changes
  • instability, and
  • possible fragmentation of bones, particularly bones of the feet and ankles
amputations
  • extremities, or
  • parts of extremities
 
Reference:  For more information on musculoskeletal disabilities, see

V.iii.11.2.l. Immune and Other Miscellaneous Complications of Diabetes Mellitus
Hyperglycemia causes the white blood cells of the immune system to function poorly.  In addition, all of the body’s fluids have higher levels of sugar and nutrients, which make them more inviting for bacteria to grow and multiply.  This causes infections to be more serious and difficult to cure.  The table below contains a description of diabetic immune and other miscellaneous complications.
Diabetic Immune and Other Miscellaneous Complications
Description
References
malignant external otitis
a bacterial infection in older patients that causes
  • severe ear pain
  • necrosis of the external auditory canal, and
  • fever, and may also cause
  • paralysis of the facial nerve
  • paralysis of other cranial nerves, and osteomyelitis of the base of the skull
nasopharyngeal mucormycosis
  • a rare and serious fungal infection, which usually develops during or following an episode of diabetic ketoacidosis
  • sudden onset with periorbital edema, pain, bloody nasal discharge, and increased lacrimation (tearing), and
  • nasal mucosa and underlying tissues become black and necrotic
emphysematous cholecystitis
  • begins as an attack of biliary colic, which rapidly progresses, and
  • recognized by x-rays that show gas in or around the gallbladder
emphysematous pyelonephritis
  • begins as an attack of biliary colic, which rapidly progresses, and
  • recognized by x-rays that show gas in the kidney area
vaginal infection
an inflammation of the vagina that creates discharge, odor, irritation, or itching
urinary tract infection
  • infection in any part of the urinary system including kidneys, ureters, bladder, and urethra, or
  • a burning sensation, abdominal pain, and frequency in urination
oral thrush
a yeast infection of the tongue, inner cheek, lip, or gums
moniliasis
yeast infections affecting moist areas of the skin
gastroparesis (paralysis of the stomach)
  • severe delayed gastric emptying (sometimes with dumping syndrome) due to vagus nerve involvement, and possible
  • nausea, vomiting, early fullness in the stomach, bloating, abdominal pain, and weight loss

V.iii.11.2.m. Skin Complications of Diabetes Mellitus
Diabetes mellitus may result in skin complications.  The table below contains a description of diabetic skin complications.
Diabetic Skin Complications
Description
candida
fungal infection, specifically a yeast infection in moist areas
dermatophytes
a group of three types of fungus causing superficial infections of the skin, hair, and nails
ulcers
sores on the skin to include disintegration of tissue
necrobiosis lipoidica diabeticorum
plaque-like yellow to brown lesions over the anterior tibial surfaces of the legs that may ulcerate
diabetic dermopathy
“shin spots” or small plaques with a raised border, also usually over the anterior tibial surfaces that may also ulcerate
bullosis diabeticorum
blisters spontaneously appearing on the hands or feet that heal in two to five weeks, sometimes with scarring and atrophy
atrophy of fatty tissue or skin thickening
resulting from insulin injections
 
Reference:  For more information on skin disabilities, see

3.  Thyroid Conditions

Introduction
This topic contains information about thyroid conditions, including

Change Date

 December 11, 2017

V.iii.11.3.a.  Definitions:  Hyper- and Hypothyroidism
Hyperthyroidism (over-active thyroid) is a disorder where the thyroid gland synthesizes or creates excessive amounts of thyroid hormone.
Note:  This condition may also be diagnosed as Graves’ disease.
Hypothyroidism (under-active thyroid) is a disorder where the thyroid gland does not produce enough thyroid hormone.

V.iii.11.3.b.  Evaluating Thyroid Disabilities After the Initial Diagnosis
When a thyroid DC calls for an initial evaluation, the initial evaluation, by its very nature, is not considered static.  Most symptoms of these conditions are alleviated within the initial period of treatment.
When the rating schedule requires the assignment of an evaluation for a specified period after the initial diagnosis, establish the initial evaluation for any applicable period for which the Veteran is eligible; and thereafter, evaluate based on residuals of the disease in the affected body system(s) as directed by the relevant DC.
Notes:
  • In cases where the claim is being decided during the initial evaluation period, establish controls for a review exam at the end of that period to determine the appropriate evaluation.
  • For any complications shown on the review examination, follow the procedures in M21-1, Part IV, Subpart ii, 2.A.1.b for awarding benefits for residuals of the primary SC disability.
  • If treatment for one form of thyroid dysfunction causes a new diagnosis of the other form of thyroid dysfunction, the Veteran is entitled to an initial evaluation for the newly diagnosed thyroid disease.
References:  For more information on

V.iii.11.3.c.  Rating Thyroid Enlargement, Nontoxic
In the context of thyroid function, nontoxic means that thyroid function is normal. Because thyroid function is normal, the disabling effects of nontoxic thyroid enlargement are generally either manifest as disfigurement or a result of pressure on adjacent organs (such as trachea, larynx, or esophagus). Evaluate this condition based on one or both of these effects, if present.
Reference: For more information on evaluating thyroid enlargement, nontoxic, see 38 CFR 4.119, DC 7902.

V.iii.11.3.d.  Definition: Myxedema
Myxedema (coma or crisis) is a life-threatening form of hypothyroidism found predominantly in undiagnosed or undertreated individuals that requires inpatient hospitalization for stabilization.

V.iii.11.3.e.  Changes in the Endocrine Rating Schedule
On December 10, 2017, VA implemented changes in the rating criteria under 38 CFR 4.119.  These changes should not be the basis of a reduction in a Veteran’s disability rating unless medical evidence establishes that the disability has actually improved.
Note:  These changes in the rating criteria are not considered liberalizing.
References:  For more information on

4.  Examples of Rating Decisions Involving the Complications of Diabetes Mellitus

Introduction

 This topic contains three examples of rating decisions involving the complications of diabetes mellitus, including

Change Date

 December 13, 2005

V.iii.11.4.a.  Example 1: Rating Decision Involving Complications of Diabetes Mellitus
Situation:  The Veteran has noncompensable complications of diabetes mellitus but does not have ketoacidosis or hypoglycemic reactions.
Result:  Do not evaluate the diabetes mellitus at 60 percent simply because noncompensable complications are present.  Assign a 40-percent evaluation if there is a requirement of insulin, restricted diet, and regulation of activities.  Include the noncompensable complications under 38 CFR 4.119, DC 7913.

V.iii.11.4.b.  Example 2: Rating Decision Involving Complications of Diabetes Mellitus
Situation:  The Veteran’s diabetes mellitus is controlled by insulin, restricted diet, and regulation of activities.  In addition, there is diabetic peripheral neuropathy compensable at 10 percent.
Result:  Rate the diabetes mellitus at 40 percent and separately evaluate the compensable complication of diabetic peripheral neuropathy in accordance with the note under 38 CFR 4.119, DC 7913.

V.iii.11.4.c.  Example 3: Rating Decision Involving Complications of Diabetes Mellitus
Situation:  The Veteran underwent a below-the-knee amputation due to complications of diabetes mellitus.  In addition
  • his diabetes mellitus requires
    • more than one daily injection of insulin
    • restricted diet, and
    • regulation of activities
  • his episodes of ketoacidosis require weekly visits to the diabetic care provider, but
  • there is no progressive loss of weight and strength.
Result:  Evaluate the diabetes mellitus at 100 percent and award SMC (k) for anatomical loss of a foot.  Since the below-the-knee amputation is secondary to diabetes mellitus, and is considered a compensable complication (in lieu of progressive loss of weight and strength), to warrant the 100-percent evaluation, it would be pyramiding to assign a separate 40-percent evaluation for the amputation.
Note:  If compensable complications are not considered in reaching the 100- percent evaluation, they may be separately evaluated.