not any separately compensable complication exists on the Codesheet). Examples: The Veteran completes VA Form 21-526b, Veterans Supplemental Claim for Compensation. In Item 7, the Veteran checks “Increased evaluation” and writes “Diabetes” “DM2 is worse,” or “20% for diabetes; oral meds required.” based on new need for insulin or oral medication to control uncomplicated diabetes if the evidence of record is sufficient to show oral medication has been prescribed for control of diabetes mellitus, and there continue to be no diabetic complications. However, to be sufficient to show that the diabetes continues to be uncomplicated, the evidence must contain a competent and credible medical assessment that there are no complications. complications if not appropriately included as part of a 100-percent evaluation under . Explanation: In expressly referring broadly or generically to an increase in the disease, claims of this pattern are interpreted as seeking higher overall compensation for diabetes – whether that is accomplished by a higher evaluation for the diabetic process under the addition of new separate compensable evaluations for diabetic complications under separate DCs, or increased evaluations for diabetic complications already evaluated under separate DCs. Therefore all options must be worked up and considered. Important: Do not solicit a claim for complications of diabetes in this claim fact pattern (or ask for clarification with respect to complications) – even if there are separately evaluated compensable diabetic complications already on the Codesheet. It is important to avoid the appearance of asking the Veteran to narrow a sufficiently unambiguous expressly made claim. expressly refers to or increase in diabetes mellitus, and one or more diabetic complications (whether or not already compensated under a separate DC on the the Diabetes Mellitus DBQ an evaluation for the diabetic process under , and separate evaluations for all identified compensable diabetic complications if not appropriately included as part of a 100-percent
Codesheet). Examples: The Veteran completes VA Form 21-526b. A evaluation is in effect under . In item 7, the Veteran checks “Increased evaluation” and writes “Diabetes now affecting my feet” The Veteran completes VA Form 21-526b. A evaluation is in effect under . There is also a separate 10-percent evaluation for left lower extremity diabetic peripheral neuropathy under . In item 7, the claimant checks “Increased evaluation” and writes “DM2 with complications.” evaluation under . Explanation: Although this pattern of claim differs from the pattern above in that it mentions diabetic complications, these claims are still interpreted as seeking higher overall compensation for diabetes – whether from the diabetic process, complications (including but not limited to any specifically mentioned in the claim) or both. Therefore all options must be worked up and considered. Important: Do not ask for clarification where the reference to complications is nonspecific, or limit the analysis of complications where the claim refers to one or more specific complications. It is important to avoid the appearance of asking the Veteran to narrow the claim. Refers to reevaluation or increase in one or more specific complications of diabetes that are already compensated under a separate DC on the Codesheet, but does not ask for an increase in diabetes mellitus (or similar wording) generally, or mention worsening of the underlying diabetic process (or mention specific facts that might correspond with worsening select the specific DBQ(s) associated with the claimed complication(s), but do not request the Diabetes Mellitus DBQ. The appropriate evaluation for each claimed diabetic complication under its DC. Explanation: In this claim pattern the claimant is specifically asking for evaluation only of a particular complication or complications separately evaluated from the diabetic process. It is therefore appropriate to limit the adjudication to that issue. Important: Worsening of a diabetic complication could indicate a broader worsening percent
of the diabetic process in such as new regulation of activities) such as to include prescription of more intensive treatment, new regulation of activities. Examples: The Veteran completes VA Form 21-526b. In Item 7, the Veteran checks “Increased evaluation” and writes “Diabetic peripheral neuropathy is worse” “My eyesight problems from my diabetes have increased,” or “increased evaluation for diabetic nephropathy.” of the diabetes generally. Solicit a claim when medical evidence received or developed in connection with the claim for an increase in diabetic complications indicates the potential for an increase in the evaluation for the diabetic process an increase in additional diabetic complications, or development of new diabetic complications. Important: An examination will almost always be necessary when assessing increases in diabetes mellitus. The evidence of record will rarely provide the full equivalent of a VA examination. When ordering the examination, inform the examiner of existing diabetic complications currently separately evaluated on the codesheet. Whenever claim wording indicates that the claimant wants a broader reevaluation of diabetes as indicated in the first two rows of the table above the Diabetes Mellitus DBQ, when properly completed, will ensure that sufficient information is obtained to evaluate the factors relating to the diabetic process in , and all diabetic complications. The DBQ prompts the examiner to complete and incorporate additional DBQs when needed to address specific complications of various body systems. return the examination as insufficient if the examiner fails to address all diabetic complications, including any complications that are already separately evaluated on the codesheet, and complete additional DBQs as indicated by the Diabetes Mellitus DBQ. References: For more information on determining the issues, see M21-1, Part III, Subpart iv, 6.B when an examination may be unnecessary because the evidence is sufficient to decide the claim, see M21-1, Part I, 1.C.3.c examinations in claims for increase, see M21-1, Part I, 1.C.3.i, and claim requirements, see , and .
parts of extremities Reference: For more information on musculoskeletal disabilities, see M21-1, Part III, Subpart iv, 4.A, and and . m. 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 M21-1, Part III, Subpart iv, 4.B, and . 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 M21-1, Part III, Subpart iv, 4.D, and . 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 M21-1, Part III, Subpart iv, 4.I, and . emphysematous pyelonephritis begins as an attack of biliary colic, which rapidly progresses, and recognized by x-rays that show gas in the kidney area M21-1, Part III, Subpart iv, 4.I , and .
vaginal infection an inflammation of the vagina that creates discharge, odor, irritation, or itching M21-1, Part III, Subpart iv, 4.I, and . 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 M21-1, Part III, Subpart iv, 4.I , and . oral thrush a yeast infection of the tongue, inner cheek, lip, or gums M21-1, Part III, Subpart iv, 4.I, and . moniliasis yeast infections affecting moist areas of the skin M21-1, Part III, Subpart iv, 4.J, and . 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 M21-1, Part III, Subpart iv, 4.I, and n. 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