Citation Nr: 18152881 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 16-35 587 DATE: November 27, 2018 REMANDED A rating in excess of 20 percent for type 2 diabetes mellitus (DM), to include erectile dysfunction (ED) and onychomycosis of bilateral toes, is remanded. REASONS FOR REMAND The Veteran appeals a September 2014 rating decision. He contends that this disability warrants a rating higher than 20 percent. Service connection and a 20 percent rating for this disability have been in effect since July 2002; separately rated diabetes-related disabilities include upper and lower bilateral peripheral neuropathy and bowel dysfunction. He is also receiving special monthly compensation for loss of use of a creative organ due to ED-related DM. To receive a rating higher than 20 percent for DM, in addition to requiring insulin and a restricted diet, there must also be a requirement of "regulation of activities." 38 C.F.R. § 4.119, Diagnostic Code 7913. The United States Court of Appeals for Veterans Claims has held that the term "regulation of activities" means that a claimant must have a medical need to avoid not only strenuous occupational activity, but also strenuous recreational activity. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Medical evidence is required to show that occupational and recreational activities have been restricted. Id. at 364. A 40 percent rating is warranted for DM requiring insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted where DM requires 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 where DM requires 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 a progressive loss of weight and strength or complications which would be compensable if separately evaluated. At the VA DM examination in August 2014, the examiner noted DM was managed by restricted diet, prescribed or hypoglycemic agents and insulin, more than 1 injection per day, without regulation of activities and with visits to DM provider less than twice per month. However, the Veteran urges that in fact he does require regulation of activities, that he requires 4 insulin injections daily, has to see his diabetes provider twice per month and has episodes of ketoacidosis or hypoglycemic reactions. An April 2015 note from a private treating source shows he is being treated regularly for DM and DM complications. In sum, the Veteran argues that the condition had worsened, that it is more severe than reflected in the 2014 examination, and that another examination is warranted to ascertain the current manifestations of this condition. The allegations of worsening that, at face value, are not inherently incredible, further development is in order. The matter is REMANDED for the following action: 1. Obtain all outstanding, pertinent VA treatment records since May 2016 as well as any updated treatment records identified by the Veteran. All records received should be associated with the claims file. 2. After completing directive 1 above, arrange for the Veteran to undergo a VA examination to determine the severity of his DM. The examiner must be provided access to all files. All indicated evaluations, studies, and tests should be conducted. The examiner is to specifically address whether the Veteran's DM requires regulation of activities, that is, does diabetes mellitus cause a medical need to avoid both strenuous occupational and recreational activity. The examination report must contain all findings to allow for the evaluation of DM, ED and onychomycosis of bilateral toes. A rationale must be provided for all opinions that are offered. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. RIPPEL