Citation Nr: 1815380 Decision Date: 03/15/18 Archive Date: 03/23/18 DOCKET NO. 14-22 257 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to an increased initial rating for type II diabetes mellitus, evaluated as 10 percent disabling prior to December 13, 2012, and as 20 percent disabling thereafter. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1968 to December 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which, in pertinent part, granted entitlement to service connection for diabetes and assigned a 10 percent rating, effective from April 1, 2011. In August 2011, the Veteran filed a notice of disagreement with the evaluation assigned. In a May 2014 rating decision, the RO increased the rating for diabetes to 20 percent, effective from December 13, 2012. Also, in May 2014, the RO issued a statement of the case, to which the Veteran filed a timely substantive appeal in June 2014. In March 2017, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge, a transcript of which is of record. FINDINGS OF FACT 1. Prior to December 13, 2012, the Veteran's diabetes mellitus was managed by a restricted diet, including herbal supplements, but it did not require oral hypoglycemic agents or insulin. 2. Since December 13, 2012, the Veteran's diabetes mellitus has been managed by the use of oral hypoglycemic agents and a restricted diet, but it has not medically required regulation of his activities. CONCLUSIONS OF LAW 1. Prior to December 13, 2012, the criteria for a rating in excess of 10 percent for diabetes mellitus were not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). 2. Since December 13, 2012, the criteria for a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In the present case, VA's duty to notify was satisfied by way of an April 2011 letter to the Veteran. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. The Veteran has not identified any outstanding evidence, to include any other medical records, which could be obtained to substantiate his appeal. In light of the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that all necessary development has been accomplished. Therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Increased Rating The Veteran contends that his diabetes mellitus is more severe than reflected in his current disability ratings. A. General Legal Criteria Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. B. Diabetes Mellitus Rating Criteria The Veteran is in receipt of a 10 percent disability rating for diabetes under Diagnostic Code 7913 for the rating period prior to December 13, 2012, and a 20 percent rating thereafter. Under Diagnostic Code 7913, a 10 percent evaluation is warranted for diabetes mellitus manageable by a restricted diet only. A 20 percent evaluation is warranted for diabetes mellitus requiring insulin and restricted diet; or, an oral hypoglycemic agent and restricted diet. A 40 percent evaluation is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent evaluation 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 evaluation is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational 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. Compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See Note (1) to 38 C.F.R. § 4.119, Diagnostic Code 7913. The Court has held that, in order to demonstrate a regulation of activities, "medical evidence" is required to show that both occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). The phrase "regulation of activities" means "avoidance of strenuous occupational and recreational activities." Camacho, 21 Vet. App. at 362 (quoting 38 C.F.R. § 4.119, Diagnostic Code 7913 (defining the term within the criteria for a 100 percent rating)). "Successive" rating criteria in a diagnostic code is 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, a veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). For example, Diagnostic Code 7913 is successive in nature because each higher evaluation requires the elements of the lower evaluation: the 10 percent evaluation requires a restricted diet; the 20 percent evaluation requires a restricted diet and insulin or oral hypoglycemic agent; the 40 percent evaluation requires insulin, restricted diet, and regulation of activities; and so forth. Camacho, 21 Vet. App. at 366. C. Factual Background Turning to the evidence of record, a February 2011 private treatment record shows that the Veteran was diagnosed with uncontrolled diabetes with an A1C level of 11.5, and he was prescribed Actos and Metformin. Later that month, the Veteran established care with a naturopathic physician for the treatment of his diabetes. See Dorland's Illustrated Medical Dictionary 1233 (defining "naturopathy" as "a drugless system of health care, making use of a wide variety of therapies, such as hydrotherapy, heat, massage, and herbal medicine, whose purpose is to treat the whole person to stimulate and support the person's own innate healing capacity"). The Veteran reported that he was given prescriptions but did not want to take them due to possible side effects of dizziness and lightheadedness. He also reported that he was unwilling to take insulin. The assessment was "type 2 diabetes...[Veteran] doesn't want to take prescription meds due to possible side effects...give [Veteran] diet and herbs to lower blood sugars." He was prescribed an anti-inflammatory diet, alpha lipoic acid, an essential fatty acid, chromium, and protoglysen. An April 2011 naturopathy treatment record shows that the Veteran stopped taking alpha lipoic acid and protoglysen and added coenzyme Q10 (CoQ10) and cinnamon. An April 2011 private primary care record shows that the Veteran's diabetes was being followed by an osteopathic physician, who was giving him chromium tablets and other herbal supplements. The Veteran also reported that he was treating his diabetes with "diet measures." Metformin and Actos were removed from the Veteran's medication list, and the physician noted that the Veteran was taking herbal remedies and chromium. The Veteran was afforded a VA examination in April 2011. The Veteran reported that he was initially told of his diabetes diagnosis during an inpatient orthopedics procedure in December 2010. The examiner noted that the Veteran's primary care physician then recommended starting oral medications, but the Veteran "has chosen to attend ADA classes and also has done dietary modification with a naturopathic physician" and that he takes "some herbal/vitamin supplements (coq10, cinnamon)." The Veteran reported that "[w]ith this regimen he has lost approximately 20 lbs of weight and states that his fingersticks are running approximately 130." Regarding diabetes complications, the Veteran had no eye complaints and no history of kidney problems. The examiner noted that the Veteran was "already on lisinopril for longstanding hypertension (and atenolol for history of chronically elevated resting heart rate)." The Veteran had no complaints of neuropathy, but the examiner noted a history of "chronic mild lower extremity (ankle) 'sock mark' edema for many years which is attributed to his obesity history and which has not required treatment." The Veteran reported a five to six year history of decline in erectile function, which he attributed to the start of lisinopril for treatment of his hypertension, and the examiner noted that "the ED thus preceded the onset of his diabetes." The examiner indicated that the current treatment for the Veteran's diabetes was "diet alone." The examiner noted no episodes of hypoglycemia reactions or ketoacidosis. The examiner also indicated that the Veteran was instructed to follow a restricted or special diet, but he was not restricted in his ability to perform strenuous activities. An eye examination showed normal visual acuity and grossly normal visual fields. An extremity examination was "[n]ormal except for mild scattered hyperpigmentation changes consistent with venous stasis (due to obesity) and NOT due to diabetes." (emphasis in original). A lower extremity reflex examination was normal bilaterally, and a bilateral lower extremity sensory examination was normal to light touch, vibration, and position sense testing. Laboratory testing showed a hemoglobin A1C level of 7.0, a random glucose of 129, and normal renal function. The examiner concluded that the Veteran had type 2 diabetes, with no evidence of visual impairment, kidney disease, or neurologic disease. Regarding hypertension, the examiner opined that it was not a complication of diabetes because its onset was prior to diabetes and because there was no evidence that it had been aggravated due to diabetes. Regarding erectile dysfunction, the examiner opined that it was not a complication of diabetes because its onset was prior to diabetes and because there was no evidence that it had exacerbated by recent onset of diabetes. In the May 2011 rating decision on appeal, the RO granted entitlement to service connection for diabetes and assigned a 10 percent rating based on a finding that the Veteran's diabetes was controlled by diet alone. In a June 2011 statement, the Veteran disagreed that his diabetes was treated with diet alone because he was also taking "required herbal medications" prescribed by a doctor and that "she was a naturopath has no effect on that they were prescribed." The Veteran also indicated that he had been directed by a doctor "to undertake an increased regimen of exercise to augment the treatment of herbals & modified diet." The Veteran further argued that the herbal supplements prescribed by his naturopathic physician should be classified as oral hypoglycemic agents because the supplements reduced his blood sugar. The Veteran asserted that he could have followed his primary care physician's recommendation and used insulin, "even though it is not indicated at [his] level of diabetes & would invariable[y] lead to a more serious & disabling set of problems" and that by taking the "least bodily stressful way to treat" his diabetes, he was limiting the chance that the disease would progress. A June 2011 VA treatment record shows that the Veteran sought to establish care. He reported that he was previously prescribed medication for diabetes, but they were very expensive and precluded him from operating heavy machinery. He indicated that he had been doing a lot of diet modification and taking supplements. The physician noted that the Veteran "had been followed by naturopath, so not on any meds." The Veteran's medication profile was reviewed and updated to include omega 3 fatty acid, cinnamon supplement, gymnema (old Indian herb), and CoQ10. The assessment was "DM-control has improved per patient report with weight loss, dietary modification, and use of herbal supplements to manage. [H]e prefers this method as long as effective." The physician also noted that a foot exam was normal and that the Veteran lost about 40 pounds and continued to watch diet and do regular walking for exercise. A July 2011 VA lab results letter to the Veteran shows that kidney function was normal, a urine test to check for protein leakage due to kidney damage from diabetes was normal, and the A1c level was "good at 6.2." A July 2011 VA diabetic teleretinal imaging consult note shows that the Veteran had moderate diabetic retinopathy on the right and no diabetic retinopathy on the left. A July 2011 VA primary care results letter to the Veteran shows that recent blood sugar readings "really look okay" and that based on the Veteran's HBA1c, the physician "would not recommend any medications at this time." The Veteran was informed that if he starts "seeing a trend upward, we can consider medication, but overall your control is good." In a July 2011 statement, the Veteran's wife asserted that due to the Veteran's diabetes, she and the Veteran had to make "dramatic changes to our diet, changed our daily routines to include additional activities, incurred additional expenses in daily diet supplements to control [the Veteran's] blood sugar, and added to our stress level while we try to cope with this disease." An August 2011 VA optometry note shows that the Veteran reported taking cinnamon, CoQ10, and gymnema. The optometrist noted a personal medical history of, inter alia, diabetes "controlled with vitamins." The Veteran's corrected distance visual acuity was 20/20 bilaterally. Visual fields were full to finger counting bilaterally. The assessment was "Type (2) DM, controlled with vitamins, with moderate non-proliferative diabetic retinopathy OD and no diabetic retinopathy OS and no clinically significant macular edema OU." A January 2012 VA primary care note shows that the Veteran reported taking omega 3 fatty acid, cinnamon supplement, gymnema, and CoQ10. The physician noted that the Veteran's diabetes control "sounds stable." A January 2012 VA lab results letter to the Veteran shows that kidney function tests were normal and a diabetes test was "great, HBA1c at 6.1 (goal < 7.0)." The Veteran was afforded a VA examination in March 2012. The examiner noted that the Veteran's diabetes was managed by "Other: Takes Naturopathic medicines only-Cinnamon 1000mg TID, Gymnema 400mg 2 pills TID, and CoQ10 100mg TID." The examiner also indicated that the Veteran did not require regulation of activities as part of his medical management of diabetes and that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. The examiner noted that the Veteran had no episodes of hospitalization for ketoacidosis or hypoglycemic reactions over the past 12 months and that the Veteran had not had progressive unintentional weight loss or loss of strength attributable to diabetes. A September 2012 VA optometry note shows that the Veteran reported stable blood sugar levels and no visual complaints. The Veteran's corrected distance visual acuity was 20/20 bilaterally. The assessment was "Type (2) DM, controlled with vitamins and diet, without diabetic retinopathy OU and no clinically significant macular edema OU." An October 2012 VA lab results letter to the Veteran shows that kidney function tests were normal and that the Veteran's HBA1c was 6.6." A December 2012 VA primary care note shows that the Veteran's blood sugar levels were increasing and that the Veteran's naturopathic physician recommended metformin. The assessment was "DM-control is pretty good; HBa1c has drifted up so would like to try metforming." The Veteran was prescribed Metformin. A March 2013 VA lab results letter to the Veteran shows that the Veteran's A1C "improved at 6.4%." In an April 2013 statement, the Veteran's representative argued that the RO's statements in the May 2011 rating decision regarding the Veteran's diabetes treatment were inaccurate. Specifically, the representative asserted that the herbal supplements used by the Veteran should be considered a hypoglycemic agent because "a hypoglycemic agent is defined as any of various agents that decrease the level of glucose in the blood and are used in the treatment of diabetes mellitus" and because the Veteran was being treated with Coenzyme Q10, "which according to the Mayo Clinic...may decrease blood pressure in patients and is used to treat diabetes." The representative also asserted that "VA should recognize herbal remedies, as with traditional medical treatment, as there is no exclusion to herbal treatments in the rating schedule." Finally, the representative pointed out that the Veteran had recently switched to Metformin. Accompanying the statement was a print-out from a dictionary website showing the aforementioned definition of hypoglycemic agent, as well as a print out from the Mayo Clinic website showing that Coenzyme Q10 "may lower blood sugar levels" and "may decrease blood pressure." A September 2013 VA primary care note shows that the Veteran's diabetes control was "very good by recent labs." An October 2013 VA treatment record shows that the Veteran's A1C was 6.4. A December 2013 VA primary care note shows "good control" of diabetes with current medical management. A May 2014 VA lab results letter to the Veteran shows that the Veteran's A1C was 6.7, and the physician noted that the Veteran's "diabetes is doing well." In a May 2014 rating decision, the RO increased the Veteran's rating to 20 percent, effective from December 13, 2012, which was the date that the Veteran was prescribed Metformin. See December 2012 VA Treatment Record. A June 2014 VA optometry note shows an assessment of "Type 2 diabetes with mild non-proliferative diabetic retinopathy OD, no signs of diabetic retinopathy OS, and no clinically significant macular edema OU." The Veteran's corrected distance visual acuity was 20/20 bilaterally. A September 2014 VA treatment record shows that the Veteran reported that his blood sugar was steadily rising over the past three months. He reported that he was eating fewer carbohydrates, exercising three times per week, and taking his metformin as prescribed. Lab tests showed an A1C of 6.6. The Veteran's physician indicated that the Veteran's diabetes was "stable at this point" with the Veteran's current treatment plan and that the Veteran was counseled on lifestyle changes to improve diabetic care. A January 2015 VA telephone encounter note shows that the Veteran reported that his blood sugars had been gradually rising over the past four months. He indicated that he was exercising three days per week, walking one mile a couple days per week, and restricting his carbohydrate intake. An April 2015 lab test showed an A1C of 7. A June 2015 VA treatment record shows that the Veteran received nutritional counseling for the management of his diabetes. The nutrition diagnosis was "[i]nconsistent carbohydrate intake related to lack of prior nutrition education as evidenced by HgbA1c 7.0." He was counseled regarding diet and meal planning. A July 2015 VA primary care note shows that the Veteran reported that his physical activity was limited due to left knee DJD. The assessment was "diabetes: fair control, A1C higher due to lack of activity, weight gain." A November 2015 VA lab results letter shows that the Veteran's A1C was 7.2 and a comment of "acceptable level, continue current medications." A January 2016 VA telephone encounter note shows that the Veteran reported that his blood sugar readings had been steadily climbing. A February 2016 VA primary care note shows that the Veteran's metformin dosage was increased. He was also advised to adhere to a diabetic diet, get at least a half hour of exercise, and lose weight. A February 2016 VA lab results letter shows that the Veteran's A1C was 8.4. During the March 2017 Board hearing, the Veteran testified that the "crux of the whole matter," was that the herbal supplements prescribed by his naturopathic physician should be considered oral hypoglycemic agents because none of the definitions for oral hypoglycemic agents are limited to prescribed pharmaceuticals. The Veteran testified that eventually, the herbal supplements stopped working "terribly well" so he went on Metformin. He indicated that over time, the Metformin stopped working "really well," so his Metformin dosage was doubled, and that he was recently prescribed Glucophage. The Veteran testified that "all this stuff has been working, it just kind of slides, it becomes unreliable after a while[,] [w]hich is exactly what the herbal stuff did." The Veteran asserted that "if it works and it's taken by mouth, it's an oral medication." The Veteran also argued that even if the herbal supplements are not considered oral hypoglycemic agents, he still meets the criteria for an increased rating because he would have been on an oral hypoglycemic agent, such as Metformin, if he had not opted to undertake an alternative regimen, i.e., herbal supplements. The Veteran suggested that because Metformin was originally recommended when he was first diagnosed with diabetes, this shows that the severity of his disability was such that he required an oral hypoglycemic agent regardless of whether he was actually taking it. D. Analysis Having carefully considered the Veteran's contentions in light of the evidence recorded and the applicable law, the Board finds that the criteria for a rating in excess of 10 percent were not met prior to December 13, 2012. In this regard, the Board notes that to warrant a higher rating under Diagnostic Code 7913 the evidence must show diabetes mellitus requiring either insulin and restricted diet or oral hypoglycemic agent and restricted diet. Here, there is no question that the Veteran's diabetes was managed with a restricted diet, and there is no evidence that the Veteran's diabetes required insulin prior to December 13, 2012. Thus, the sole issue relevant to this period of the appeal is whether the Veteran required an oral hypoglycemic agent to control his diabetes prior to December 13, 2012. The Board has carefully considered the Veteran's argument that the herbal supplements he took to help control his blood sugar should be considered oral hypoglycemic agents for rating purposes. Although the term "oral hypoglycemic agent" is not defined in the regulation, the Board must consider the plain language of the regulation and consider the terms in accordance with their common meaning. See Lockheed Corp. v. Widnall, 113 F.3d 1225, 1227 (Fed. Cir. 1997). However, the Court has also recognized the affirmative duty to avoid an interpretation of regulatory language that would produce "an illogical and absurd result." Zang v. Brown, 8 Vet. App. 246, 252-53 (1995); see also Splane v. West, 216 F.3d 1058, 1068-69 (Fed. Cir. 2000) (explaining that canons of construction require giving effect to the clear language of a statute and avoid rendering any portions meaningless or superfluous). The Veteran is essentially asserting that any substance taken by mouth that may lower blood sugar should be considered an oral hypoglycemic agent. Taken to its logical conclusion, the Veteran's contention reveals its own flaws. In this regard, under such a broad reading of the term "oral hypoglycemic agent," that criterion could arguably be satisfied by mere diet modifications, which would render superfluous the less severe, 10 percent criterion of diabetes "manageable by restricted diet only." Furthermore, such a broad reading could produce the "absurd result" that a Veteran whose diabetes is controlled through diet restrictions and cinnamon supplements could receive the same rating as a Veteran who requires diet restrictions and insulin. The Board has also considered the Veteran's argument that he meets the criteria for a 20 percent rating because he was initially prescribed oral hypoglycemic agents, such as Metformin, but he decided to try managing his diabetes with diet modifications and herbal supplements instead. Such an interpretation of the rating criteria is inconsistent with the regulatory intent of Diagnostic Code 7913, which supports the view that the degree of impairment from diabetes mellitus should be determined according to how well the disease is controlled. See Camacho v. Nicholson, 21 Vet. App. 360, 365 (2007) (citing 58 Fed. Reg. 5691, 5693 (Jan. 22, 1993)); see also Middleton v. Shinseki, 727 F.3d 1172, 1177 (Fed. Cir. 2013) (holding that the plain language of DC 7913 reciting the criterion "[r]equiring insulin" for each of the 20% and 40% ratings "clearly requires that the [V]eteran is administered insulin"). The evidence in this case, to include the Veteran's own statements, clearly shows that prior to December 13, 2012, the Veteran was controlling his diabetes without the use of an oral hypoglycemic agent, such as Metformin, despite the fact that he was initially prescribed it. See, e.g., July 2011 VA Treatment Record (noting that the Veteran's overall diabetes control was good and that based on the Veteran's blood sugar readings and HBA1c level, the Veteran's physician "would not recommend any medications at this time); June 2011 Veteran's Statement in Support of Claim (asserting that he could have taken prescription medications "even though it is not indicated at [his] level of diabetes & would invariable[y] lead to a more serious & disabling set of problems" and that by taking the "least bodily stressful way to treat" his diabetes, he was limiting his chance that the disease would progress). Moreover, the medical evidence in this case is against a finding that the herbal supplements used by the Veteran were on par with oral hypoglycemic agents as contemplated by the rating criteria. In this regard, both VA examiners were aware of the herbal supplements the Veteran was using, but both VA examiners nonetheless indicated that the Veteran's diabetes was not managed by use of an oral hypoglycemic agent. The April 2011 VA examiner noted the Veteran's use of "some herbal/vitamin supplements (coq10, cinnamon)" and then opined that the Veteran's diabetes was managed by "diet alone." Similarly, the March 2012 VA examiner noted that the Veteran was taking "Cinnamon 1000mg TID, Gymnema 400mg 2 pills TID, and CoQ10 100mg TID," and then opined that the Veteran's diabetes was managed by "Other: Takes Naturopathic medicines only," rather than by an oral hypoglycemic agent. When read as a whole and in the context of the evidence of record, it is clear that the examiners did not consider the herbal supplements used by the Veteran to be oral hypoglycemic agents. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record); see also Monzingo v. Shinseki, 26 Vet. App. 97, 105, (2012) (a medical report must be read as a whole in the context of the claim and, even an opinion lacking in detail may be provided some probative value based upon the amount of information and analysis contained therein). Similarly, VA treatment records contain numerous statements suggesting that the Veteran's diabetes was not being managed by "medication," but rather by diet and vitamins. Specifically, when the Veteran first established care at a VA Medical Center in June 2011, the examining physician noted the Veteran's use of herbal supplements and indicated that the Veteran "had been followed by naturopath, so not on any meds." In July 2011, the same primary care physician informed that based on his recent lab tests, the physician "would not recommend any medications at this time," but if the Veteran starts "seeing a trend upward, we can consider medication, but overall your control is good." Likewise, the Veteran's VA optometrist noted in August 2011 that the Veteran was taking cinnamon, CoQ10, and gymnema and stated that the Veteran's diabetes was "controlled with vitamins." See also September 2012 VA Optometry Record (assessing the Veteran with Type (2) DM, controlled with vitamins and diet). The Veteran is competent to report his diabetes symptoms and treatment methods. See 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person). However, as a lay person without appropriate medical expertise, the Veteran is not competent to provide an opinion as to a complex medical question, such as the proper classification of herbal supplements versus prescribed oral hypoglycemic agents, such as Metformin, in evaluating the severity of diabetes. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature"); Layno v. Brown, 6 Vet. App. 465, 469- 71(1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). The Board finds that the VA examination reports, indicating that the Veteran's diabetes was managed by diet alone or through the use of vitamins, but not by use of oral hypoglycemic agents, combined with treatment records reflecting that the Veteran's diabetes was not managed by "medication," is the most probative evidence of record on the issue. As such, the competent medical evidence of record is against a finding that the Veteran required an oral hypoglycemic agent to control his diabetes prior to December 13, 2012. Accordingly, a rating in excess of 10 percent is not warranted prior to December 13, 2012. Regarding the period since December 13, 2012, the Board finds that the criteria for a rating in excess of 20 percent were not met. In this regard, the Board notes that to warrant a higher rating under Diagnostic Code 7913 the evidence must show diabetes mellitus requiring insulin, a restricted diet, and regulation of activities. In the present case, there is no medical evidence or argument that the Veteran has had to regulate his activities as defined by Camacho. Rather, treatment records show that physical activity was generally advised or encouraged, and they do not otherwise show that regulation of activity was necessary to control the Veteran's diabetes. See, e.g., February 2016 VA Treatment Record (Veteran was advised to get a least a half hour of exercise); September 2014 VA Treatment Record (Veteran reported exercising three times per week). In addition, the VA examiners who conducted the April 2011 and March 2012 examinations indicated that the Veteran did not require regulation of activities as part of the medical management of diabetes mellitus. In the absence of medical evidence showing that the Veteran has been required to regulate his activities, as defined by Camacho, a rating in excess of 20 percent is not warranted for the period since December 13, 2012. Pursuant to Note 1 under Diagnostic Code 7913, the Board must assign separate ratings for any compensable complications of the Veteran's service-connected diabetes mellitus, type II. All noncompensable complications are considered part of the diabetic process. 38 C.F.R. § 4.119; Diagnostic Code 7913, Note (1). The Board notes that the Veteran has been diagnosed with diabetic retinopathy. Retinopathy is rated under Diagnostic Code 6006 according to the General Rating Formula for Diagnostic Codes 6000 through 6009. 38 C.F.R. § 4.79. Under the General Rating Formula, eye disabilities are rated based on either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher rating. An incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Generally, corrected distant vision determines the level of impairment of visual acuity. 38 C.F.R. § 4.76 (b). A noncompensable rating is assigned when vision is corrected to 20/40 in both eyes; there is no rating for visual acuity superior to 20/40. 38 C.F.R. § 4.79. Visual impairment can also be rated based on impairment of visual field or muscle function. 38 C.F.R. §§ 4.77, 4.78. Here, the Veteran's corrected distant vision was 20/20 bilaterally, corresponding to a noncompensable rating pursuant to Diagnostic Code 6006. See June 2014 VA Treatment Record (corrected distance 20/20 bilaterally); August 2012 VA Treatment Record (corrected distance 20/20 bilaterally); April 2011 VA Examination Report (normal visual acuity). Nor does the evidence support a finding of visual field loss, impaired muscle function, or incapacitating episodes. The Veteran's diabetic retinopathy has been described as mild to moderate. Thus, a separate compensable rating for diabetic retinopathy is not warranted. Regarding other complications of diabetes, the Board notes that the Veteran has been diagnosed with hypertension and erectile dysfunction; however, the April 2011 VA examiner specifically opined that neither condition was a complication of diabetes. There is no evidence of any other separate, compensable complications of diabetes. Based on the foregoing, the Veteran has not been shown to meet the criteria for increased evaluations under the rating criteria. Prior to December 13, 2012, the Veteran's diabetes was managed by restricted diet, to include herbal supplements, but neither insulin nor an oral hypoglycemic agent was required. Since December 13, 2012, the Veteran has been shown to require an oral hypoglycemic agent and a restricted diet to control his diabetes, he does not require a regulation of activities, which is a necessary component for a higher evaluation. Nor does the evidence support any separate compensable evaluations for complications of the service-connected diabetes mellitus. Accordingly, the Veteran is not entitled to an evaluation in excess of 10 percent for his diabetes mellitus prior to December 13, 2012, or in excess of 20 percent thereafter. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER Prior to December 13, 2012, a rating in excess of 10 percent for diabetes mellitus is denied. Since December 13, 2012, a rating in excess of 20 percent for diabetes mellitus is denied. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs