Citation Nr: 20072871 Decision Date: 11/12/20 Archive Date: 11/12/20 DOCKET NO. 15-45 487 DATE: November 12, 2020 ISSUES 1. Entitlement to an increased disability evaluation for diabetes mellitus in excess of 20 percent prior to October 22, 2019. 2. Entitlement to an increased disability evaluation for diabetes mellitus in excess of 40 percent from October 22, 2019. ORDER Entitlement to an increased disability evaluation for diabetes mellitus in excess of 20 percent prior to October 22, 2019 is denied. Entitlement to an increased disability evaluation for diabetes mellitus in excess of 40 percent from October 22, 2019 is denied. FINDINGS OF FACT 1. Prior to October 22, 2019, diabetes mellitus is manifested by insulin required with more than one daily injection, and restricted diet to control glucose levels; with no medically recommended restriction of activities. 2. From October 22, 2019, diabetes mellitus is manifested by avoidance of strumous occupational and recreational activities as part of medical management of the disease, insulin required with more than one daily injection, progressive loss of weight and strength, and restricted diet; with no episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, twice a month visits to a diabetic care provider, or complications that would not be compensable if separately evaluated. CONCLUSIONS OF LAW 1. The criteria for an increased disability evaluation in excess of 20 percent for diabetes mellitus prior to October 22, 2019 have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.119, Diagnostic Code 7913 (2018). 2. The criteria for an increased disability evaluation in excess of 40 percent for diabetes mellitus from October 22, 2019 have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.119, Diagnostic Code 7913 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2000 to September 2006. This matter is before the Board of Veterans Appeals (Board) on appeal from an August 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board Hearing in August 2018. A copy of the hearing transcript has been associated with the claims file. The issues were remanded by the Board in March 2019 for additional development. The requested development has been completed, and the appeal is back before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97 (2008). Later, a September 2020 rating decision granted an increased, 40 percent disability evaluation for diabetes mellitus effective October 22, 2019. As the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, the claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Significantly, as a separate compensable disability, the RO granted service connection for diabetic retinopathy of the left eye. Lastly, the Board observes that in October 2020, VA received a VA 21-526EZ Application for Disability Compensation and Related Compensation Benefits showing the issue of service connection for a psychiatric disorder, claimed as depression. A VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability is also of record. Those issues are still undergoing development before the RO. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability rating has been previously staged. As discussed below, the same stages are still warranted. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to an increased disability evaluation for diabetes mellitus in excess of 20 percent prior to October 22, 2019 The Board incorporates its discussion from the sections above by reference. By way of background, diabetes mellitus is currently assigned a 20 percent disability evaluation pursuant to 38 C.F.R. § 4.119, DC 7913. Under DC 7913, a 20 percent rating is warranted where treatment requires insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. 38 C.F.R. § 4.119, DC 7913. A 40 percent rating is warranted when the disease requires the taking of insulin, a restricted diet, and regulation of activities. “Regulation of activities” is defined by Diagnostic Code 7913 as the “avoidance of strenuous occupational and recreational activities.” Competent medical evidence is required to establish “regulation of activities,” namely, avoidance of strenuous occupational and recreational activities, for a 40 percent rating under Diagnostic Code 7913. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). Because of the successive nature of the rating criteria for diabetes, e.g., the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the three criteria listed in the 40 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Stated another way, if a component is not met at any one level, a Veteran can only be rated at the level that did not require the missing component. Id. A 60 percent rating requires the taking of insulin, a 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 total schedular (100 percent) rating for diabetes mellitus requires 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. 38 C.F.R. § 4.119, Diagnostic Code 7913. Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under Diagnostic Code 7913). Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119. By way of evidentiary history, the current rating reflects the findings of an August 2013 VA examination. The VA examiner indicated that the Veteran uses prescribed insulin with more than one injection per day. The VA examiner indicated that he does not require regulation of activities, visits diabetic care providers less than 2 times per month, and has experienced 0 episodes of ketoacidosis requiring hospitalization over the past 12 months. The VA examiner remarked, “INCREASE: There is no change in sc diagnosis of diabetes mellitus.” Next, the Veteran filed a timely August 2014 Notice of Disagreement (NOD). He avers that diabetes mellitus should be assigned a 60 percent disability evaluation due to multiple injections, restricted diet, regulation of activities, ketoacidosis, and loss of strength. In an attached page of handwritten lay evidence, the Veteran describes that he is on a restricted diet and has restricted activities. He is on both fast and slow acting insulin. The following year, a June 3, 2015 VA Nutrition Consultation is of record. It shows that the Veteran had ketoacidosis and was admitted to the ICU at the Tulane Hospital in 2014. Since then, there is a note of no significant weight change. There were no skin issues. The Veteran was advised that he had excessive carbohydrate intake and inadequate fiber intake, as evidenced by hyperglycemia, HgA1c greater than 5.8%, and other constraints. The VA Dietician recommended: INTERVENTIONS: 1. Meals and Snacks: Recommend 3 balanced meals per day and 1-2 healthy snacks. 2. Nutrition Education: Plate Method for Diabetes, CHO counting booklet a. Discussion with patient showed understanding of instruction provided. b. Knowledge deficit seen, further reinforcement needed. c. Patient demonstrated understanding of instruction by planning sample meal using cho-counting system Compliance prognosis: fair Consistently, the October 2015 Statement of the Case (SOC) acknowledged, “Although it was noted that you are not specifically on a restricted diet, current medical treatises state that a primary objective in the treatment of Diabetes is to maintain glucose levels through proper nutrition. Therefore, dietary restrictions are conceded as a widely accepted method of minimizing the disabling manifestations of Diabetes.” In November 2015, the Veteran perfected his appeal. He wrote that he requires multiple insulin injunctions, restricted diet, and regulation of activities. He had “an” episode of ketoacidosis requiring one hospitalization. Next, on February 19, 2017, a set of private treatment records were received. One is entitled “Application for a Review by the Physical Disability Board of Review (PDBR) of the Rating Awarded Accompanying a Medical Separation from the Armed Forces of the United States.” It shows that the Veteran’s date of separation was October 13, 2006. The Veteran wrote that he requires insulin multiple times daily, has a restricted diet, and has regulation of his daily activities. He has been hospitalized with ketoacidosis. Attached are private treatment records from Tulane Hospital / Clinic Patient Care. On page 5 of 5 is a set of discharge instructions. They show that the Veteran was admitted on June 7, 2014. He was admitted for diabetic ketoacidosis. The Veteran was provided educational information addressing his symptoms. Years later, the Veteran presented credible testimony at the August 2018 hearing. The Veteran is a type I diabetic. He takes insulin, eats a restricted diet, and regulates his activities. The Veteran testified that that he used to be very active with such activities as basketball and jogging. However, he now avoids strenuous activity because he had previous drops in his blood sugar if he engaged in any exercise that was too strenuous. The Veteran elaborated, “And there was (sic) three occasions where after working out, after jogging, after playing basketball that my sugars did dip into the low 20s, which is far under the lowest recommended number for sugars.” He was hospitalized in 2014 because of an episode of ketoacidosis. Put simply, the Veteran testified that moderate exercise is recommended, but strenuous exercise is not recommended because of the potential drop in blood sugar. He now only walks with his mom to get “a little cardio in.” Also at the August 2018 hearing, the Veteran’s representative highlighted the rating guidance for regulation of activities contained in the M-21-1 Adjudication Procedure Manual. See August 2018 Hearing Transcript, p. 6. Indeed, M-21-1 III.iv.4.M.1.e. Information on Regulation of Activities clarifies: The term regulation of activities is defined parenthetically in 38 C.F.R. § 4.119, DC 7913 to mean the requirement of “avoidance of strenuous occupational and recreational activities.” 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. In turn this must be understood as meaning that the avoidance is required to help control blood sugar. Additional ongoing VA and private treatment records show impressions of and treatment for diabetes mellitus, and are substantially the same. In the instant case, the Veteran contends that he is entitled to a 60 percent evaluation for diabetes mellitus type I. The Veteran avers that he requires multiple daily insulin injections of both slow and fast acting insulin. He reports a history of hospitalization for ketoacidosis less than two times per month. The Veteran asserts that while moderate exercise is recommended, he has been advised against strenuous exercise. See August 2014 Notice of Disagreement (NOD), October 2015 VA Form 9, January 2016 VA 646. Prior to October 22, 2019, diabetes mellitus is currently rated as 20 percent disabling. The 38 C.F.R. § 4.119, DC 7913. The current 20 percent rating contemplates diabetes mellitus managed with more than one daily injection of insulin. In order to receive a higher, 40 percent rating, the evidence of record must establish that diabetes mellitus requires insulin, a restricted diet, and regulation of activities. This is not the case here, as the most probative evidence does not show medically advised significant restrictions of activities. It also does not show the frequency of hospitalizations due to ketoacidosis or presentation to diabetic care providers of the frequency to warrant a higher rating. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report restricting diet, insulin injections, and treatment by medical professionals. He is competent to relate what he has been told by a professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran testified at the August 2018 hearing regarding the impairment caused by diabetes. The Veteran testified that moderate exercise is recommended, but strenuous exercise is not recommended because of the potential drop in blood sugar. He now only walks with his mom to get “a little cardio in.” We have considered his lay statements to the extent they are competent. Here, the most probative evidence is the August 2013 VA examination results, presenting a clear picture of the severity of the Veteran’s diabetes during this stage. As a threshold consideration, for VA purposes, “regulation of activities” means physician-directed restrictions on strenuous physical activities in an effort to control diabetic complications or prevent injury. The Veteran’s diabetes mellitus was managed by diet and insulin injections. The VA examiner indicated that the Veteran does not require regulation of activities, visits diabetic care providers less than two times per month, and has experienced zero episodes of ketoacidosis requiring hospitalization over the past 12 months. The Veteran did not have progressive unintentional weight loss attributable to diabetes. The VA examiner remarked, “INCREASE: There is no change in sc diagnosis of diabetes mellitus.” The Veteran’s condition has been relatively stable but for one hospitalization in 2014. In summary, the August 2013 VA examination results show that diabetes requires treatment with insulin, and is best summarized by the current 20 percent disability evaluation. In addressing the Veteran’s representative’s argument at the August 2018 hearing, we have considered the rating guidance for regulation of activities contained in the M-21-1 Adjudication Procedure Manual. See generally M-21-1 III.iv.4.M.1.e. However, it unequivocally shows that voluntary avoidance of strenuous activity by the Veteran, undertaken with the intention of avoiding hypoglycemic episodes, does not meet the regulatory criteria. The Veteran competently testified that he still exercises, although he does not engage in strenuous activities. Still, the VA examiner indicated that the Veteran does not have regulation of activities. This is a medical determination, and we have assigned the most probative weight to the August 2013 VA examination results. Although we discuss the M-21 as raised by the Veteran’s representative, we are ultimately bound by and applied the rating criteria in 38 C.F.R. § 4.119. In addition, the Veteran testified that moderate exercise was still recommended. See Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). In short, although the evidence demonstrates that the Veteran requires insulin and the RO has conceded a restricted diet for glucose control, there is no evidence that his limitations rise to the level of doctor-prescribed regulation of activities, which could warrant an increased disability evaluation of 40 percent. There is also no evidence of multiple hospitalizations due to ketoacidosis or presentation to diabetic care providers of the frequency that would warrant an increased disability evaluation. We have considered his lay statements, and they do not show any impairment more severe than that already contemplated by the current disability evaluation. The 20 percent rating most closely approximates the Veteran’s level of disability for this stage. There is no doubt to resolve. Therefore, an increased disability evaluation in excess of 20 percent for diabetes mellitus prior to October 22, 2019 is not warranted. 2. Entitlement to an increased disability evaluation for diabetes mellitus in excess of 40 percent from October 22, 2019 The Board incorporates its discussion from the sections above by reference. By way of background, diabetes mellitus is currently assigned a 40 percent disability evaluation effective October 22, 2019 pursuant to 38 C.F.R. § 4.119, DC 7913. As discussed below, this is the date when there was a change in the severity of the disability. In order to have an even higher disability evaluation, there must be taking of insulin, a 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. This is not the case here, as the most probative evidence does not show such severe impairment. By way of history, following the March 2019 Board Remand, the Veteran was afforded an October 22, 2019 VA Diabetes Mellitus examination with Disability Benefits Questionnaire (DBQ). The VA examiner documented that the Veteran has moderately severe diabetes mellitus. He takes insulin with meals and requires more than one injection per day. He requires regulation of activities. The VA physician documented, “Veteran reports that he was previously living an active life, notes that his glucose was too low, says glucometer read 22, at which time he stopped any strenuous activity such as weight lifting and basketball. Veteran only walks for physical activity, usually 2-3 times weekly.” The VA examiner also documented, “Veteran feels symptoms have affected his life. He reports lethargy, fatigue, always sleepy, reports constant administration of insulin increases his hunger and debilitates him. Admits to polyuria, polyphagia and polydipsia.” The VA examiner indicated the Veteran had no hospitalizations during the past year. The VA examiner also indicated that the Veteran visited his diabetic care provider less than two times per month. Still, he had progressive weight loss and weakness. The VA physician indicated that the Veteran has complications of diabetic retinopathy, nephropathy, and peripheral neuropathy. However, follow-up examinations for these specific conditions found that the Veteran did not have nephropathy, and no objective evidence to support a diagnosis of peripheral neuropathy. Diabetic retinopathy was confirmed in the left eye. The VA examiner concluded, “Veteran’s nature of regulation of activities due to diabetes mellitus is for mild to moderate exercise which is medically advisable but avoidance of strenuous exercise is required and has been prescribed by his previous providers due to history of and risk for hypoglycemic episodes. Veteran reports that he has adjusted exercise to a stable level and pace with no recent hypoglycemic episodes.” Recently, a May 29, 2020 VA treatment record shows that the Veteran called to discuss his health plan. It shows in part: HPI-pt reports being diagnosed with diabetes type I in 2007. He has been taking Insulins since then. He denies any polydipsia, polyuria, h/o neuropathy or retinopathy. “I am not perfect with my Insulin. I forget to take it sometimes. I try not to forget my cholesterol medication”. Additional ongoing VA and private treatment records show impressions of and insulin injections for diabetes mellitus, and are substantially the same. In August 2020, the Veteran was afforded a set of VA examinations with medical opinions for the eyes, kidneys, and peripheral nerves. For the left eye, the VA examiner identified, “mild nonproliferative diabetic retinopathy, without macular edema.” The diabetic peripheral neuropathy examination shows a conclusion, “No Diagnosis of Diabetic Peripheral Neuropathy confirmed. Subjective report only. Symptoms are intermittent and could be explained by his elevated blood sugars. There is no objective evidence on exam to support patient has a diabetic peripheral neuropathy.” Significantly, a September 2020 rating decision considered the results of the VA examinations, and granted service connection for diabetic retinopathy of the left eye. Ongoing VA treatment records show impressions of and treatment for diabetes mellitus, and are substantially the same. The Veteran contends that he is entitled to a 60 percent evaluation for diabetes mellitus type I. The Veteran explains that he requires multiple daily insulin injections of both slow and fast acting insulin. He reports a history of hospitalization for ketoacidosis less than two times per month. The Veteran asserts that while moderate exercise is recommended, he has been compelled to cease strenuous exercise. See August 2014 Notice of Disagreement (NOD), October 2015 VA Form 9, January 2016 VA 646. From October 22, 2019, diabetes mellitus is currently rated as 40 percent disabling. The 38 C.F.R. § 4.119, DC 7913. The current rating contemplates diabetes mellitus with avoidance of strumous occupational and recreational activities, insulin required with more than one daily injection, progressive loss of weight and strength, and restricted diet; with no taking of episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, or twice a month visits to a diabetic care provider. In order to receive a higher, 60 percent rating, the evidence of record must establish that diabetes mellitus treatment 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. The Veteran does not experience such severe impairment. He is now separately been compensated for a left eye disability. He does not have the frequency of hospitalizations due to ketoacidosis or presentation to diabetic care providers of the frequency to warrant a higher rating. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report restricting diet, insulin injections, and being told by a medical professional that he should regulate his activities. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, the most probative evidence is the October 22, 2019 VA examination results, presenting a clear picture of the severity of the Veteran’s diabetes during this stage. This is the date upon which there is evidence of a change. The VA examiner elicited a lay history from the Veteran, including regarding regulation of activities, and performed a complete physical examination. The VA examiner documented that the Veteran requires more than one insulin injection per day. Regarding regulation of activities, the VA physician documented, “Veteran reports that he was previously living an active life, notes that his glucose was too low, says glucometer read 22, at which time he stopped any strenuous activity such as weight lifting and basketball. Veteran only walks for physical activity, usually 2-3 times weekly.” The VA examiner also described, “Veteran feels symptoms have affected his life. He reports lethargy, fatigue, always sleepy, reports constant administration of insulin increases his hunger and debilitates him. Admits to polyuria, polyphagia and polydipsia.” The VA examiner indicated the Veteran had no hospitalizations during the past year. The VA examiner also indicated that the Veteran visited his diabetic care provider less than two times per month. Still, he had progressive weight loss and weakness. In summary, the October 2019 VA examination results show a change in the severity of impairment, for which an increased disability evaluation has already been granted. The severity of diabetes mellitus is most closely approximated by the current 40 percent disability evaluation. In addressing the Veteran’s representative’s argument at the August 2018 hearing, we have considered the rating guidance for regulation of activities contained in the M-21-1 Adjudication Procedure Manual. See generally M-21-1 III.iv.4.M.1.e. There has been a change, in that the October 22, 2019 VA examiner indicated that the diabetes requires regulation activities as part of medical management of diabetes mellitus. This change is contemplated by the increased 40 percent evaluation granted by the RO. See September 2020 rating decision. Although we discuss the M-21 as raised by the Veteran’s representative, we are ultimately bound by and applied the rating criteria in 38 C.F.R. § 4.119. In short, the most probative evidence shows that the Veteran’s present condition is managed by diet, insulin, and regulation of activities, which is best summarized by the current 40 percent disability evaluation. He has a history of diet and insulin use, and has more recently had to regulate his activities per medical advice. See Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). The Veteran has not had ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. Upon being afforded a set of VA examinations, left eye diabetic retinopathy has been separately service-connected. In other words, the current disability evaluation adequately encompasses his level of impairment, and there are no other complications that would not be compensable if separately evaluated. We have considered his lay statements, and they do not show any impairment more severe than that already contemplated by the current disability evaluation. The 40 percent rating most closely approximates the Veteran’s level of impairment for this stage. There is no doubt to resolve. Therefore, a disability evaluation in excess of 40 percent for diabetes mellitus prior to October 22, 2019 is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Bodi, Associate Counsel 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.