Citation Nr: 21032749 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 17-22 465 DATE: May 27, 2021 ORDER Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to July 28, 2016 is granted. Entitlement to a TDIU due to service-connected disabilities from July 28, 2016 is dismissed. Entitlement to a rating in excess of 40 percent for diabetes mellitus, type II prior to July 27, 2020 is denied. Entitlement to a 60 percent rating for diabetes mellitus, type II, and no higher, from July 27, 2020 is granted. FINDINGS OF FACT 1. Prior to July 28, 2016, the Veteran's service-connected disabilities rendered him unable to secure and follow a substantially gainful occupation. 2. From July 28, 2016, the Veteran's combined disability rating is 100 percent. 3. For the period prior to July 27, 2020, the preponderance of the evidence is against a finding that the Veteran's diabetes mellitus, type II, was manifested by episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. 4. For the period from July 27, 2020, the Veteran's diabetes mellitus, type II has been manifested by episodes of ketoacidosis requiring one hospitalization per year; the preponderance of the evidence is against a finding that the Veteran's diabetes mellitus, type II, has been manifested by episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider. CONCLUSIONS OF LAW 1. Prior to July 28, 2016, the criteria for entitlement to a TDIU due to service-connected disabilities have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 2. From July 28, 2016, the claim for entitlement to a TDIU due to service-connected disabilities is dismissed as moot. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 3. The criteria for entitlement to a rating in excess of 40 percent for diabetes mellitus, type II prior to July 27, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913. 4. The criteria for entitlement to a 60 percent rating, and no higher, for diabetes mellitus, type II from July 27, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.119, DC 7913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1986 to May 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), in Nashville, Tennessee, which, inter alia, denied TDIU and continued the 40 percent disability rating for diabetes mellitus, type II. In December 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously before the Board in March 2020. At that time, the Board, inter alia, remanded the claims for further evidentiary development. 1. Entitlement to a TDIU due to service-connected disabilities prior to July 28, 2016 VA disability ratings are based, as far as practicable, on the average impairment of earning capacity attributable to disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Id. Where the schedular rating is less than total, a total disability rating may nonetheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Thus, in any case where the veteran is unemployable by reason of service-connected disabilities but has failed to meet the percentage standards discussed above, rating boards will submit the case to the Director, Compensation and Pension Service, for extra-schedular consideration under 38 C.F.R. § 4.16(b). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term unemployability is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341 (a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Prior to July 28, 2016, service connection was in effect for panic disorder with agoraphobia and major depressive disorder, with anxious distress, rated as 30 percent disabling from June 1, 2006, and as 50 percent disabling from June 27, 2011; gastroesophageal reflux disorder (GERD), rated as 0 percent disabling from June 1, 2006, and as 60 percent disabling from November 6, 2012; bilateral plantar fasciitis, rated as 0 percent disabling from June 1, 2006; diabetes mellitus, type II, with erectile dysfunction and a finding of a fatty liver, rated as 20 percent disabling from June 1, 2006, and as 40 percent disabling from June 27, 2011; patellofemoral syndrome with degenerative changes, right knee, rated as 10 percent disabling from June 1, 2006; residuals of left ankle injury, rated as 10 percent disabling from June 1, 2006; residuals of right ankle injury, rated as 10 percent disabling from June 1, 2006; post operative chronic subacromial impingement with degenerative changes, claimed as right rotator cuff tear/impediment, rated as 10 percent disabling from June 1, 2006; tinnitus, rated as 10 percent disabling from June 1, 2006; peripheral neuropathy, left lower extremity, rated as 10 percent disabling from June 27, 2011; peripheral neuropathy, right lower extremity, rated as 10 percent disabling from June 27, 2011; allergic rhinitis/sinusitis, rated as 0 percent disabling from June 1, 2006; bronchitis, rated as 0 percent disabling from June 1, 2006; hemorrhoids, rated as 0 percent disabling from June 1, 2006; biopsy scar on stomach, rated as 0 percent disabling from June 1, 2006; right post operative shoulder scar with keloid formation, rated as 0 percent disabling from June 1, 2006; residual scar, tendon laceration, 5th digit injury, right hand, rated as 0 percent disabling from June 1, 2006; scar on right leg shin area, rated as 0 percent disabling from June 1, 2006; bilateral dermatitis and dyshidrotic eczema of hands, rated as 0 percent disabling from June 1, 2006; and tendon laceration, 5th digit injury right hand, rated as 0 percent disabling from June 1, 2006. The Veteran's combined disability rating is 80 percent from June 27, 2011 and 90 percent from November 6, 2012. Thus, the Veteran satisfies the percentage requirements set forth in section 4.16(a) for consideration of a TDIU. Because the Veteran satisfies the percentage requirements set forth in section 4.16(a) for consideration of TDIU, the next question for consideration is whether his service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation. The Veteran has a Bachelor's degree in Business Administration. He reports that he worked for an e-learning school and a pharmacy benefit company until 2012 when he became too disabled to work. The Veteran reports that he stopped working due to his diabetes mellitus, type II. See VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability. At the December 2019 Board hearing, referenced above, the Veteran and his representative clarified that the Veteran was unable to work due to the combined effects of his service-connected GERD, diabetes mellitus, type II, and peripheral neuropathy, as well as feet, ankle, shoulder, and psychiatric disabilities. See December 2019 Transcript of Hearing, pages 4-12. Available medical evidence, including VA examination reports, demonstrate limitations caused by symptoms associated with the Veteran's service-connected disabilities, notably pain, numbness, tingling, anxiety, and episodes of uncontrollable nausea and vomiting requiring hospitalization. The Veteran was afforded VA examinations for his bilateral ankle and right knee disabilities in August 2011. The Veteran reported chronic bilateral ankle and right knee pain, which had progressively worsened. The examiner determined that the Veteran's bilateral ankle and right knee disabilities impacted his ability to work, noting that the Veteran's ankles and right knee limited his ability to perform physical tasks and restricted the types of jobs he was able to perform. The Veteran was afforded a VA examination for his diabetes mellitus in August 2011. The examiner noted that the Veteran had been prescribed an oral hypoglycemic agent and required more than 1 insulin injection per day. It was also noted that the Veteran's diabetes was managed by a restricted diet and required regulation of activities. The examiner determined that the Veteran's diabetes mellitus did not impact his ability to work. The Veteran was afforded a VA examination for peripheral neuropathy in April 2012. The examiner noted a diagnosis of diabetic peripheral neuropathy of the bilateral lower extremities. The Veteran reported numbness, tingling, and pain in his feet, which had worsened. The examiner determined that the Veteran's peripheral neuropathy impacted his ability to work, explaining that the Veteran's feet got numb which required him to get up and move around. The examiner further explained that the Veteran's job involved "sitting next to the telephone all the time" and that getting up and moving around interfered with the Veteran's ability to perform the duties of this job. In a November 2012 Disability Benefits Questionnaire (DBQ) for esophageal conditions, a private physician, Dr. A.A., indicated diagnoses of GERD, hiatal hernia, and gastroparesis. The following symptoms were noted: persistently recurrent epigastric distress, reflux, nausea, and vomiting. The physician determined that the episodic recurrent nature of the Veteran's gastrointestinal flare-ups impacted his ability to work. In a November 2012 DBQ for diabetes mellitus, Dr. A.A. noted that the Veteran had been prescribed Metformin and required more than 1 injection of insulin per day for his diabetes. It was also noted that his diabetes was managed by a restricted diet. Regulation of activities was not noted. The physician determined that the Veteran's diabetes impacted his ability to work, explaining that flare-ups of hyperglycemia caused nausea and vomiting which could last up to 48 hours. A September 2013 private hospital record noted that the Veteran was admitted for an acute exacerbation of gastroparesis, severe nausea and vomiting, and mild abdominal discomfort. See September 2013 Hospital Admission Record from F.H. The Veteran was afforded a VA examination for diabetes mellitus in December 2013. The examiner indicated that the Veteran required more than 1 injection of insulin per day and regulation of activities, noting that yardwork caused hypoglycemic episodes. The examiner determined that the Veteran's diabetes impacted his ability to work, as the Veteran must avoid strenuous activity and must restrict his activities. The Veteran was also afforded a VA examination for stomach conditions in December 2013. The examiner noted a 2011 diagnosis of mild gastroparesis secondary to diabetes. The Veteran reported that he had been prescribed erythromycin, however, he continued to experience uncontrollable episodes of nausea and vomiting. He reported that he had been to the hospital 2 times during the past year as the symptoms had become severe. The examiner determined that the Veteran's stomach condition impacted his ability to work, indicating that the Veteran had difficulty during episodes of nausea and vomiting and had been hospitalized twice during the past year for such. In January and February 2014 VA opinions, the examiners determined that the Veteran's psychiatric disability rendered him unemployable. The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). After considering the evidence of record, the Board agrees with the conclusions of the August 2011, April 2012, and December 2013 VA examiners, as well as the November 2012 opinions from the private physician, Dr. A.A., that the Veteran's service-connected disabilities impacted his ability to work. Although the January and February 2014 VA examiners found that the Veteran's psychiatric disability rendered him unemployable solely based on his psychiatric symptoms, the Board finds that the Veteran is unemployable due to the combined effects of his service-connected disabilities, and the Veteran has not contended otherwise. More specifically, the Board has considered the Veteran's pain, numbness, tingling, and anxiety, as well as episodes of uncontrollable nausea and vomiting requiring hospitalization. Based on the foregoing, and in light of his educational and occupational history, the Board finds that the combined effects of the Veteran's service-connected physical and mental disabilities rendered him incapable of substantial gainful employment, to include sedentary employment. Accordingly, the Board has weighed the probative evidence of record and finds that the evidence is at least in equipoise as to whether the combined effects of the Veteran's service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation. The benefit-of-the-doubt rule is therefore for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board will resolve the reasonable doubt in the Veteran's favor and find that the evidence supports the grant of TDIU prior to July 28, 2016. See 38 U.S.C. § 5107. 2. Entitlement to a TDIU due to service-connected disabilities from July 28, 2016 As of July 28, 2016, service connection is in effect for panic disorder with agoraphobia and major depressive disorder, with anxious distress, rated as 70 percent disabling; GERD, rated as 60 percent disabling; bilateral plantar fasciitis, rated as 0 percent disabling (rated as 50 percent disabling from September 27, 2016); diabetes mellitus, type II, with erectile dysfunction and a finding of a fatty liver, rated as 40 percent disabling; patellofemoral syndrome with degenerative changes, right knee, rated as 10 percent disabling; residuals of left ankle injury, rated as 10 percent disabling; residuals of right ankle injury, rated as 10 percent disabling; post operative chronic subacromial impingement with degenerative changes, claimed as right rotator cuff tear/impediment, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; peripheral neuropathy, left lower extremity, rated as 10 percent disabling; peripheral neuropathy, right lower extremity, rated as 10 percent disabling; allergic rhinitis/sinusitis, rated as 0 percent disabling; bronchitis, rated as 0 percent disabling; hemorrhoids, rated as 0 percent disabling; biopsy scar on stomach, rated as 0 percent disabling; right post operative shoulder scar with keloid formation, rated as 0 percent disabling; residual scar, tendon laceration, 5th digit injury, right hand, rated as 0 percent disabling; scar on right leg shin area, rated as 0 percent disabling; bilateral dermatitis and dyshidrotic eczema of hands, rated as 0 percent disabling; and tendon laceration, 5th digit injury right hand, rated as 0 percent disabling. A review of the evidence indicates that the Veteran has had a combined 100 percent rating since July 28, 2016. See 38 C.F.R. § 4.25. The regulations pertaining to the assignment of a TDIU rating provide that such a rating may be assigned where the schedular rating is less than total. 38 C.F.R. § 4.16(a). In light of the fact that the RO has assigned a 100 percent combined schedular evaluation for the service-connected disabilities beginning on July 28, 2016, the issue of entitlement to a TDIU from July 28, 2016 is therefore moot. Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008) (holding that 100 percent rating does not render a TDIU claim moot where there is a possibility of special monthly compensation based on 100 percent rating with a separate 60 percent rating based on a different disability). The Veteran has been granted a 100 percent rating from July 28, 2016, based on the combined effect of his service-connected disabilities. The Board notes the holding in Bradley v. Peake, 22 Vet. App. 280, 294 (2008) that VA must still consider a TDIU claim despite a total disability rating being in effect in order to determine the Veteran's eligibility for special monthly compensation under 38 U.S.C. § 1114(s). Here, unlike Bradley, the Veteran is not seeking special monthly compensation or TDIU based on a single disability, and the total rating includes the disabilities for which he is seeking TDIU. As such, there remains no legal basis upon which to assign a TDIU from July 28, 2016. 3. Entitlement to a rating in excess of 40 percent for diabetes mellitus, type II The Veteran contends that his service-connected diabetes mellitus, type II is more severe than currently rated. The Veteran's diabetes mellitus, type II is evaluated under DC 7913. Under DC 7913, a 10 percent rating is warranted for diabetes mellitus which is manageable by restricted diet only. A 20 percent rating is warranted where the condition requires one or more daily injection of insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted where the condition requires one or more daily injection of insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted where the condition requires one or more daily injection of 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 the condition 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, DC 7913. Compensable complications of diabetes are 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 DC 7913. Id. at Note 1. Background The record contains multiple notations of hospitalizations and ER visits between 2011 and 2013 for nausea and vomiting associated with gastroparesis. Urinalysis indicated elevated ketone levels. See 2011-2013 private and VA treatment records; December 2013 correspondence, received December 2019; December 18, 2019 Transcript of Hearing, page 9. The Veteran was afforded a VA examination for his diabetes mellitus in August 2011. The examiner noted that the Veteran had been prescribed an oral hypoglycemic agent and required more than 1 insulin injection per day. It was noted that the Veteran's diabetes was managed by a restricted diet and required regulation of activities. It was also noted that the Veteran visited his diabetic provider for episodes of ketoacidosis and hypoglycemia less than 2 times per month. The examiner noted that the Veteran had not required hospitalization for any episodes of ketoacidosis or hypoglycemia over the past 12 months. The examiner found that the Veteran did not have progressive unintentional weight loss or loss of strength attributable to diabetes. In a November 2012 DBQ completed by a private physician, Dr. A.A., it was noted that the Veteran had been prescribed Metformin and required more than 1 injection of insulin per day for his diabetes. It was also noted that his diabetes was managed by a restricted diet. Regulation of activities was not noted. The physician noted that the Veteran had not required hospitalization for any episodes of ketoacidosis or hypoglycemia over the past 12 months. The physician noted that the Veteran had not experienced progressive unintentional weight loss, however, he had progressive loss of strength attributable to diabetes. The Veteran was afforded a VA examination in December 2013. The examiner noted a 2006 diagnosis of diabetes mellitus, type II. The examiner noted that the Veteran required more than 1 injection per day of insulin and regulation of activities. It was noted that the Veteran visited his diabetic provider for episodes of ketoacidosis and hypoglycemia less than 2 times per month. The examiner noted that the Veteran had not required hospitalization for any episodes of ketoacidosis or hypoglycemia over the past 12 months. The examiner also noted that the Veteran had a 10 percent loss of his baseline weight. At the December 2019 Board hearing, referenced above, the Veteran testified that he had 11 hospitalizations and/or ER visits between 2011 and 2013 due to ketoacidosis attacks or nausea and vomiting. See December 18, 2019 Transcript of Hearing, page 9. VA medical records dated in July 2020 noted that the Veteran had been admitted to the hospital with complaints of nausea and vomiting for 1 week, which had become worse over the last 3 days. It was noted that the Veteran's nausea and vomiting could be due to hyperglycemia, gastrointestinal reflux disease, or gastroparesis, or could be multifactorial. A diagnosis of diabetic ketoacidosis was also noted. See July 27-29, 2020 VA treatment records. Pursuant to the Board's March 2020 remand instructions, a VA medical opinion was obtained in August 2020. The examiner noted that the Veteran required more than 1 injection per day of insulin but did not require regulation of activities. It was noted that the Veteran visited his diabetic provider for episodes of ketoacidosis and hypoglycemia less than 2 times per month. The examiner noted that the Veteran had not required hospitalization for any episodes of ketoacidosis or hypoglycemia over the past 12 months. The examiner found that the Veteran did not have progressive unintentional weight loss or loss of strength attributable to diabetes. The examiner also indicated that elevated ketone levels noted during the Veteran's hospitalizations and ER visits between 2011 and 2013 were not indicative of ketoacidosis. The examiner opined, Although elevated levels of ketones in blood and urine may suggest DKA (diabetic ketoacidosis) it does not necessarily mean a ketoacidosis state; that is why DKA was not found diagnosed on currently available VA files. Prior to July 27, 2020 After careful review of the evidence, the Board finds that prior to July 27, 2020, a rating in excess of 40 percent is not warranted for the Veteran's diabetes mellitus, type II. While VA examination reports and the medical evidence of record indicate that the Veteran's diabetes mellitus required one or more daily injection of insulin, restricted diet, and regulation of activities, in order to warrant a higher 60 percent rating, the Veteran's diabetes must be manifested by episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or require twice a month visits to a diabetic care provider. The evidence weighs against such manifestations. Although the Veteran reported frequent hospitalizations between 2011 and 2013 for ketoacidosis attacks or nausea and vomiting, the August 2020 VA examiner reviewed the evidence of record and determined that elevated levels of ketones in the Veteran's blood and urine did not indicate ketoacidosis in the Veteran's case, as none of his medical records during that time showed a diagnosis of such. The Board assigns great probative weight to the examiner's opinion, as it was based on a thorough review of the Veteran's claims file, coupled with the examiner's medical expertise. Additionally, although the November 2012 DBQ noted progressive loss of strength attributable to diabetes and the December 2013 VA examination noted a 10 percent loss of the Veteran's baseline weight, a higher 100 percent rating is also not warranted, as the evidence does not show that the Veteran's diabetes was manifested by episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider. Finally, the Board notes that the Veteran is in receipt of separate, compensable ratings for his other disabilities associated with his diabetes mellitus, including GERD and peripheral neuropathy of the bilateral lower extremities. The Board notes that these complications have been service-connected and rated separately and are not currently on appeal. The Veteran also does not assert, nor does the record show, that he has any additional complications of diabetes mellitus that have not already been service-connected and evaluated by VA. In light of the above, the Board finds that prior to July 27, 2020 the Veteran's disability picture is contemplated by the 40 percent rating, and, therefore, a preponderance of the evidence is against a rating in excess of 40 percent for diabetes mellitus, type II. Thus, the benefit-of-the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the Veteran's claim for entitlement to a rating in excess of 40 percent for diabetes mellitus, type II prior to July 27, 2020 is denied. From July 27, 2020 After careful review of the evidence, the Board finds that from July 27, 2020, a 60 percent rating, and no higher, is warranted for the Veteran's diabetes mellitus, type II. In that regard, the Board notes that from July 27, 2020, the Veteran's diabetes was manifested by one or more daily injection of insulin, restricted diet, regulation of activities, and one episode of ketoacidosis requiring hospitalization, as noted in the July 2020 VA medical records. The Board finds that a higher 100 percent rating is not warranted, as the evidence does not show that the Veteran's diabetes was manifested by episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider. (Continued on the next page) As set forth above, the Board notes that the Veteran is in receipt of separate, compensable ratings for his other disabilities associated with his diabetes mellitus, including GERD and peripheral neuropathy of the bilateral lower extremities. The Board notes that these complications have been service-connected and rated separately and are not currently on appeal. The Veteran also does not assert, nor does the record show, that he has any additional complications of diabetes mellitus that have not already been service-connected and evaluated by VA. As the preponderance of the evidence is against a rating higher than 60 percent for diabetes mellitus, type II from July 27, 2020, the benefit of the doubt doctrine is not for application and the claim to this extent is denied. 38 U.S.C. § 5107(b), 38 C.F.R. § 3.102. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, 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.