Diabetes Mellitus is a condition that runs rampant among the veteran population. Of those particularly affected is the Vietnam Era community. As these veterans approach the years of wisdom, so too does diabetes creep alongside them. There is no shortage of medical literature on the connection between type 2 diabetes and veterans who were exposed to Agent Orange in Vietnam, Korea and Thailand. Indeed, the VA’s 2015 Annual Benefits Report noted diabetes mellitus as the 9th most prevalent service-connected disability of all compensation recipients, with an estimated 431,166 claims awarded. In 2015, there were 1,347,883 compensation recipients of the Vietnam Era, constituting 32% of the veteran population receiving benefits. Do the math and you find that almost 32% of the Vietnam veterans receiving compensation have diabetes mellitus. Interestingly, 411,698 of those individuals are males. Of course, these statistics are only reflective the veterans receiving compensation. Imagine what the statistics would be if they included non-service connected veterans as well!
If you are a veteran who is pursuing a compensation claim for type 2 diabetes, or are already receiving compensation for diabetes, you may find it difficult to understand how the VA’s rating system works for diabetes mellitus. The purpose of this post is walk you through the VA’s rating schedule so you know what to look for and what to expect in terms of compensation.
Once the VA has ascertained that a veteran’s diabetes mellitus condition is service connected, the raters refer to the rating schedule to determine the level at which the veteran will be paid for that condition. The rating schedule for diabetes is Diagnostic Code (DC) 7913, which breaks down the ratings for diabetes into five levels.
|DC 7913 – Level 1||Rate w/ no dependents||Rate w/ 1 dependent *|
|10% – Manageable by restricted diet only||$133.17||N/A|
* Remember that a veteran can be paid for dependents only after he/she has attained a combined rating of 30% or more. Any combined rating below 30% will not be paid for dependents
This rating criterion means that if the veteran has been diagnosed with diabetes mellitus and has been told by his doctor to watch his blood sugar and what he eats, the VA will pay him at a 10% level. If the veteran has only been diagnosed, but not given any instructions by his doctor, the VA will assign a 0% non-compensable rating. This means that the VA recognizes that he has been diagnosed with diabetes and that his condition is related to service, but believes that the condition is not severe enough to warrant payment. This is not a bad thing. As soon as the doctor prescribes some kind of action to treat diabetes – such as a restricted diet – the veteran can apply for an increased rating based on the new development of his condition.
|DC 7913 – Level 2||Rate w/ no dependents||Rate w/ 1 dependent|
|20% – Requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet||$263.23||N/A|
If a doctor prescribes a diabetic medication, such as the ones below, in addition to a restricted diet, the VA will grant an increase to 20%. The medications below are common oral hypoglycemic medications and their generic names.
|Class Name||Example||What it does|
|Biguanides||Metformin||1) Decrease hepatic glucose production
2) Decrease gastrointestinal glucose absorption
3) Increase target cell insulin sensitivity
|Sulfonylureas||· Glyburide (Diabeta, Glynase, Glynase PresTab)
· Glipizide (Glucotrol, Glucotrol XL, Minodiab)
· Glimepiride (Amaryl)
· Tolazamide (Tolinase)
· Tolbutamide (Orinase)
|1) Increase beta-cell insulin secretion
2) Decrease hepatic glucose output
3) Increase insulin receptor sensitivity at peripheral target tissues
|Thiazolidinediones||· Pioglitazone (Actos)
· Rosiglitazone (Avandia)
|Increase insulin receptor sensitivity|
|Alpha-glucosidase Inhibitors||· Acarbose (Precose)
· Miglitol (Glycet)
|Inhibits upper gastrointestinal enzymes that convert dietary starch and other complex carbs into simple sugars, which can be absorbed|
|Gliflozin||· Invokana (canagliflozin) or Sulisent
· Farxiga (dapagliflozin)
|Inhibits glucose from being reabsorbed in the kidneys, causing glucose to be eliminated through the urine.|
When your doctor prescribes one of the hypoglycemic medications listed above, this is your cue: time for a rating increase!
|DC 7913 – Level 3||Rate w/ no dependents||Rate w/ 1 dependent|
|40% – Requiring insulin AND restricted diet AND regulation of activities||$587.36||$651.36|
Notice that the VA rating code includes “and’s” but no “or’s”. In order to qualify for this rating, the veteran must be on insulin, and on a restricted diet, and unable to pursue certain types of activities. At this point, the diabetes condition has increased significantly in severity. Gone are the hypoglycemic medications, and now on to stronger therapies. By now, the veteran is unable to manage his blood sugar by means of medications, and now has to supplement with insulin.
If you are already using insulin, you are probably aware of how many different types of insulin there are. Fundamentally, all insulin types have the same function: to control blood sugar levels. However, different types are designed to provide blood sugar control for varying lengths of time. This seems a little counter-productive – don’t we want blood sugar control all the time? Of course, but everybody reacts to insulin differently. Determining the best type of insulin is dependent on many factors, such as the amount of residual endogenous insulin, the person’s age, weight and ethnicity, the degree of glucose control, and the person’s daily activities.
Below are examples of common types of insulin and their brand names.
|Type||Brand Name||Role in blood-sugar management|
|Rapid-Acting:||Covers insulin needs for meals eaten at the same time as the injection. This type of insulin is often used with longer-acting insulin.|
|Short-Acting:||Covers insulin needs for meals eaten within 30-60 minutes.|
|Velosulin||Used in insulin pump|
|Intermediate:||Covers insulin needs for about half the day or overnight.|
|Ultra-Long-Acting:||Provides steady insulin levels over 24hrs. Injected once a day.|
|Long-Acting:||Provides steady insulin over 20-24 hrs.|
|Insulin glargine||Basaglar, Lantus|
|Toujeo ** NEW|
|Pre-Mixed:||Generally taken 2-3 times a day before mealtime|
In addition to insulin therapy, the VA rating code also requires that the veteran’s activities be regulated. This, of course, is very vague. However, the VA Disability Benefits Questionnaire for type 2 diabetes defines the regulation of activities as: “avoidance of strenuous occupational and recreational activities with the intention of avoiding hypoglycemic episodes.” While this definition provides some clarity, it also makes an interesting point: that the VA also considers the regulation of occupational activities. For example: Bob Smith is a framer. In the past, he has always been very active on the job. However, now that his diabetes condition has progressed, his doctor has put restrictions on his job activities, including refraining from climbing ladders and carrying more than 20 pounds. This would qualify as restriction of activities.
|DC 7913 – Level 4||Rate w/ no dependents||Rate w/ 1 dependent|
|60% – Requiring insulin AND 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||$1,059.09||$1,156.09|
Notice how much the rate of compensation jumped. $471.73, to be exact. You will also note that when the VA rates diabetes, they skip the 50% rating entirely. This means that their standard for a 60% rating for diabetes is high, and that a veteran would have to be in pretty bad shape medically to “earn” this rating.
Let’s break down the rating. The first part of the rating is the same as that of the 40% rating.
- Requiring insulin AND restricted diet AND regulation of activities
The rating code then adds new elements.
- Episodes of ketoacidosis OR hypoglycemic episodes, requiring one of the following:
- One or two hospitalizations per year; OR
- Twice a month visits to diabetic care provider
- Complications that the VA would not be able to rate by themselves
Diabetic Ketoacidosis (DKA)
The second criterion lists two complications of diabetes. The first is ketoacidosis. This condition occurs when an individual’s diabetes is out of control. Diabetic ketoacidosis (DKA) is a buildup of acids in the blood. When blood sugar is too high for too long, the body does not have enough insulin to use glucose for energy, so it starts to burn down fat. The process of burning fat rather than glucose causes a chemical reaction that produces a waste product called ketones. These ketones build up in the blood and urine. High levels of ketones are poisonous and can lead to coma. If a veteran is experiencing ketoacidosis, he/she might experience symptoms such as excessive thirst, frequent urination, nausea and vomiting, abdominal pain, shortness of breath, and confusion.
According to medical literature, ketoacidosis is not very common in persons with type 2 diabetes. Ideally, insulin control prevents ketoacidosis from occurring. While this is good for your health, it is bad news for your rating with the VA. However, even if it is unlikely that ketoacidosis will occur naturally, this condition may occur due to the medications you are taking. For example, new hypoglycemic medications such as Invokana and Farxiga have known concerns to increase risk of ketoacidosis. The moral of the story is this: be aware of the side effects of the medications you are taking.
Hypoglycemia is on the other end of the diabetes control spectrum. Hypoglycemia occurs when the blood glucose levels are too low. The most common cause of hypoglycemia is diabetes medication. This is because too much insulin or medication to reduce blood sugar may drop levels too far. Hypoglycemic symptoms occur when blood glucose levels fall below 70 mg/dl. It can also occur if you exercise more, thus using up more glucose than you normally would. According to the American Diabetes Association, hypoglycemic attacks are on the rise in the ER for adults 18 and older.
Symptoms of hypoglycemia can include:
- Lightheadedness or dizziness
- Blurred or impaired vision
- Weakness or fatigue
- Confusion, including delirium
- Sweating, chills and clamminess
- Irritability or impatience
- Lack of coordination
- Seizures or unconsciousness
It is important to note that episodes of ketoacidosis or hypoglycemia alone are not enough to warrant a 60% rating. The rating schedule also requires hospitalizations occurring once or twice a year, OR visits to the diabetic care provider at least twice a month. However, episodes of ketoacidosis or hypoglycemia go hand in hand with hospitalizations and/or frequent visits to the doctor. Chances are, if your diabetes is so badly out of control that you have episodes of ketoacidosis, you will be in the hospital, or, at the very least, going to your doctor regularly to manage your blood sugar levels. Concurrently, if your blood sugar drops so low that your experience hypoglycemia, you will very likely wind up in the ER at least once, if not more often than that.
The third criterion for the 60% rating involves the presence of other complications that would not otherwise be compensable by the VA. Examples of this might include fatigue, weight problems or diabetic foot problems. This criterion may also include the presence of complications that could be rated separately by the VA, but not to a compensable degree. These might include hypertension, retinopathy, peripheral neuropathy, and early stages of kidney conditions.