ࡱ>  W~bjbj>> :rTTuj!j!j!j!j!~!~!~!8!$"~!+%4(((() 3X6d0222222$ 2Vj!7))77Vj!j!((4kxBBB7j!(j!(B70BB6 Լ(`h r>8RH+;8Լj!Լ077B77777VVB777+7777777777777 0 : Section F. Endocrine Conditions  PRIVATE INFOTYPE="OTHER" Overview In This SectionThis section contains the following topics: TopicTopic Name1 (old 22)Diabetes Mellitus 2Complications of Diabetes Mellitus3 (old 23)Thyroid Conditions4 (old 24)Exhibit 1: Examples of Rating Decisions Involving the Complications of Diabetes Mellitus 1. Diabetes Mellitus  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about diabetes mellitus, including definition of diabetes mellitus symptoms of diabetes mellitus successive criteria requirement for the next higher disability evaluation, and evaluating complications of diabetes mellitus. Change DateApril 8, 2015 PRIVATE INFOTYPE="CONCEPT"  a. Definition: Diabetes MellitusDiabetes mellitus is a metabolic disorder in which the body is unable to use glucose (a type of sugar obtained from food) effectively. Hyperglycemia, an abnormally high level of blood sugar, results. Diabetes mellitus is not seriously disabling if, on a diet sufficient to maintain the weight and strength of the claimant, the blood glucose can be kept within normal limits, and urine is absent glucose. As diabetes mellitus progresses it becomes more difficult to control, even with insulin complications develop which increase the degree of disability, and increasing limitation of activity due to unstable blood sugar levels limits employability.  b. Symptoms of Diabetes MellitusThe cardinal symptoms of uncontrolled diabetes mellitus are polyuria (excessive urination) polydipsia (excessive thirst) polyphagia (excessive hunger) weakness, and loss of weight. The presence of sugar in the urine is characteristic of, but not essential to, a diagnosis of diabetes mellitus. Notes: A diagnosis of diabetes mellitus cannot be made from glycosuria alone, as this may result from a low renal threshold for sugar, or excessive ingestion of sugar. Persistent hyperglycemia, a blood sugar of 170 milligrams (mg) per 100 cubic centimeters (ccs) blood after 12-hour fast, and glycosuria may be related to hyperthyroidism dyspituitarism pregnancy apoplexy cerebral trauma, or severe infections.  c. Successive Criteria Requirement for the Next Higher Disability EvaluationWhen determining the appropriate disability evaluation to assign for diabetes mellitus, note that criteria must be successive in order to award a higher disability evaluation. This means the Veteran can only be rated at the next higher disability evaluation when all criteria at the lower disability evaluation are met plus element(s) specific to the higher evaluation are satisfied. Reference: For criteria on diabetes mellitus, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=ff0446622e8f862b4088917492918417&node=se38.1.4_1119&rgn=div8" 38 CFR 4.119, Schedule of Ratings Endocrine System, under Diagnostic Code (DC) 7913  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" Camacho v. Nicholson, July 6, 2007, No. 05-1394 regarding successive criteria, and  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" Tatum v. Shinseki, September 28, 2009, No. 07-2728 regarding reaffirmation of successive criteria when evaluating diabetes mellitus.  d. Evaluating Complications of Diabetes MellitusPer  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=1dddb21ada7284bf859d7a1671212a15&node=pt38.1.4&rgn=div5" \l "se38.1.4_1119" 38 CFR 4.119, DC 7913, evaluate compensable complications of diabetes mellitus separately unless they are a part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under DC 7913. Once diabetic complications begin, multiple complications are usually considered or involved. References: For more information to include examples of rating diabetes mellitus and its complications, see M21-1, Part III, Subpart iv, 4.F.2 applying the bilateral factor, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=PART&n=pt38.1.4" \l "se38.1.4_126" 38 CFR 4.26 applying the amputation rule, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_168" 38 CFR 4.68 avoidance of pyramiding, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=2&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_114" 38 CFR 4.14 requirements for unemployability, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_116" 38 CFR 4.16, and levels of special monthly compensation (SMC), see  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.3_1350" 38 CFR 3.350. 2. Complications of Diabetes Mellitus  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about complications of diabetes mellitus, including scope of complications of diabetes mellitus cardiovascular complications of diabetes mellitus when evidence supports that hypertension is or is not a complication of diabetes mellitus addressing unclaimed hypertension as a complication of diabetes mellitus development on the relationship between diabetes mellitus and hypertension neurological complications of diabetes mellitus rating the level of incomplete paralysis of the peripheral nerves ophthalmological complications of diabetes mellitus genitourinary complications of diabetes mellitus musculoskeletal complications of diabetes mellitus immune and other miscellaneous complications of diabetes mellitus, and skin complications of diabetes mellitus. Change DateApril 8, 2015 PRIVATE INFOTYPE="CONCEPT"  a. Scope of Complications of Diabetes MellitusThe complications of diabetes mellitus include, but are not limited to, the following body systems cardiovascular neurological ophthalmological genitourinary gynecological musculoskeletal immune, and skin. Note: Diabetic complications may involve various body systems. In determining whether to address a disability in a rating decision as associated with diabetes mellitus, consider whether the disability is a residual or a manifestation of the diabetes mellitus or whether it represents a distinct diagnostic entity. Since diabetic complications refer to residuals of diabetes mellitus, there is no need to obtain a specific claim. It is presumed that diabetic complications are a progression of the disease. Reference: For more information regarding effective dates, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=d5b6da8f0d543c6cb76084a49d13c46d&ty=HTML&h=L&r=SECTION&n=se38.1.3_1157" 38 CFR 3.157(b)(1)  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=999b64cdd5f1101b464f9f105b639f1c&node=se38.1.3_1114&rgn=div8" 38 CFR 3.114, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=bd4b4db3a17c6b6957fadd12063ec2d5&node=se38.1.3_1400&rgn=div8" 3.400(o)(2).  b. Cardiovascular Complications of Diabetes MellitusDiabetic cardiovascular complications include, but are not limited to hypertension atherosclerosis (used interchangeably with arteriosclerotic heart disease (coronary artery disease)) peripheral arterial disease peripheral vascular disease cardiomyopathy congestive heart failure, and stroke (macrovascular complication). References: For more information on cardiovascular complications, see M21-1, Part III, Subpart iv, 4.E, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_1104" 38 CFR 4.104, and macrovascular complications to include stroke, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=aee3a09b2de7f04436d9b078d17d0779&node=se38.1.4_1124a&rgn=div8" 38 CFR 4.124(a). c. When Evidence Supports That Hypertension Is or Is Not a Complication of Diabetes MellitusAnalyze the evidentiary record to determine if it contains evidence specifically addressing whether hypertension is or is not a complication of diabetes mellitus. In the absence of record evidence specifically addressing the question of whether hypertension is related to diabetes mellitus consider hypertension to be a complication of diabetes mellitus when onset of hypertension occurred after a diagnosis of diabetes mellitus with diabetic nephropathy (The onset of hypertension after diabetes mellitus without diabetic nephropathy is not sufficient.), and do not consider hypertension to be a complication of diabetes mellitus when onset of hypertension was before diabetes mellitus (with or without diabetic nephropathy), and there has been no change in the treatment of hypertension or increase in blood pressure readings. Important: Evaluate the competency, credibility, and probative value of evidence in line with the principles in M21-1, Part III, Subpart iv, 5. The analysis above should be used in determining whether or not to address unclaimed hypertension as a complication of diabetes mellitus and making a decision on the merits of the raised claim as detailed in M21-1, Part III, Subpart iv, 4.F.2.d. d. Addressing Unclaimed Hypertension as a Complication of Diabetes MellitusRaise and decide whether hypertension is a complication of diabetes mellitus in the absence of an explicit claim only when the evidence supports a grant. Do not raise and deny service connection for hypertension as a complication of diabetes mellitus when it is not explicitly claimed. Do not raise the issue simply because the record shows hypertension and diabetes mellitus (even if there is diabetic nephropathy). This alone is not sufficient to support that hypertension is a complication of diabetes mellitus. Important: The policy stated in this block does not prohibit a determination of whether hypertension is a complication of diabetes mellitus when initial evaluation or reevaluation of diabetes mellitus is within the scope of the claim. The scope and degree of severity of complications is part of any claim involving evaluation of diabetes mellitus. However, the issue, unless explicitly claimed, should only be raised if service connection may be awarded for hypertension as a complication of diabetes mellitus. e. Development on the Relationship Between Diabetes Mellitus and HypertensionThere are fact patterns where the evidence supports or does not support that hypertension is a complication of diabetes mellitus. In the context of an explicit claim that hypertension is a complication of diabetes mellitus or in the context of evaluation of the extent of diabetes mellitus (to include whether there are complications of diabetes mellitus), a medical diagnosis or opinion may be necessary to determine whether hypertension is a complication of diabetes mellitus. When there is an explicit claim as discussed above, obtain a medical diagnosis or opinion to determine if hypertension is a complication of diabetes mellitus in the following fact patterns medical evidence shows hypertension was diagnosed before diabetes mellitus or before diabetic nephropathy, but there has been a subsequent change in the treatment of hypertension and/or an increase in blood pressure readings thereafter (particularly if this occurred after the onset of diabetic nephropathy), or medical evidence shows no clear indication as to when hypertension was diagnosed, or whether hypertension has worsened since the onset of diabetic nephropathy. Important: When there is not an explicit claim that hypertension is a complication of diabetes mellitus and when hypertension in an initial evaluation or reevaluation of diabetes mellitus is not within the scope of the claim, do not develop for a diagnosis or opinion on whether hypertension is a complication of diabetes mellitus.  f. Neurological Complications of Diabetes MellitusDiabetic neurological complications affecting the nervous system stem from a disturbance of metabolism or ischemia (inadequate blood supply) to the nerves. One of the most common disabilities is peripheral neuropathy. Complications affecting the peripheral nerves can extend from the brain and spinal cord to the muscles, skin, and internal organs. Below is a description of symptoms that can be caused by a peripheral nerve disability.  Symptoms of Peripheral NeuropathyDescriptionparesthesias numbness, and tinglinghyperesthesiasincreased sensitivity to touchhypesthesia (or hypoesthesia) decreased sensitivity to touchloss of sensation lack of feeling pain burning lancinating, or lightning sensationsdysesthesia unusual and unpleasant sensation after normal stimulationmuscle weaknesslack of strength Note: Findings are typically in a stocking-glove distribution. Reference: For more information on neurological complications, see M21-1, Part III, Subpart iv, 4.G, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_1124a" 38 CFR 4.124a. g. Rating the Level of Incomplete Paralysis of the Peripheral NervesThe Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire (DBQ) directs the examining physician to provide an assessment of the extent of incomplete paralysis in Section X, Nerves Affected: Severity Evaluation for Upper Extremity Nerves and Radicular Groups and Section XI, Nerves Affected: Severity Evaluation for Lower Extremity Nerves. Note: The level of incomplete paralysis entered into the Evaluation Builder must be based upon the complete findings of the DBQ and/or other evidence. The level of incomplete paralysis must not solely be predicated upon the examiners assessment of the level of incomplete paralysis. Follow the general guidelines below for rating the level of incomplete paralysis of the peripheral nerves  If the level of incomplete paralysis regarding peripheral nerves isThen the evidence will indicate the following criteria...Mildsubjective symptoms, and/or decreased sensation. Moderateabsence of sensation confirmed by objective findings.Severemore than sensory findings are demonstrated, such as atrophy, weakness, diminished reflexes, and so on. Example: An examiners assessment of an extent of incomplete paralysis for a peripheral nerve disability as severe is only one factor for consideration of which level of incomplete paralysis to enter into the Evaluation Builder. If the DBQ findings do not support the determination that there is severe incomplete paralysis (for example, there is only complaint of diminished sensation without atrophy, weakness, or any functional loss), the Rating Veterans Service Representative (RVSR) is not required to assign an evaluation for severe incomplete paralysis since the findings on the DBQ do not support a severe level. Reference: For more information on determining the issues of neuritis or neuralgia, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_1123" 38 CFR 4.123, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_1124" 38 CFR 4.124. h. Ophthalmological Complications of Diabetes MellitusDiabetic ophthalmological complications are largely due to blood vessel damage caused by high blood sugars such as leakage (hemorrhage) and/or blood vessel blockage. Below is a description of diabetic eye complications. Diabetic Eye ComplicationsDescriptiondiabetic retinopathyimpairment or loss of vision due to damage affecting blood vessels of the retinacataract clouding or opaqueness of the lens of the eyeglaucomaincreased fluid pressure in the eye, and causes loss of visual fields due to optic nerve damage Reference: For more information on ophthalmological complications, see M21-1, Part III, Subpart iv, 4.B, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4fc5b9f32005906d099c84f3082247e&ty=HTML&h=L&r=SECTION&n=se38.1.4_179" 38 CFR 4.79. i. Genitourinary Complications of Diabetes MellitusDiabetic nephropathy is a common diabetic genitourinary complication of diabetes mellitus and may be rated based on criteria including renal dysfunction, if renal function is affected voiding dysfunction, if there is incontinence from autonomic nephropathy urinary tract infection, if there is chronic pyelonephritis, as appropriate kidney transplant hemodialysis, or nephrectomy. Note: Erectile dysfunction (impotence/retrograde ejaculation) is another common complication of diabetes mellitus. Reference: For more information on genitourinary complications and potential entitlement to SMC, see M21-1, Part III, Subpart iv, 4.I M21-1, Part IV, Subpart ii, 2.H  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=707784593c29000a1d05368fb3bb539c&node=se38.1.4_1115a&rgn=div8" 38 CFR 4.115a, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=1dddb21ada7284bf859d7a1671212a15&node=pt38.1.4&rgn=div5" \l "se38.1.4_1115b" 38 CFR 4.115b. j. Musculoskeletal Complications of Diabetes MellitusDiabetic musculoskeletal complications affect the feet, ankles, bones, extremities, and overall gait. Below is a description of diabetic musculoskeletal complications. Diabetic Musculoskeletal ComplicationsDescriptionfoot complications affects muscles, joints, and bonesfoot neuropathic ulcersresults from abnormal pressure and lack of sensitivity to pain leads to callus formation, osteomyelitis, and/or gangreneabnormalities of gaitsensory ataxia to include loss of balance and poor muscle coordination due to loss of position senseCharcot joints (neuropathic osteoarthropathy)degenerative changes instability, and possible fragmentation of bones, particularly bones of the feet and anklesamputationsextremities, or parts of extremities Reference: For more information on determining the issues, see M21-1, Part III, Subpart iv, 4.A, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=abf6b94acdb88dcd10e4cbb09801fb4c&ty=HTML&h=L&r=SECTION&n=se38.1.4_171a" 38 CFR 4.71a and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=abf6b94acdb88dcd10e4cbb09801fb4c&ty=HTML&h=L&r=SECTION&n=se38.1.4_173" 4.73. k. Immune and Other Miscellaneous Complications of Diabetes MellitusHyperglycemia causes the white blood cells of the immune system to function poorly. In addition, all of the body's fluids have higher levels of sugar and nutrients, which make them more inviting for bacteria to grow and multiply. This causes infections to be more serious and difficult to cure. Below is a description of diabetic immune and other miscellaneous complications. Diabetic Immune and Other Miscellaneous ComplicationsDescriptionmalignant external otitis a bacterial infection in older patients that causes severe ear pain necrosis of the external auditory canal, and fever, and may also cause paralysis of the facial nerve paralysis of other cranial nerves, and osteomyelitis of the base of the skullnasopharyngeal mucormycosisa rare and serious fungal infection, which usually develops during or following an episode of diabetic ketoacidosis sudden onset with periorbital edema, pain, bloody nasal discharge, and increased lacrimation (tearing), and nasal mucosa and underlying tissues become black and necroticemphysematous cholecystitis begins as an attack of biliary colic, which rapidly progresses, and recognized by x-rays that show gas in or around the gallbladderemphysematous pyelonephritisbegins as an attack of biliary colic, which rapidly progresses, and recognized by x-rays that show gas in the kidney area vaginal infectionan inflammation of the vagina that creates discharge, odor, irritation, or itchingurinary tract infectioninfection in any part of the urinary system including kidneys, ureters, bladder, and urethra, or a burning sensation, abdominal pain, and frequency in urinationoral thrusha yeast infection of the tongue, inner cheek, lip, or gumsmoniliasisyeast infections affecting moist areas of the skingastroparesis (paralysis of the stomach)severe delayed gastric emptying (sometimes with dumping syndrome) due to vagus nerve involvement, and possible nausea, vomiting, early fullness in the stomach, bloating, abdominal pain, and weight loss Reference: For more information on determining the issues, see M21-1, Part III, Subpart iv, 4.B M21-1, Part III, Subpart iv, 4.C M21-1, Part III, Subpart iv, 4.D M21-1, Part III, Subpart iv, 4.I  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=aee3a09b2de7f04436d9b078d17d0779&node=se38.1.4_187&rgn=div8" 38 CFR 4.87  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=aee3a09b2de7f04436d9b078d17d0779&node=se38.1.4_197&rgn=div8" 38 CFR 4.97  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=aee3a09b2de7f04436d9b078d17d0779&node=se38.1.4_1114&rgn=div8" 38 CFR 4.114  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=aee3a09b2de7f04436d9b078d17d0779&node=se38.1.4_1115a&rgn=div8" 38 CFR 4.115(a)  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=aee3a09b2de7f04436d9b078d17d0779&node=se38.1.4_1115b&rgn=div8" 38 CFR 4.115(b)  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=aee3a09b2de7f04436d9b078d17d0779&node=se38.1.4_1116&rgn=div8" 38 CFR 4.116, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=abf6b94acdb88dcd10e4cbb09801fb4c&ty=HTML&h=L&r=SECTION&n=se38.1.4_188b" 38 CFR 4.88b. l. Skin Complications of Diabetes MellitusDiabetes mellitus may result in skin complications. Below is a description of diabetic skin complications. Diabetic Skin ComplicationsDescriptioncandida fungal infection, specifically a yeast infection in moist areasdermatophytesa group of three types of fungus causing superficial infections of the skin, hair, and nailsulcerssores on the skin to include disintegration of tissuenecrobiosis lipoidica diabeticorum plaque-like yellow to brown lesions over the anterior tibial surfaces of the legs that may ulceratediabetic dermopathyshin spots or small plaques with a raised border, also usually over the anterior tibial surfaces that may also ulceratebullosis diabeticorumblisters spontaneously appearing on the hands or feet that heal in two to five weeks, sometimes with scarring and atrophyatrophy of fatty tissue or skin thickeningresulting from insulin injections Reference: For more information on determining the issues, see M21-1, Part III, Subpart iv, 4.J, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=abf6b94acdb88dcd10e4cbb09801fb4c&ty=HTML&h=L&r=SECTION&n=se38.1.4_1118" 38 CFR 4.118. 3. Thyroid Conditions  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about thyroid conditions, including definition of hyperthyroidism rating conditions due to hyperthyroidism, and rating nontoxic adenoma. Change DateApril 8, 2015 PRIVATE INFOTYPE="CONCEPT"  a. Definition: HyperthyroidismHyperthyroidism (over-active thyroid) is a condition caused by excessive functioning of the thyroid gland. PRIVATE INFOTYPE="PROCEDURE"  b. Rating Conditions Due to HyperthyroidismUse the table below to rate conditions due to hyperthyroidism.  If hyperthyroidism results inThen a disease of the heartevaluate the condition as hyperthyroid heart disease under  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=41e6e6316d47eb163d1224b42c281020&node=se38.1.4_1104&rgn=div8" 38 CFR 4.104, DC 7008, if doing so would result in a higher evaluation than using the criteria for hyperthyroidism in  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=41e6e6316d47eb163d1224b42c281020&node=se38.1.4_1119&rgn=div8" 38 CFR 4.119, DC 7900.ophthalmopathyevaluate the condition as field of vision, impairment of, under DC 6080; diplopia under DC 6090; or impairment of central visual acuity under DC 6061-6079 under  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=41e6e6316d47eb163d1224b42c281020&node=se38.1.4_179&rgn=div8" 38 CFR 4.79, if doing so would result in a higher evaluation than using the criteria for hyperthyroidism in  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=41e6e6316d47eb163d1224b42c281020&node=se38.1.4_1119&rgn=div8" 38 CFR 4.119, DC 7900. psychiatric manifestations evaluate the condition under the appropriate DC under  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=4f88225e4c9b4845fc97dd74c28a3cd3&node=se38.1.4_1130&rgn=div8" 38 CFR 4.130, if doing so would result in a higher evaluation than using the criteria for hyperthyroidism in  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=41e6e6316d47eb163d1224b42c281020&node=se38.1.4_1119&rgn=div8" 38 CFR 4.119, DC 7900.digestive conditionsevaluate the condition under the appropriate DC under  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=4f88225e4c9b4845fc97dd74c28a3cd3&node=se38.1.4_1114&rgn=div8" 38 CFR 4.114, if doing so would result in a higher evaluation than using the criteria for hyperthyroidism in  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=41e6e6316d47eb163d1224b42c281020&node=se38.1.4_1119&rgn=div8" 38 CFR 4.119, DC 7900.  Important: Under  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=4f88225e4c9b4845fc97dd74c28a3cd3&node=se38.1.4_114&rgn=div8" 38 CFR 4.14, the evaluation of the same manifestation under different diagnoses is to be avoided. Therefore, if a symptom is used to assign an evaluation under a DC other than DC 7900 for hyperthyroidism, that same symptom may not also be used to assign an evaluation under DC 7900. In addition, if a symptom is used to assign an evaluation under DC 7900, that same symptom may not also be used to assign an evaluation under a separate DC. Notes: Cumulative criteria is criteria in which the lower levels build upon each other while successive criteria is criteria that has higher evaluations for increased duration of symptoms. For DCs in which evaluation criteria are successive or cumulative in nature,  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=fcf1a3ef374ddad4c8335bce3e7cdaf4&node=se38.1.4_17&rgn=div8" 38 CFR 4.7 does not apply. In contrast to successive and cumulative criteria, variable criteria refer to criteria in a particular DC in which a Veteran could potentially establish all of the criteria required for an evaluation at a higher level without establishing any of the criteria for a lesser disability rating, such as in DC 7903. In such cases,  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=3d621b4699614fcd9ed226e2983d5a21&node=se38.1.4_17&rgn=div8" 38 CFR 4.7 applies under  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" \l "bmt" Tatum v. Shinseki, 23 Vet.App. 152 (2009). Reference: For more information on hyperthyroidism and a change in the previously assigned diagnosis or etiology, see  HYPERLINK "http://www.ecfr.gov/cgi-bin/text-idx?SID=117bd5b7bffe726578f32c6b0dd65862&node=se38.1.4_1119&rgn=div8" 38 CFR 4.119, DC 7900, hyperthyroidism, and  HYPERLINK "http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=abf6b94acdb88dcd10e4cbb09801fb4c&ty=HTML&h=L&r=SECTION&n=se38.1.4_113" 38 CFR 4.13.  c. Rating Nontoxic AdenomaA nontoxic adenoma or tumor of the thyroid may be rated zero percent, 20 percent, or higher, if other organs are affected. Note: Since the thyroid influences the general rate of metabolism, growth, and development, disease of the thyroid may affect other vital organs and interfere with their functions, resulting in higher evaluations which should be evaluated under the DC for the particular organ involved. 4. Exhibit 1: Examples of Rating Decisions Involving the Complications of Diabetes Mellitus  PRIVATE INFOTYPE="OTHER"  IntroductionThis exhibit contains three examples of rating decisions involving the complications of diabetes mellitus. Change DateDecember 13, 2005 a. Example 1Situation: The Veteran has noncompensable complications of diabetes mellitus but does not have ketoacidosis or hypoglycemic reactions. Result: Do not evaluate the diabetes mellitus at 60 percent simply because noncompensable complications are present. Assign a 40 percent evaluation if there is a requirement of insulin, restricted diet, and regulation of activities. Include the noncompensable complications under DC 7913. PRIVATE INFOTYPE="PRINCIPLE"  b. Example 2Situation: The Veterans diabetes mellitus is controlled by insulin, restricted diet, and regulation of activities. In addition, there is diabetic peripheral neuropathy compensable at 10 percent. Result: Rate the diabetes mellitus at 40 percent and separately evaluate the compensable complication of diabetic peripheral neuropathy in accordance with the note under DC 7913. PRIVATE INFOTYPE="PRINCIPLE"  c. Example 3Situation: The Veteran underwent a below-the-knee amputation due to complications of diabetes mellitus. In addition his diabetes mellitus requires more than one daily injection of insulin restricted diet, and regulation of activities his episodes of ketoacidosis require weekly visits to the diabetic care provider, but there is no progressive loss of weight and strength. Result: Evaluate the diabetes mellitus at 100 percent and award SMC (k) for anatomical loss of a foot. Since the below-the-knee amputation is secondary to diabetes mellitus, and is considered a compensable complication (in lieu of progressive loss of weight and strength), to warrant the 100 percent evaluation, it would be pyramiding to assign a separate 40 percent evaluation for the amputation. Note: If compensable complications are not considered in reaching the 100 percent evaluation, they may be separately evaluated. 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