1. EVALUATION OF DIABETES MELLITUS
CAMACHO V. NICHOLSON

2. INTRODUCTION Type 2 diabetes mellitus claims problematic because of
VA error in assigning effective date
Claims of under-evaluation
Failure to examine
Evaluation of secondary conditions
Special importance due to probable number of DIC claims

3. CAMACHO V. NICHOLSON ISSUES PRESENTED
What “regulation of activities” means under DC 7913?
Is medical evidence of “regulation of activities” required?

4. CASE BACKGROUND Vet served 8/66 to 8/69.
Worked as Motor Vehicle Operator at VAMC—transport patients
12/00 claimed SC for DM type 2
12/01 awarded SC
assigned 20% and appealed
Vet claimed entitled to 40% evaluation

5. FACTS
10/04 dr. report that dr. would defer to medical center guidelines
Dr. said vet could work as something other than a van driver
Vet testified that DM kept him from activities like climbing stairs, gardening, ground maintenance
3/04 vet says hard to exercise due to knee problem and full-time job
8/04 letter from nurse practitioner/employer that vet disqualified from driving patients due to DM (from Employee Health Clinic Manager at VAMC)

6. BVA DECISION
20% rating--vet requires insulin & restricted diet, or oral hypoglycemic agent & restricted diet
40% rating--vet requires insulin, restricted diet, & regulation of activities
BVA-- 40% inappropriate b/c no medical evidence demonstrating that vet required to regulate his activities.

7. CAVC Decision
Under DC “regulation of activities” means avoidance of strenuous occupational or recreational activities.
Medical evidence needed to show that activities must be regulated
Based on regulatory history, regulation of activities must be medically necessary, and the necessity must be shown with medical evidence.

8. CAVC Decision
CAVC-- plausible basis for the BVA’s finding that there was no medical evidence as to regulation of activities.
The Court agreed with the BVA that there was no medical evidence b/c
Employer’s decision not to let the veteran drive (although made by a nurse) was employment decision, not medical decision
10/04 dr. report not medical evidence b/c dr. deferred to employer’s decision—he didn’t offer his own medical opinion
no medical evidence that vet should avoid strenuous activity—dr. recommended more exercise

9. CAVC DECISION
Vet did not argue that VAE inadequate, or violation of duty to assist
Remedy for discrimination by employer-- Rehabilitation Act 29 U.S.C. §§ and ADA, 42 U.S.C. §§ However, the CAVC has no jurisdiction over these statutes.

10. CAVC DECISION .
Vet met 2 of 3 requirements for a 40% rating under DC 7913, the regulation is written in the conjunctive (meaning all three are required) not disjunctive.
Court left unanswered the meaning of “strenuous” and whether it could apply to mental as well as physical activity

11. JUDGE KASOLD’S DISSENT
Judge Kasold disagreed with the majority opinion.
He noted that a dr. had questioned vet’s ability to safely drive
Said the dr’s opinion that vet could perform work that did not involve driving meant that dr thought vet should not drive
§ 4.10 requires dr to fully describe effects of disability on employment--dr deferral to employment guidelines should be viewed as incorporating those restrictions into his medical opinion

12. COMMENT & ADVOCACY ADVICE
DM impairs the body’s ability to utilize sugars
Common Complications:
Neuropathy –numbness and weakness in the extremities.
Retinopathy – Damage to blood vessels that can lead to cloudy vision blindness.
Kidney Disease – Impairment of blood filtration.
Cardiovascular/Circulatory Problems – Increased risk of heart disease

13. COMMENT & ADVOCACY ADVICE RATING REQUIREMENTS FOR DIABETES MELLITUS
DC 7913
100% - more than 1 daily injection of insulin, restricted diet, & regulation of activities (avoidance of strenuous occupational and recreational activities) w episodes of ketoacidosis or hypoglycemic reactions requiring at least 3 hospitalizations/yr OR weekly visits to care provider, PLUS either loss of weight and strength OR compensable complications if separately evaluated.
60% - Requiring insulin, restricted diet, & regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring 1 or 2 hospitalizations/yr OR 2/month visits to care provider, PLUS noncompensable complications if separately evaluated

14. COMMENT & ADVOCACY ADVICE RATING REQUIREMENTS FOR DIABETES MELLITUS
40% - Requiring insulin, restricted diet, & regulation of activities.
20% - Requiring insulin & restricted diet, or; oral hypoglycemic agent & restricted diet.
10% - Manageable by restricted diet only.

15. VA Clinician’s Guide circumstances under which diagnosed.
approximate frequency and dates of hospitalization.
number and types of insulin
other hypoglycemic agents?
restrictions on diet, physical activity, or weight loss.
secondary conditions or complications?
If medical reports not clear enough to apply DC 7913, argue exam inadequate.
For 40% rating claims or higher, it should be argued that exam is inadequate if it does not specifically mention whether regulation of activities preferable or required.

16. COMMENT & ADVOCACY ADVICE REQUIRMENTS UNDER CAMACHO
“regulation of activities” –MUST BE medical evidence showing that DM requires avoidance of strenuous occupational and recreational activities.
evidence submitted must clearly be medical evidence.
examiners at least must note that strenuous occupational and recreational activates should be avoided.
Try to get dr’s direct statement : “I am a care provider for [veteran’s name]. For proper care of [his/her] diabetes, [he/she] should avoid strenuous occupational and recreational activities.”

17. COMMENT & ADVOCACY ADVICE REQUIRMENTS UNDER CAMACHO
Remember that “strenuous” has not been fully defined by the court, so it is worth pursing physical as well as restrictions on mental activities at this point.
Make sure that the factual record is well developed and that the VA fulfills its obligations under the duty to assist 38 U.S.C. § 5103 A.
Advocates should also pursue possible compensation for depression and mental illness.
It has been shown that depression can often result from exposure to a chronic conditions such as diabetes if the condition is server enough.