VA Secondary Conditions to Diabetes

Diabetes is rated under Diagnostic Code 7913 at 10, 20, 40, 60 or 100 percent, but for many veterans the larger value sits in its complications. Under 38 CFR § 3.310, a condition caused or worsened by your service-connected diabetes is service connected too. Many veterans are service connected for Type 2 diabetes through the Agent Orange list in 38 CFR § 3.309(e) (see presumptive conditions), and the secondary claims build on that grant. This page covers what you can claim, the rule that decides whether a complication is rated separately, the research behind each link, which claims to file first, and how the ratings combine.

What can you claim secondary to diabetes?

Any condition a doctor can tie to your diabetes, with reasoning, can be claimed. In the Board's 2021 to 2026 decisions the most common were these.

• Nerve conditions of the legs and arms. See peripheral neuropathy.
• Erectile dysfunction.
• High blood pressure.
• Kidney disease.
• Sleep apnea.
• Eye conditions, including retina conditions, diabetic retinopathy, cataracts, glaucoma and vision loss.
• Heart disease.

The Board section further down lists every condition claimed secondary to diabetes with enough rulings to show, with its count and grant rate. The link can also run the other way: see diabetes secondary to hypertension.

How secondary service connection works for diabetes

VA grants a secondary claim in two ways under 38 CFR § 3.310.

• Caused by. Your service-connected diabetes caused the condition, at least as likely as not.
• Aggravated by. The condition is worse because of your diabetes, meaning it would be less severe but for the diabetes (M21-1 V.ii.2.D). VA rates only the part above the condition's baseline before the aggravation.

The text of § 3.310(b) still tells VA to subtract "natural progress," but VA's current claims manual (M21-1 V.ii.2.D, revised after Spicer v. McDonough) no longer applies that part, and the worsening does not have to be permanent. VA still needs a baseline shown by medical evidence, and it rates the difference between that baseline and the current level. An opinion that answers only "caused by" and skips aggravation is inadequate (El-Amin v. Shinseki, 26 Vet. App. 136 (2013)).

Rated separately or inside the diabetes rating: the DC 7913 rule

This is the rule that decides what each complication is worth. Here is Note (1) to Diagnostic Code 7913 in 38 CFR § 4.119, word for word.

"Evaluate compensable complications of diabetes 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."

In plain terms, it works like this.

• A complication that would rate 10 percent or more under its own code gets its own rating, and that rating combines with the diabetes rating under 38 CFR § 4.25.
• The exception is 100 percent. The 100 percent level requires, among other things, "complications that would be compensable if separately evaluated." If VA uses those complications to reach 100 percent, it does not rate them again on their own.
• A complication that would rate 0 percent stays inside the diabetes rating. It is still part of the record: the 60 percent level counts "complications that would not be compensable if separately evaluated," along with insulin, diet, regulation of activities and episodes of ketoacidosis or low blood sugar needing hospital care or frequent provider visits.

Severity changes, so a complication that is noncompensable today can earn its own rating later. Erectile dysfunction is rated 0 percent under Diagnostic Code 7522, and the code's footnote tells VA to review special monthly compensation for loss of use of a creative organ (SMC-K) under 38 CFR § 3.350(a), which is paid in addition to your combined rating.

The most common secondary conditions to diabetes

Nerve conditions of the legs and arms

Neuropathy is the most common complication of diabetes. A review in Nature Reviews Disease Primers (Feldman and colleagues, 2019) describes diabetic neuropathy as a loss of sensory function that begins in the feet and lower legs, often with pain, and states that over time at least 50 percent of people with diabetes develop it. Each arm and leg is rated separately under the peripheral nerve codes in 38 CFR § 4.124a, with the bilateral factor when both arms or both legs are rated. For the sciatic nerve in the leg (Diagnostic Code 8520), mild incomplete paralysis is 10 percent, moderate 20, moderately severe 40 and severe 60. When the involvement is wholly sensory, the schedule limits the rating to the mild or, at most, the moderate level, so the exam should record any weakness, muscle loss or reflex changes, not only numbness.

Erectile dysfunction

A meta-analysis of 145 studies covering 88,577 men (Kouidrat and colleagues, Diabetic Medicine, 2017) found erectile dysfunction in 52.5 percent of men with diabetes overall, and men with diabetes had 3.62 times the odds of healthy controls. The rating is 0 percent; the SMC-K review is where the money is.

High blood pressure

High blood pressure appears in over two-thirds of people with Type 2 diabetes, and a Lancet review (Ferrannini and Cushman, 2012) describes plausible mechanisms: insulin resistance in the nitric oxide pathway that relaxes blood vessels, high insulin levels driving the sympathetic nervous system and sodium and fluid retention, and high blood sugar stimulating the hormone system that controls blood pressure. Timing matters. An older review (Simonson, Diabetes Care, 1988) notes that in Type 1 diabetes blood pressure usually rises as kidney function declines, while many people with Type 2 diabetes already have high blood pressure at diagnosis, some of it ordinary essential hypertension. If your blood pressure was high before the diabetes, the stronger argument is usually aggravation. Hypertension rates at least 10 percent under Diagnostic Code 7101 when a history of diastolic pressure predominantly 100 or more requires continuous medication, so it is usually rated on its own.

Kidney disease

Type 2 diabetes is the leading cause of end-stage kidney disease in most developed countries (Koye and colleagues, Advances in Chronic Kidney Disease, 2018). Diagnostic Code 7541 rates kidney involvement in diabetes as renal dysfunction under 38 CFR § 4.115a, by kidney filtration rate (GFR) held for at least three consecutive months in the past year: 30 percent for 45 to 59, 60 percent for 30 to 44, 80 percent for 15 to 29, and 100 percent below 15 or with dialysis. Early damage, a GFR of 60 to 89 with albumin in the urine, rates 0 percent, which under Note (1) keeps it inside the diabetes rating until the GFR falls further. Regular kidney labs are the evidence.

Eye conditions and vision loss

A pooled analysis of 22,896 people with diabetes (Yau and colleagues, Diabetes Care, 2012) found any diabetic retinopathy in 34.6 percent, with rates rising with diabetes duration, blood sugar and blood pressure. Retinopathy is a major cause of vision loss, and macular swelling is treated with eye injections and advanced disease with laser (Wong and colleagues, Nature Reviews Disease Primers, 2016). In a UK study of 56,510 people with diabetes (Becker and colleagues, Eye, 2018), cataracts were diagnosed or removed at 20.4 per 1,000 person-years against 10.8 in the general population. A meta-analysis of 47 studies (Zhao and colleagues, Ophthalmology, 2015) found glaucoma risk 1.48 times higher with diabetes, rising 5 percent for each year since diagnosis.

Eye conditions are rated under the formula in 38 CFR § 4.79 on vision loss or on treatment visits in the past 12 months, whichever is higher: 10 percent for one or two visits, up to 60 percent for seven or more. Injections and laser count as treatment. Glaucoma that needs continuous medication rates at least 10 percent (Diagnostic Codes 6012 and 6013).

Sleep apnea

The research mostly runs the other way. In three large US cohorts (Huang and colleagues, Diabetes Care, 2018), diabetes was tied to later sleep apnea, but the link nearly disappeared after accounting for weight and waist size; insulin-treated diabetes kept a higher risk. The same study found sleep apnea raised the risk of later diabetes. An opinion has to deal with weight directly, and this is one of the harder diabetes chains.

Heart disease

Across 102 studies of 698,782 people (Emerging Risk Factors Collaboration, Lancet, 2010), diabetes doubled the risk of coronary heart disease, independent of other risk factors. Ischemic heart disease is also on the Agent Orange list in 38 CFR § 3.309(e), so herbicide-exposed veterans may not need the diabetes link at all. Heart disease is rated on the workload (METs) that brings on symptoms, with 10 percent when continuous medication is required.

Which secondary claims to file first

Three questions sort the claims worth filing.

1. Is there a current diagnosis? Neuropathy needs nerve findings, retinopathy an eye exam, kidney disease repeated labs.
2. Will it be compensable on its own? Under Note (1), a complication only adds a percentage at 10 percent or more. Neuropathy, high blood pressure on medication, glaucoma on drops, eye conditions needing treatment visits and kidney disease below a GFR of 60 usually qualify.
3. Will a doctor explain the link? Neuropathy, retinopathy and kidney disease have well-established links; high blood pressure and sleep apnea need opinions that deal with timing and weight.

Raven Nexus organizes your records and the relevant research into a draft your doctor can review, and C&P exam prep helps you describe weakness and balance problems, not only numbness.

How secondary ratings combine with diabetes

VA combines ratings under 38 CFR § 4.25, largest first, and each smaller rating takes its share of what remains. Under 38 CFR § 4.26, ratings for both legs are combined first and 10 percent of that value is added.

Take diabetes at 20 percent (oral medication and a restricted diet) and mild neuropathy at 10 percent in each leg. The legs combine to 19, and the bilateral factor brings that to about 21. That 21 and the diabetes 20 combine to about 37, which VA rounds to 40 percent. Add kidney disease at 30 percent: VA starts with the 30, the legs bring it to about 45, and the diabetes brings it to 56, which rounds to 60 percent. A 20 percent diabetes rating anchors a 60 percent combined rating, and an SMC-K award for erectile dysfunction would be paid on top.

Questions veterans ask about secondary conditions to diabetes

What are VA secondary conditions to diabetes?

The most common in Board decisions are nerve conditions of the legs and arms, erectile dysfunction, high blood pressure, kidney disease, sleep apnea and eye conditions. Any condition a doctor can tie to your diabetes with reasoning can be claimed.

Does VA rate diabetic neuropathy separately from diabetes?

Yes, when it is compensable. Note (1) to Diagnostic Code 7913 rates compensable complications separately, and each affected arm and leg gets its own rating.

Why did VA put my diabetes complication inside the diabetes rating?

Either it would rate 0 percent on its own, which Note (1) treats as part of the diabetic process, or VA used it to support a 100 percent diabetes rating. If it has worsened, ask for a new rating.

Can sleep apnea be secondary to diabetes?

It can, but it is a hard claim. Research ties the two mostly through weight, so the opinion has to explain why diabetes, not weight alone, caused or worsened your sleep apnea.

Is erectile dysfunction secondary to diabetes worth claiming?

Yes. The rating is 0 percent, but the code's footnote sends VA to review SMC-K, which is paid in addition to your combined rating.

Sources

• 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one; Spicer v. McDonough (Federal Circuit); 38 CFR § 3.309(e), herbicide presumptions.
• 38 CFR § 4.119, Diagnostic Code 7913 and Note (1); 38 CFR § 4.124a, peripheral nerves and Diagnostic Code 8520; 38 CFR § 4.115a, renal dysfunction; 38 CFR § 4.115b, Diagnostic Codes 7541 and 7522; 38 CFR § 3.350(a), special monthly compensation.
• 38 CFR § 4.79, General Rating Formula for Diseases of the Eye and Diagnostic Codes 6012 and 6013; 38 CFR § 4.104, Diagnostic Code 7101 and the General Rating Formula for Diseases of the Heart.
• 38 CFR § 4.25, combined ratings; 38 CFR § 4.26, bilateral factor.
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Feldman EL, Callaghan BC, Pop-Busui R, et al. Diabetic neuropathy. Nature Reviews Disease Primers. 2019;5(1):41. PMID 31197153.
• Kouidrat Y, Pizzol D, Cosco T, et al. High prevalence of erectile dysfunction in diabetes: a systematic review and meta-analysis of 145 studies. Diabetic Medicine. 2017;34(9):1185-1192. PMID 28722225.
• Ferrannini E, Cushman WC. Diabetes and hypertension: the bad companions. Lancet. 2012;380(9841):601-610. PMID 22883509.
• Simonson DC. Etiology and prevalence of hypertension in diabetic patients. Diabetes Care. 1988;11(10):821-827. PMID 3073072.
• Koye DN, Magliano DJ, Nelson RG, et al. The Global Epidemiology of Diabetes and Kidney Disease. Advances in Chronic Kidney Disease. 2018;25(2):121-132. PMID 29580576.
• Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012;35(3):556-564. PMID 22301125.
• Wong TY, Cheung CM, Larsen M, et al. Diabetic retinopathy. Nature Reviews Disease Primers. 2016;2:16012. PMID 27159554.
• Becker C, Schneider C, Aballéa S, et al. Cataract in patients with diabetes mellitus-incidence rates in the UK and risk factors. Eye. 2018;32(6):1028-1035. PMID 29386666.
• Zhao D, Cho J, Kim MH, et al. Diabetes, fasting glucose, and the risk of glaucoma: a meta-analysis. Ophthalmology. 2015;122(1):72-78. PMID 25283061.
• Huang T, Lin BM, Stampfer MJ, et al. A Population-Based Study of the Bidirectional Association Between Obstructive Sleep Apnea and Type 2 Diabetes in Three Prospective U.S. Cohorts. Diabetes Care. 2018;41(10):2111-2119. PMID 30072403.
• Emerging Risk Factors Collaboration; Sarwar N, Gao P, Seshasai SR, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215-2222. PMID 20609967.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds.