While recently doing some research for my service-connected Diabetes Mellitus (DM), I reviewed all Board of Veteran Appeals (BVA) decisions in 2007 and 2008 (first four months) concerning requests to increase a rating from 20% to 40% for DM and noticed what appeared to be a “catch-22” situation that often resulted in a denial by the BVA for the increase. DM at the 40% rating level requires that there be evidence of a medical finding of “regulation of activities” in the medical record. If the veteran has been encouraged to exercise or is admittedly exercising for assistance with DM control, that has been found by the BVA to be evidence that there is no regulation of activities absent any specific medical notes of regulation of activity restrictions. Since habitually medical providers will encourage diabetics to exercise, in many cases as a physical therapy to any obesity, this quite often sets up an “automatic” denial for the increase requested. I support exercising as a means of assisting DM control, but don’t believe it should be in of itself the cause for any increase denial if no other regulation of activities wording shown in the medical record. Additionally, ALL C&P examinations for DM are requested to provide indication of any regulation of activities requirements that are in the medical record. If no VA or private physician has indicated specifically that there were regulation of activities, the C&P examiner will include a statement that there was no regulation of activities present in their C&P findings (near as I can tell their guidelines do not allow them to make a medical determination there was regulation of activities without one previously being in the claim file – they are only reporting what they find in the claim file as regards regulation of activities in a C&P exam). Of the 336 DM cases found in my 2007-2008 BVA case research for veterans that had a 20% DM rating and were seeking an increase and case not remanded by the BVA, denial because the 40% rating requirement for regulation of activities was not met as the primary denial reason occurred in 60.4% of these cases. In order to counteract this somewhat automatic denial issue for veterans with service-connected DM, consider printing out the next two paragraphs on a sheet of paper and providing this to your VA primary care physician on your next visit: Can you agree to advise me on the statement in the next paragraph and include the statement in that paragraph exactly as written in your medical notes for this visit? If not, what can you agree to place in your notes for this visit that would be close to the wording as shown? “The patient was advised to avoid strenuous occupational and recreation activities that would either raise their stress to levels that would adversely affect their blood sugars or increase their frequency of hypoglycemic episodes.” Also prior to the visit with your VA primary care physician, print out the ADA’s take on stress and diabetes and show that to the physician in case the physician disagrees with the stress part of the statement. That page can be found on the Internet here: http://www.diabetes.org/type-2-diabetes/stress.jsp If the VA primary care physician wants to revise the statement, the most important words to be sure are included are “avoid strenuous occupational and recreational activities”. If your VA primary care physician will not agree to provide a statement substantially similar to the previous paragraph in their treatment notes, seek out a private care physician for a second opinion. For private care physicians where you are seeking a 2nd opinion, the wording should be revised to something similar to the following when asking them to provide supporting medical opinions in their care notes for the visit: “The patient came in today with their VA medical records to seek out a 2nd opinion on their diabetic care. After careful review of the medical history provided and questioning them on their specific diabetic condition and symptoms, I advised the patient to avoid strenuous occupational and recreation activities that would either raise their stress to levels that would adversely affect their blood sugars or increase their frequency of hypoglycemic episodes.” It is important to stress to the physician in either case that you are not asking them to lie about your condition, just asking them if they can medically support adding this statement to your medical records.