Citation Nr: 0910774 Decision Date: 03/23/09 Archive Date: 04/01/09 DOCKET NO. 04-23 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an increased evaluation for service- connected brain syndrome associated with brain trauma and post-traumatic stress disorder (PTSD), evaluated as 30 percent disabling prior to July 30, 2002, and as 50 percent disabling from July 30, 2002. 2. Entitlement to an increased evaluation for service- connected panhypopituitarism, currently evaluated as 10 percent disabling. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD Christopher McEntee, Counsel INTRODUCTION The Veteran had active service from January 1970 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1994 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA), in Los Angeles, California. The Board has remanded this matter several times. In April 2000, the Board remanded the claims for additional development. In December 2005, the Board remanded this matter to afford the Veteran his requested hearing before the Board, which was held in July 2006. In May 2007, the Board remanded this matter for additional medical inquiry. And then, in October 2008, the Board again remanded this matter for an additional Board hearing held by the undersigned in January 2009. VA offered a new hearing to the Veteran because the Judge who conducted the July 2006 hearing is not currently employed by the Board. FINDINGS OF FACT 1. The medical evidence of record indicates that the Veteran's service-connected brain disorder was productive of occasional and intermittent mild impairment prior to August 9, 2000. 2. The medical evidence of record indicates that the Veteran's brain disorder has caused severe impairment of social and industrial adaptability since August 9, 2000. 3. The medical evidence of record indicates that the Veteran's service-connected panhypopituitarism was well controlled by his medication prior to November 21, 2007. 4. The medical evidence of record does not preponderate against the Veteran's claim for increase for his panhypopituitarism in that the evidence indicates muscle weakness, mental disturbance, and weight gain since November 21, 2007. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 30 percent, for the Veteran's service-connected brain syndrome associated with brain trauma and PTSD, had not been met prior to August 9, 2000. 38 U.S.C.A. § 1155 (West 1991 & 2002); 38 C.F.R. §§ 4.124a, 4.130, 4.132 (as in effect prior to November 7, 1996), and 4.124a, 4.130 (2008). 2. The criteria for a disability evaluation of 70 percent, for the Veteran's service-connected brain syndrome associated with brain trauma and PTSD, have been met from August 9, 2000. 38 U.S.C.A. § 1155 (West 1991 & 2002); 38 C.F.R. §§ 4.124a, 4.130, 4.132 (as in effect prior to November 7, 1996), and 4.124a, 4.130 (2008). 3. The criteria for a disability evaluation in excess of 10 percent, for the Veteran's service-connected panhypopituitarism, had not been met prior to November 21, 2007. 38 U.S.C.A. § 1155 (West 1991 & 2002); 38 C.F.R. § 4.119 (as in effect prior to June 6, 1996), and 4.119 (2008). 4. The criteria for a disability evaluation of 60 percent, for the Veteran's service-connected panhypopituitarism, have been met from November 21, 2007. 38 U.S.C.A. § 1155 (West 1991 & 2002); 38 C.F.R. § 4.119 (as in effect prior to June 6, 1996), and 4.119 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In the interest of clarity, the Board will initially discuss whether the claims decided in this decision have been properly developed for appellate purposes. The Board will then address the merits of the claims, providing relevant VA law and regulations, the relevant facts, and an analysis of its decision. I. Veterans Claims Assistance Act of 2000 The Board must determine whether the claimant has been apprised of the law and regulations applicable to this matter, the evidence that would be necessary to substantiate the claims, and whether the claims have been fully developed in accordance with the Veterans Claims Assistance Act of 2000 (VCAA) and other applicable law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002). VA is required to provide notice of the VCAA to a claimant as required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1). More specifically, VA is required to notify a claimant of the evidence and information necessary to substantiate a claim and whether the claimant or the VA is expected to provide the evidence, and is required to request from the claimant any other evidence in his or her possession that pertains to the claim. Id. VA provided notification letters to the Veteran in June 2004 and May 2007. 38 U.S.C.A. § 5103 and 38 C.F.R. § 3.159. In these letters, VA informed the Veteran of the evidence needed to substantiate his claims, and of the elements of his claims. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2007). VA advised the Veteran of the respective duties of the VA and of the Veteran in obtaining evidence needed to substantiate his claims. And VA requested from the Veteran relevant evidence, or information regarding evidence which VA should obtain. Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also 73 Fed. Reg. 23353 (the requirement of requesting that the claimant provide any evidence in his/her possession that pertains to the claim was eliminated by the Secretary [effective May 30, 2008] during the course of this appeal, and this change eliminates the fourth element of notice as required under Pelegrini). The Board notes two deficiencies with VCAA notification, however. VA did not provide a notification letter to the Veteran until after the initial adjudication of his increased rating claims in February 1994. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2007) (VCAA notice must be provided to a claimant before the initial unfavorable RO decision). And, though VA provided the Veteran with general notification on disability evaluations in the May 2007 letter, VA has not provided the Veteran with a particular notification letter detailing the disability criteria at issue in his increased rating claims for brain syndrome and panhypopituitarism. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Nevertheless, the Board finds that any presumed prejudice incurred by the Veteran as a result of the untimely and incomplete notice has been rebutted by the record, and that proceeding with a final decision is appropriate here. See Sanders v. Nicholson, 487 F.3d 881 (2007). See also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328. First, as will be noted below, the Veteran's increased rating claims will be granted in part by this decision. As such, when this matter is returned to the RO, any notice defect with regard to the rating criteria will be addressed when effectuating the awards. Second, the Board notes that VA provided the Veteran with the relevant rating criteria here in the May 1996 Statement of the Case (SOC), and the several Supplemental SOCs (SSOCs) dated between April 1997 and February 2008. Third, the February 2008 SSOC amounts to a full readjudication of the Veteran's claims following effective notice in the previous SOC and SSOCs. See Mayfield, 444 F.3d 1328. Based on this background, the Board finds the untimely and incomplete notice to be harmless error in this matter. The VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A. The VCAA provides that the assistance provided by the Secretary shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary, as further defined by statute, to make a decision on the claim. 38 U.S.C.A. § 5103A. In this matter, the Board finds that VA's duty to assist has been satisfied. VA afforded the Veteran the opportunity to appear before one or more hearings to voice his contentions. VA obtained medical records relevant to this appeal. And VA provided the Veteran with VA compensation examinations for his claims. In sum, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with VA's duties to notify or assist the Veteran in this appeal. Therefore, the Veteran has not been prejudiced as a result of the Board deciding his claims here. II. The Merits of the Claims for Increased Rating The Veteran has been service connected for a traumatic brain injury since a March 1972 rating decision. In an August 1982 rating decision, the RO service connected the Veteran for panhypopituitarism, also due to the in-service traumatic brain injury. In May 1992, the Veteran claimed increased ratings for these disorders. At that time, the Veteran had been rated as 30 percent disabled from June 1982 for his brain injury, and 10 percent disabled from August 1981 for panhypopituitarism. In a February 1994 rating decision, the RO denied the Veteran's increased rating claims. The Veteran appealed, and in April 2000, the Board remanded the claims for additional development. In February 2003, the RO increased the rating for the brain injury (recharacterized as "chronic brain syndrome associated with brain trauma and post-traumatic stress disorder") to 50 percent, effective from July 30, 2002. As that increase did not constitute a full grant of the benefit sought, the increased rating issue has remained in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). In its February 2003 decision, the RO continued the 10 percent rating for panhypopituitarism. As indicated earlier, this case was thereafter remanded three times to afford the Veteran his requested Board hearings, and to conduct additional medical inquiry. In this decision, the Board will assess whether ratings in excess of 30 and 10 percent are warranted from May 19, 1991 (one year prior to the date of the Veteran's May 1992 claims for increase) at any time during the appeal period. See Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service- connected disability exhibits symptoms that would warrant different ratings); see also 38 U.S.C.A. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). Ratings for service-connected disabilities are determined by comparing the symptoms the Veteran is presently experiencing with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based as far as practical on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The Board addresses the Veteran's two increased rating claims separately below. A. Service-connected Brain Syndrome Associated with Brain Trauma and PTSD The RO has rated the Veteran's service-connected brain syndrome under Diagnostic Code (DC) 8045-9304. In the assignment of DC numbers, hyphenated diagnostic codes may be used. The number assigned to the residual condition on the basis of which the rating is determined will generally represent injuries. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27 (2008). See also Tropf v. Nicholson, 20 Vet. App. 317 (2006). Diagnostic Code 8045 addresses brain disease due to trauma. This provision directs VA to evaluate brain disorders under the DC that specifically deals with the symptoms caused by the traumatic brain injury. See 38 C.F.R. § 4.124a. Given the neurological and psychological manifestations resulting from the Veteran's injury, this disorder is rated under DC 9304, which addresses dementia due to head trauma. See 38 C.F.R. § 4.130. VA has already found a 30 percent rating warranted from June 1982, and a 50 percent rating warranted from July 2002. As such, the Board has sought evidence of record that would warrant a rating increase in excess of 30 percent from May 1991 (one year prior to the Veteran's claim for increase on appeal), or an increase in excess of 50 percent from July 2002. In addressing the evidence in this matter, the Board notes that the rating criteria under DC 9304 changed in November 1996, since the Veteran filed his increased rating claim in May 1992. See 61 Fed. Reg. 52,695 (Oct. 8, 1996) (codified at 38 C.F.R. § 4.130); see also Karnas v. Derwinski, 1 Vet. App. 308 (1991) (where a regulation changes after the claim has been filed and before the administrative process has been concluded, the version most favorable to the Veteran applies unless otherwise provided by the Secretary of Veterans Affairs); VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 3- 2000 (Apr. 10, 2000). Accordingly, the Board will consider both sets of criteria in evaluating the Veteran's claim here. Under the older criteria of DC 9304 ratings of 50, 70, and 100 percent were authorized above 30 percent for organic mental disorders. A 50 percent rating was for assignment where considerable impairment of social and industrial adaptability was shown. A 70 percent rating was for assignment where severe impairment of social and industrial adaptability was shown. And a 100 percent rating was warranted if the medical evidence indicated impairment of intellectual functions, orientation, memory and judgment, and lability and shallowness of affect of such extent, severity, depth, and persistence as to produce total social and industrial inadaptability. See 38 C.F.R. § 4.132 (1996). As the RO ultimately (in its February 2003 rating decision) considered the Veteran's PTSD in evaluating the service- connected brain syndrome, the Board has also reviewed the older criteria for rating PTSD, which also changed in 1996. Under the older criteria rating psychoneurotic disorders such as PTSD, a 50 percent evaluation was warranted when the ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent evaluation was warranted when the ability to establish and maintain effective or favorable relationships with people is severely impaired. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation was warranted when the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic, symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. Demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132 (1996). The revised rating criteria, effective November 1996, provide for the evaluation of dementia due to head trauma, under a General Rating Formula for Mental Disorders, which takes into account the objective signs and manifestations of a psychiatric disorder for rating purposes. Ratings in excess of 30 percent consist of 50, 70, and 100 percent evaluations as well. Under the newer criteria of DC 9304, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9304. Under the revised DC 9304, a 70 percent rating for PTSD is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. Id. A 100 percent evaluation is authorized under the revised DC 9304 for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9304. Again, as VA has already found a 30 percent rating warranted here, the Board has limited its analysis to whether a rating higher than 30 percent was warranted prior to July 2002, and whether a rating is warranted in excess of 50 percent after July 2002. In doing so, the Board has found that a rating in excess of 30 percent was unwarranted prior to August 9, 2000. But from that date, the medical evidence indicates that a 70 percent rating has been warranted. The medical evidence of record dated since then shows that the Veteran's mental disorder causes severe impairment of social and industrial adaptability. See 38 C.F.R. § 4.132 (1996). Medical Evidence The medical evidence of record dated since May 1991 consists of VA treatment records, several VA compensation examination reports, and three private treatment reports dated in April 2007. Prior to August 9, 2000 In an August 1993 VA compensation examination report evaluating the Veteran's thyroid, the Veteran reported that he had been feeling depressed, fatigued, easily angered, and that he "didn't want to do anything." But the examiner reported that these symptoms "cleared" with treatment the Veteran underwent for his service-connected panhypopituitarism. The examiner reported the Veteran as feeling well at the time of the examination. The examiner described the Veteran as alert, noted that he responded well to conversation, and noted that he did not appear to be severely depressed. In another August 1993 VA compensation examination report, testing of the Veteran's mental status indicated dementia due to the Veteran's difficulty with memory. But the examiner noted that orientation, attention, immediate recall, calculations, similarities, construction, copying, and information were all normal. In a December 1995 VA mental disorders compensation examination report, the examiner noted the Veteran's subjective complaints of anger, short tempter, inability to accept criticism, nightmares, intrusive memories, and avoidance behavior of people. The Veteran indicated minimal vigilance and minimal startle response. The examiner found the Veteran fully oriented, with appropriate mood, affect, thought content, intact judgment and insight, and with a good memory for recent events. The examiner found the Veteran without suicidal or homicidal ideations, without depressive symptoms, and without delusions, hallucinations, or ideas of reference. And the examiner noted that the Veteran had then been working part time at a car rental agency. But the examiner noted the Veteran with a blunt and constricted affect. And the examiner stated that the Veteran manifested minimal-mild PTSD symptoms. The examiner assigned the Veteran a Global Assessment of Functioning (GAF) score of 70. A January 1996 VA neurology examination report noted the complaints of the Veteran, and of his spouse, that the Veteran easily gets angry and is "a little short of memory." But the examiner found the Veteran with a normal neurological examination based on a mental status test. A February 1996 VA compensation examination report, which reflects an evaluation of the Veteran's thyroid, reported the Veteran as alert, oriented, without fatigue or nervous problems. The Veteran underwent a November 1998 VA mental disorders compensation examination. The report of this exam noted the Veteran's reported anger, tendency to isolate, difficulty with comprehension, and frustration with his current employment as a full-time security guard. But the examiner found the Veteran as fully oriented, cooperative, coherent, clear, logical, congruent, with a normal mood, with good concentration, with an intact memory, and with intact judgment. The examiner noted no sleep disturbances or impairment, no perceptual or conceptual disturbances, and stated that there was no thought content suggestive of obsessive, ritualistic behavior or panic attacks, or of impaired impulse control. The examiner diagnosed the Veteran with mild PTSD characterized by minimal, transient, and intermittent symptoms. He assigned the Veteran a GAF score of 75. In a December 1998 VA neurology examination report, it is noted that the Veteran reported anger that concerns him. He noted that he worked full time as a security guard. He reported his memory as "so-so." After cognitive testing, the examiner found the Veteran as essentially normal cognitively and neurologically. Following the Board's April 2000 remand, the Veteran again underwent VA compensation examination. In July 2000, the Veteran underwent compensation examination for his neurological disorders. The examiner noted "evidence of mild persidua of traumatic injury consisting in mild upper motor neuron signs[.]" This examiner stated that the full range of cognitive and emotional deficits "can best be determined by psychological testing[.]" In August 2000, the Veteran underwent compensation examination for mental disorders. The Veteran reported depression, irritability, anger, fatigue, a lack of concentration, poor memory, and poor comprehension. The examiner found the Veteran as oriented, alert, punctual, euthymic, organized, lucid, coherent, with an appropriate affect, and normal speech. The examiner found no evidence of a thought disorder, of a sleep disorder, or of suicidal and homicidal ideations. The examiner noted that the Veteran continued in his full time employment as a security guard. But the examiner also noted that the Veteran had difficulty with his concentration, his memory, and his language function. The examiner assigned the Veteran a GAF score of 70, and stated that the Veteran had mild symptoms. From August 9, 2000 The VA neurologist who conducted the July 2000 examination then added an addendum report to the record, dated on August 9, 2000. The Board finds this addendum to be the compelling evidence of record that an increase to 70 percent is warranted here due to the severe impairment of social and industrial adaptability caused by the service-connected brain disorder. See 38 C.F.R. § 4.132 (1996). After reviewing the August 2000 mental disorders compensation examination report, this examiner stated that, as a result of the Veteran's injury, he had "a disorder of language and memory-related language with performance in either the impaired memory or low normal range in those functions." He stated that the July and August 2000 examinations demonstrated "cognitive emotional and physical deficits." He characterized each of the symptoms as mild, but stated that the disorders would interfere with the Veteran's ability to "pursue his maximal potential[.]" Of particular significance, he stated that "the accumulative affect would tend to make the Veteran less and less competitive in the job market and consequently being asked to keep up with an average level of demands when his actual capabilities are below average; and particularly when the capabilities in the areas of language and communication are below average, would tend to put him at somewhat of a disadvantage and pose a strain." The Veteran again underwent VA neurology examination in September 2002. This examiner noted the Veteran's complaints of worsening memory, poor speech, and explosive anger. And the Veteran again underwent VA mental disorders compensation examination in November 2002. The examiner noted the Veteran as oriented, and euthymic with an appropriate affect. But the examiner noted that testing found the Veteran with an impaired attention span, with an impaired working memory, with impaired visual perceptual functioning, with impaired memory recognition performance, and with slow cognitive processing speed. Pursuant to another remand for additional medical inquiry, the Veteran underwent another VA neuropsychology compensation examination in June 2007. This examiner again noted that the Veteran was oriented, coherent, with a good mood and appropriate affect. And he noted the Veteran's continued full-time employment as a security guard. But, again, neuropsychological testing revealed substantial deficits in the Veteran's brain functioning. The testing indicated significant impairment with the Veteran's memory, attention span, perceptual functioning, and cognitive processing speed. This examiner assigned a GAF score of 60. In November 2007, the Veteran underwent a VA endocrine compensation examination. The report provided details regarding the Veteran's panhypopituitarism. But the report did offer relevant information for this particular claim. The examiner noted that the Veteran had episodes of anger and subsequent amnesia that are likely seizure equivalent and related to the service-connected brain disease. The Veteran underwent VA neurology compensation examination in December 2007. The examiner noted the Veteran as slow, but then proceeded to find, most likely, the Veteran has no specific deficits in relation to his head trauma, and that limitations in regard to head trauma are not evident. The record also contains private hospital reports dated in April 2008. These reports indicate that the Veteran had recently failed to return home following his work shift, and was later found naked in his automobile, experiencing diarrhea. The report indicated that the Veteran had experienced amnesia that night, and was not sure how he got into his vehicle. The physician noted the Veteran's history of seizures, and characterized the Veteran's episode as multifactorial, and likely related to his "acute renal failure[.]" Analysis Based on the totality of this evidence, the Board finds that a rating in excess of 30 percent is not warranted prior to August 9, 2000. The evidence prior to that date indicates that the Veteran experienced mild symptoms associated with his brain disorder. But, a 70 percent rating is warranted from August 9, 2000. The VA neurologist's opinion of that date demonstrates that, though each of the Veteran's several symptoms indicates mild to moderate impairment respectively, collectively, these symptoms cause the Veteran severe impairment of social and industrial adaptability. See 38 C.F.R. § 4.132 (1996). The medical evidence dated after August 9, 2000 (to include the December 2007 VA report that found the Veteran mainly asymptomatic, and the April 2008 private reports that show the Veteran's amnesiac breakdown) does not preponderate against this finding. As such, a rating in excess of 30 percent is not warranted prior to August 9, 2000. But, from that date, a rating of 70 percent is warranted. The Board finds a 100 percent rating unwarranted for the service-connected brain syndrome, however. The Veteran's impairment cannot be described as "total." As indicated since the early 1990s, the Veteran has been employed as a security guard. Though the record shows that the Veteran is not pleased with this work, and that he earns little money, it is nevertheless clear in the record that the Veteran is employed and employable. Moreover, the medical reports of record consistently demonstrate that, though impaired by his brain disorder, the Veteran is logical, oriented, coherent, and is not delusional. See 38 C.F.R. §§ 4.130, 4.132 (1991) (2008). In summary, the Board finds a 70 percent rating warranted from August 9, 2000 for service-connected brain syndrome associated with brain trauma and PTSD. See Hart, supra. But the preponderance of the evidence is against an evaluation in excess of 30 percent prior to August 9, 2000, or in excess of 70 percent after that date. See AB, supra. The benefit-of- the-doubt rule does not apply therefore to any claim for an additional increase beyond that granted in this decision. As such, any such claim for increase must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Service-connected Panhypopituitarism In this matter, the RO has rated the Veteran's service- connected panhypopituitarism under DC 7909-7903. See 38 C.F.R. § 4.27 (2008). Diagnostic Code 7909 addresses hypopituitarism (diabetes insipidus). Diagnostic Code 7903 addresses hypothyroidism. See 38 C.F.R. § 4.119. VA has already found a 10 percent rating warranted from August 1981. As such, the Board has sought evidence of record that would warrant a rating in excess of 10 percent from May 1991 (one year prior to the Veteran's claim for increase on appeal) under either DC 7909 or DC 7903, or both. In addressing the evidence in this matter, the Board notes that this rating criteria has also changed since May 1992. These criteria, which pertain to disorders of the endocrine system, were amended effective June 6, 1996. See 61 Fed. Reg. 20,446 (May 7, 1996). Accordingly, the Board will consider both sets of criteria in evaluating the Veteran's claim here. See Karnas, supra. The ratings in excess of 10 percent, under the former and revised criteria, range from 20 to 100 percent. Under the former criteria of DC 7909, a 20 percent rating was warranted for hypopituitarism (diabetes insipidus) with polyuria and polydipsia. A 40 percent rating was warranted for moderately severe symptoms with polyuria with increase in urinary chlorides, etc. A 60 percent rating was warranted for severe diabetes insipidus manifested by excessive thirst with intake of water and polyuria with dehydration with increased serum osmality >295 mOsm/kg with decreased urine osmality <38 mOsm/kg. A 100 percent rating was warranted for pronounced diabetes insipidus with excessive thirst with intake of water and severe polyuria with episodes of syncope, systolic and diastolic blood pressure below normal, requiring parenteral replacement therapy. See 38 C.F.R. § 4.119, DC 7909 (1991). Under the former criteria of DC 7903, hypothyroidism was 30 percent disabling when moderately severe, sluggish mentality and other indications of myxedema, decreased levels of circulating thyroid hormones (T4 and/or T3 by specific assay). It was 60 percent disabling when severe, the symptoms under "pronounced" somewhat less marked, decreased levels of circulating thyroid hormones (T4 and/or T3 by specific assay). And it was 100 percent disabling when pronounced, with a long history and slow pulse, decreased levels of circulating thyroid hormones (T4 and/or T3 by specific assay), sluggish mentality, sleepiness, and slow return of reflexes. See 38 C.F.R. § 4.119, DC 7903 (1991). Under the revised criteria of DC 7909, a rating of 20 percent is assigned for hypopituitarism (diabetes insipidus) with evidence of polyuria with near-continuous thirst. A rating of 40 percent is assigned for polyuria with near-continuous thirst and one or more episodes of dehydration in the past year not requiring parenteral hydration. A rating of 60 percent is assigned for polyuria with near-continuous thirst and one or two documented episodes of dehydration requiring parenteral hydration in the past year. A rating of 100 percent is assigned for polyuria with near-continuous thirst more than two documented episodes of dehydration requiring parenteral hydration in the past year. See 38 C.F.R. § 4.119, DC 7909 (2008). And under the revised criteria of DC 7903, a 30 percent rating is warranted for hypothyroidism when there are symptoms of fatigability, constipation, and mental sluggishness. A 60 percent rating may be assigned when there are symptoms of muscular weakness, mental disturbance, and weight gain. A 100 percent rating is warranted when symptoms include cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. See 38 C.F.R. § 4.119, DC 7903 (2008). Again, as VA has already found a 10 percent rating warranted here, the Board has limited its analysis to whether a rating higher than 10 percent has been warranted during the appeal period (i.e., since May 1991). In doing so, the Board has found that a rating in excess of 10 percent was not warranted prior to November 21, 2007. But from that date, the medical evidence indicates that a 60 percent rating has been warranted. The medical evidence of record dated since then shows that the Veteran's panhypopituitarism causes muscle weakness, mental disturbance, and weight gain. See 38 C.F.R. § 4.119, DC 7903 (2008). Medical Evidence The medical evidence of record dated since May 1991 consists of VA treatment records, several VA compensation examination reports, and the private treatment reports of April 2004. Prior to November 21, 2007 An August 1993 VA compensation examination report found the Veteran euthyroid as a result of medication use for panhypopituitarism. The examiner noted that the Veteran used hydrocortisone daily, depo-testosterone, intramuscularly every three weeks, levothyroxine daily, and DDAVP, two sprays for each nostril, daily, for control of anti-diuretic hormone deficiency. The examiner noted that the Veteran reported to feeling well, and that his disease was in remission. A February 1996 VA compensation examination report indicates that the Veteran reported no cold or heat intolerance, that his weight had been stable, that he does not have excessive thirst. The report did note nocturia three times, some fatigability, and some skin eruption on his hands. But the Veteran reported to feeling generally well, and the examiner found the Veteran as alert and clinically euthyroid, with normal blood pressure and a normal heart rate. A December 1998 VA compensation examination report indicates that the Veteran denied any change in symptomatology since his February 1996 examination. The Veteran did report continued fatigue. But he reported no excessive thirst or urination, no cardiovascular problems, no gastrointestinal symptoms, no headaches or vision problems, no weight instability. On examination, the examiner noted no myxedema, no muscle weakness, noted normal vital signs, and noted the Veteran as alert and oriented. The examiner also noted essentially normal lab results reflecting studies of the Veteran's urine and blood. VA treatment records dated between November 2000 and June 2006 detail the Veteran's treatment for panhypopituitarism. These records show that, until 2004, the Veteran denied incontinence, excessive thirst or urination, headaches, diplopia, fevers, and heat/cold intolerance. In multiple examinations, the examiner found no edema, and normal pulse and blood pressure. These records reflect the Veteran's statements that he felt well. But, in VA treatment records dated in February 2004, poor compliance with synthroid and testosterone medication is noted. And in records dated in March 2004, it is indicated that laboratory results showed "problems with medical compliance[.]" The Veteran's treating physician stated that he did not understand the Veteran's "recent non- compliance." The examiner then noted the Veteran as clinically hypothyroid with hoarse voice and slow mentation. And noted that the Veteran admitted to occasionally forgetting his DDAVP, which results in occasional polyuria. VA treatment records dated between July 2004 and October 2004 indicate that the Veteran stated that he was taking his medication as prescribed, and that he denied fatigue, lightheadedness with standing, reduced libido, changes in bowel movements, constipation, polyuria, polydipsia, polyphalgia, or muscle weakness. The Veteran did indicate weight gain, and did indicate some cold intolerance, and headaches from heat. In October 2004, a physician indicated that the weight gain and cold intolerance may be related to hypothyroidism. And beginning in October 2004, VA treating personnel noted the Veteran as appearing clinically hypothyroid and hypogonadal. One examiner noted the Veteran with thick course skin and with sluggish reflexes and problematic lab results. And VA treatment records from October 2004 to September 2005 indicate that the Veteran "continued" to be non-compliant with his prescription medication regimen for panhypopituitarism. In a September 2005 VA treatment record, a VA physician described the Veteran as "much more compliant" with his medication treatment program, and described the Veteran as "stable." But December 2005 to June 2006 treatment records indicate non-compliance again, and state that the Veteran had increased thirst, urination, and nocturia. From November 21, 2007 The Veteran again underwent VA compensation examination on November 21, 2007. The examiner noted in his report that the Veteran had a normal pulmonary examination and had normal blood pressure. But the examiner also noted that magnetic resonance imaging (MRI) indicated marked hypoplastic pituitary with a small pituitary stalk. The examiner noted the Veteran's complaints that he feels sluggish "all the time[,]" that he uses a cane for right side weakness, that he experiences episodes of anger and mood swings, and that he has memory difficulties. The Veteran stated that, when he forgets to use his medication, he urinates at night frequently and feels excessively thirsty. The Veteran noted diarrhea and constipation approximately once per month. The examiner noted a pulse of 56. He noted moist skin, with normal hydration, but noted a darkening of the skin over the Veteran's forearms. He noted smaller than average testes, and pubic hair distribution of a feminine type. The examiner noted muscle weakness in the Veteran's grip and legs. And the Veteran's lab work indicated readings that were below normal. In his opinion, the November 2007 examiner found the Veteran's mood swings, lethargy, muscle weakness, anger, amnesia episodes, and sluggishness related to his panhypopituitarism. The examiner found that these symptoms affected the Veteran's home and work situations. Finally, the Board again notes the April 2008 private hospital reports noting the Veteran's diarrhea, amnesia, mental disturbance, and speculation that the incident was related to the Veteran's "acute renal failure[.]" Analysis The Board has reviewed the medical evidence of record pertaining to the Veteran's service-connected panhypopituitarism. And the Board finds that a rating in excess of 10 percent would not be warranted under either the former or the revised DC 7909. These provisions repeatedly note excessive thirst and urination as criteria to consider when determining an appropriate rating. The Board finds that the evidence since May 1991 demonstrates that, when the Veteran is compliant with his prescribed medication, polyuria and polydipsia are not problems. See 38 C.F.R. § 4.119, DC 7909 (1991) (2008). The Board likewise finds a rating in excess of 10 percent unwarranted under the former criteria of DC 7303. For a rating increase to 30 percent under that provision, the evidence must show sluggishness, in addition to myxedema, and decreased levels of circulating thyroid hormones. While the evidence shows sluggishness, the evidence also shows that the Veteran's skin is essentially normal, and that his lab work was essentially normal when following his medication regimen. See 38 C.F.R. § 7303 (1991). A rating increase is warranted, however, under the revised DC 7303. Under this provision, a 30 percent rating is warranted with symptoms of fatigability, constipation, and mental sluggishness. A 60 percent rating is warranted for symptoms of muscular weakness, mental disturbance, and weight gain. And a 100 percent rating is warranted for symptoms such as cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. See 38 C.F.R. § 4.119, DC 7909 (2008). The evidence of record shows, since November 21, 2007, that the Veteran's disorder has been productive of muscular weakness, mental disturbance, and weight gain. Medical evidence dated in 2004 and 2005 indicate that the Veteran's symptoms may have been due to noncompliance with his medication prescription. But the November 21, 2007 report does not indicate noncompliance. Rather, that examiner makes clear that the Veteran has muscle weakness and mental disturbance directly related to his service-connected disorder. VA treatment records dated since 2004 show, moreover, that the Veteran's weight has fluctuated over the years, which his treating physician found perhaps related to his endocrinology disorder. And the April 2008 private records - though unclear on the exact nature of the incident addressed - do not preponderate against the other evidence of record showing muscle weakness, mental disturbance, and weight instability. A 60 percent rating is therefore warranted from November 21, 2007. In considering whether the apparent worsening of the Veteran's disorder resulted from noncompliance, or from an increase in the severity of his disease, the Board considered VA's doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board finds a 100 percent rating - the next-highest rating under DCs 7909 and 7903 - unwarranted however. See 38 C.F.R. § 4.119, DCs 7903, 7909 (1991) (2008). To meet the criteria for a 100 percent evaluation under either of the versions of DCs 7903 or 7909, the evidence must show parenteral replacement therapy (former and revised DC 7909), decreased levels of circulating thyroid hormones (former DC 7903), and cardiovascular involvement (revised DC 7303). The record does not demonstrate that the Veteran's service- connected panhypopituitarism involves symptoms this pronounced. In making this determination, the Board notes that, even with the Veteran's disability, he still works full time for a job at which he ambulates, and to which he commutes by car. See 38 C.F.R. § 4.119 (1991) (2008). In summary, the Board finds a 60 percent rating warranted from November 21, 2007 for service-connected panhypopituitarism. See Hart, supra. But the preponderance of the evidence is against an evaluation increase in excess of 10 percent prior to November 21, 2007, or to 100 percent after that date. See AB, supra. The benefit-of-the-doubt rule does not apply therefore to any claim for an additional increase beyond that granted in this decision. As such, any such claim for increase must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. The Board has closely reviewed and considered the Veteran's statements, and those of his spouse in the hearing transcripts of record. While these statements may be viewed as evidence, the Board must also note that laypersons without medical expertise or training are not competent to offer medical evidence on matters involving diagnosis and etiology. Therefore, the statements alone are insufficient to prove the Veteran's claims. Ultimately, a lay statement, however sincerely communicated, cannot form a factual basis for granting a claim requiring medical determinations. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). Finally, the Board finds an extra-schedular rating unwarranted here. Application of the regular schedular standards is found practicable in this matter. Hence the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) for assignment of an extra-schedular evaluation. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER 1. An increased rating, for the Veteran's service-connected brain syndrome associated with brain trauma and PTSD, is denied prior to August 9, 2000. 2. A disability rating of 70 percent, for the Veteran's service-connected brain syndrome associated with brain trauma and PTSD, is granted from August 9, 2000, subject to VA laws and regulations governing the payment of monetary awards. 3. An increased rating, for the Veteran's service-connected panhypopituitarism, is denied prior to November 21, 2007. 4. A disability rating of 60 percent, for the Veteran's service-connected panhypopituitarism, is granted from November 21, 2007, subject to VA laws and regulations governing the payment of monetary awards. ____________________________________________ John E. Ormond, Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs