Citation Nr: 21070495 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 16-00 064 DATE: November 24, 2021 ORDER Entitlement to a disability rating in excess of 40 percent for service-connected panhypopituitarism is denied. FINDING OF FACT The preponderance of the evidence shows that the Veteran's service-connected panhypopituitarism is not manifested by one or two documented episodes of dehydration requiring parenteral hydration in the past year CONCLUSION OF LAW The criteria for a disability rating in excess of 40 percent for service-connected panhypopituitarism are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7909. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1978 to October 1989. This case is before the Board of Veterans' Appeals (Board) on appeal from a November 2011 Regional Office (RO) rating decision. In that rating decision, the RO denied a disability rating in excess of 20 percent for service-connected panhypopituitarism. The Veteran's notice of disagreement (NOD) was received in September 2012. The RO issued a statement of the case (SOC) in November 2015. The Veteran's VA Form 9, substantive appeal to the Board, was received in December 2015. In September 2018 and March 2021, the Board remanded the case to the RO for further development and adjudicative action. During the appeal, in a July 2020 rating decision, the RO increased the Veteran's disability rating to 40 percent for service-connected panhypopituitarism, effective January 22, 2010. During the appeal, the RO granted service connection for benign prostatic hyperplasia and assigned a 20 percent disability rating, effective January 22, 2010 in an April 2021 rating decision. This represents a full grant of the benefit sought on appeal with respect to that issue and therefore such issue is no longer in appellate status or before the Board. Entitlement to a disability rating in excess of 40 percent for service-connected panhypopituitarism. The Veteran contends that he is entitled to a higher disability rating for his service-connected panhypopituitarism because his symptoms include dehydration, and he has had to go to the emergency room several times to receive IV resuscitation and corticosteroids. The Veteran's service-connected panhypopituitarism is currently evaluated as analogous to diabetes insipidus under Diagnostic Code 7909. During the pendency of this appeal, VA amended 38 C.F.R. § 4.119 (Schedule of ratings endocrine system), including the rating criteria for diabetes insipidus under Diagnostic Code 7909. See 82 FR 50802 -50807 (Final Rule published Nov. 2, 2017 and effective December 10, 2017). When a law or regulation changes during the pendency of an increased rating claim, the Board first must determine whether application of the revised version would produce retroactive results. Specifically, a new rule may not extinguish any rights or benefits that the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03. However, if the revised version of the regulation is more favorable, then the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, then VA may apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Prior to December 10, 2017, Diagnostic Code 7909 provided a structured scheme of specific, successive, cumulative criteria. Each higher rating included the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is assigned for polyuria with near-continuous thirst. A 40 percent rating is assigned for polyuria with near-continuous thirst, and one or more episodes of dehydration in the past year not requiring parenteral hydration. A 60 percent rating is assigned for polyuria with near-continuous thirst, and one or two documented episodes of dehydration requiring parenteral hydration in the past year. A 100 percent rating is assigned for polyuria with near-continuous thirst, and more than two documented episodes of dehydration requiring parenteral hydration in the past year. Because Diagnostic Code 7909 contained successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran's disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran' favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). As of December 10, 2017, under amended Diagnostic Code 7909, a 10 percent rating is assigned for diabetes insipidus with persistent polyuria or requiring continuous hormonal therapy. A higher, 30 percent rating is assigned for three months after initial diagnosis. An accompanying note provides, "Thereafter, if diabetes insipidus has subsided, rate residuals under the appropriate diagnostic code(s) within the appropriate body system." The medical evidence reflects that the Veteran's panhypopituitarism has not subsided and therefore, evaluating the Veteran under the pre-amended Diagnostic 7909 is more favorable to the Veteran. The question in this appeal is whether the Veteran's panhypopituitarism requires one or two documented episodes of dehydration requiring parenteral hydration in the past year or more than two documented episodes of dehydration requiring parenteral hydration in the past year. The Board finds that the Veteran did not have any documented episodes of dehydration requiring parenteral hydration throughout the appeal period. In this regard, the medical evidence in the VA examination reports dated in July 2010, October 2015, June 2020, and April 2021 do not show that the Veteran had one or more episodes of dehydration requiring parenteral hydration in the past year. The Veteran's VA treatment records also reflect that any episodes of dehydration were not treated with parenteral hydration. While the Veteran reported in the June 2020 VA examination that over the years, he had made several visits to the emergency room with episodes of dehydration that required IV resuscitation and cortisol with the most recent emergency room visit two weeks prior to the examination, this is not documented in the medical record. He noted that prior to the June 2020 emergency room visit, he had not been to an emergency room for several years. A June 2020 VA emergency room record shows that the Veteran sought treatment for headaches, chills, and decrease appetite. The physician conducted blood work, CT scan, and consulted with the on-call endocrine fellow. The plan was to continue doubling of hydrocortisone and resume normal dosing Saturday. A July 2020 VA treatment record documented that the Veteran's recent episode of severe headache and malaise was likely an adrenal crisis. The physician noted that management should include hydration and IV glucocorticoids in the future. The Veteran stated that he has had about 12 episodes of adrenal crisis since being diagnosed in 1988 and he knows how to recognize a crisis and how to handle it by doubling or tripling his steroid medication and increase his fluid intake. An April 2021 VA examination noted that the Veteran stated that his condition has been stable over the past year and that he last went to the emergency room in June 2020 without receiving IV hydration, which endocrine noted should have happened. The Veteran reported that he also experiences cold chills, heat intolerance with nausea, dry heaves, profound fatigue, severe headaches with light and sound sensitivity. He will double or triple steroid medication that day sometimes into the following day. In a May 2021 addendum opinion, the April 2021 VA examiner noted that the Veteran's most recent emergency room visit was in June 2020 for adrenal crisis. He was not treated with IV fluids/medications during that visit, and he was discharged home with instructions to double up steroid dosage for a couple of days then return to normal dosing. The examiner observed that the claims file shows show no indication of multiple emergency room visits prior to June 2020. However, there are multiple reports of continuous issues with thirst starting in 2001 until September 2020 with the Veteran reporting in September 2020 that he drinks "lots of Pedialyte." In light of the foregoing, the preponderance of the evidence shows that there were no documented episodes of dehydration requiring parenteral hydration at any time during the appeal period. Accordingly, the preponderance of the evidence is against assigning a rating in excess of 40 percent at any time during the period on appeal. D. SMART Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Berry, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.