Citation Nr: 21070921 Decision Date: 11/27/21 Archive Date: 11/27/21 DOCKET NO. 19-05 544 DATE: November 27, 2021 ORDER Entitlement to a compensable rating for residuals of a pituitary tumor is denied. Entitlement to a compensable rating for radiation-induced alopecia, secondary to residuals of a pituitary tumor is denied. Entitlement to a compensable rating for amenorrhea, secondary to residuals of a pituitary tumor is denied. Entitlement to a compensable rating for female sexual arousal disorder, secondary to residuals of a pituitary tumor is denied. Entitlement to an award of special monthly compensation for loss of use of a creative organ is warranted as of March 5, 2016. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has any residual symptoms specific to the endocrine system. 2. The Veteran's radiation-induced alopecia does not manifest in a loss of all body hair. 3. The Veteran's amenorrhea does not require continuous treatment. 4. The evidence supports a finding that the Veteran has experienced symptoms of female sexual arousal disordercorresponding to loss of use of a creative organsince at least March 5, 2016 when VA received her increased rating claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating for residuals of a pituitary tumor have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.119, Diagnostic Code 7915. 2. The criteria for entitlement to a compensable rating for radiation-induced alopecia, secondary to residuals of a pituitary tumor have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.118, Diagnostic Code 7831. 3. The criteria for entitlement to a compensable rating for amenorrhea, secondary to residuals of a pituitary tumor have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.116, Diagnostic Code 7615. 4. The criteria for Entitlement to a compensable rating for female sexual arousal disorder, secondary to residuals of a pituitary tumor have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.116, Diagnostic Code 7632. 5. The criteria for special monthly compensation based on loss of use of a creative organ have been met as of March 5, 2016. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1994 to March 2000, and from May 2000 to February 2003. This case comes on appeal of a March 2017 rating decision. The Veteran testified before the Board at a February 2020 video conference hearing. This case has previously been before the Board on two occasions. Most recently, in August 2020, the Board remanded the issue of entitlement to a compensable rating for residuals of a pituitary tumor, status post transsphenoidal adenomectomy. Notably, the Veteran's residuals of a pituitary tumor have been rated under 38 C.F.R. § 4.119, Diagnostic Code 7915, for benign neoplasm of the endocrine system. Diagnostic Code 7915 instructs the evaluator to rate based on the residuals of endocrine dysfunction. In light of this, in its most recent decision, the Board noted that the Veteran had identified loss of menstruation, loss of sexual arousal, and loss of hair as residuals of her pituitary tumor, and treatment thereof, that had not been considered in evaluating her disability. Following the Board's remand, in September 2021, the agency of original jurisdiction (AOJ) issued a rating decision granting separate service connection for amenorrhea, female sexual arousal disorder, and radiation-induced alopecia. The AOJ assigned noncompensable ratings to each of these, while also awarding a grant of special monthly compensation for loss of use of a creative organ. See 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350. Given that the rating schedule for the Veteran's pituitary disability requires the Board to evaluate based on the disability's residuals, it is therefore necessary to evaluate the propriety of the rating assigned in the September 2021 rating decision. Increased Ratings Disability evaluations are determined by the application of the facts presented to the VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. (1999); Hart v. Mansfield, 21 Vet. App. (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. Generally, separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 1. Entitlement to a compensable rating for residuals of a pituitary tumor As was discussed above, the Veteran's residuals of a pituitary tumor, status post transsphenoidal adenomectomy, are rated under 38 C.F.R. § 4.119, Diagnostic Code 7915. That Diagnostic Code instructs the evaluator to rate based on the residuals of endocrine dysfunction. Since filing her increased rating claim in March 2016, the Veteran has undergone several VA endocrine diseases examinations. In April 2020, due to the ongoing COVID-19 pandemic, an examiner was not able to examine the Veteran in person, but instead reviewed her files. Based on this review, the examiner reported that the only diagnosed endocrine condition was the Veteran's status post transseptal transsphenoidal hypophysectomy, secondary to her pituitary tumor. The Veteran did not require continuous medication for an endocrine condition. There were no signs or symptoms related to Cushing's syndrome, acromegaly, diabetes insipidus, Addison's disease, or any other endocrine conditions. In December 2020, the Veteran was able to undergo an in-person examination. There, the examiner reported that neurological and psychological systems were residually affected by the Veteran's pituitary condition. The Board notes that the Veteran's acquired psychiatric disorder and her headaches have been service connected and evaluated separately and are not part of this appeal. Regarding the endocrine condition itself, the examiner once again reported that continuous medication was not required to control the condition. The Veteran reported a prior diagnosis of Cushing's syndrome in 2001, but the examiner reported no symptoms associated with Cushing's syndrome at the time of the examination. Similarly, there were no symptoms associated with acromegaly, diabetes insipidus, Addison's disease, or any other endocrine condition. Following the Board's most recent remand, in May 2021, the Veteran underwent another VA examination. The diagnosis was unchanged and the examiner reported that the pituitary condition affected reproductive symptoms, skin symptoms, and neurological symptomsthe first two of which will be addressed further below. The examiner again reported that the Veteran did not require continuous medication for control of an endocrine condition. There were no symptoms attributable to Cushing's syndrome, acromegaly, diabetes insipidus, or Addison's disease, or any other endocrine condition. Throughout the period on appeal, the Veteran's medical records demonstrate regular complaints of symptoms related to other body symptoms the Veteran has alleged are affected by her pituitary surgery and radiation treatment. However, there is no evidence of any additional symptoms specific to the endocrine system during that period. Thus, based on these records and the examinations discussed above, the preponderance of the evidence is against a finding that the Veteran experiences any residual symptoms of the endocrine system that would warrant a compensable rating under Diagnostic Code 7915. As the preponderance of the evidence is against this finding, the "benefit of the doubt" rule is not applicable and the Board must deny the claim. See 38 U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a compensable rating for radiation-induced alopecia, secondary to residuals of a pituitary tumor In the May 2021 VA examination, the examiner reported that the residuals of the Veteran's pituitary condition resulted in symptoms of the skin. Specifically, the Veteran has reported that ever since being treated with radiation, her hair has fallen out. Accordingly, the Veteran also underwent a skin conditions examination in May 2021. At that examination, the examiner reported a diagnosis of radiation-induced alopecia. Alopecia is evaluated under 38 C.F.R. § 4.118, Diagnostic Code 7831. Under Diagnostic Code 7831, a noncompensable rating is available for alopecia with loss of hair limited to scalp and face. A 10 percent rating is available for alopecia with loss of all body hair. On physical examination, the examiner reported that the Veteran was noted to have minimal hair on her extremities and short, thin, coarse scalp hair. Based on the criteria of Diagnostic Code 7831, since there is not a loss of all body hair, a 10 percent rating is not warranted. As the preponderance of the evidence is against a finding of a loss of all body hair, the "benefit of the doubt" rule is not applicable and the Board must deny the claim for a compensable rating. See 38 U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a compensable rating for amenorrhea, secondary to residuals of a pituitary tumor 4. Entitlement to a compensable rating for female sexual arousal disorder, secondary to residuals of a pituitary tumor At the May 2021 endocrine conditions examination, the examiner reported that the residuals of treatment for the Veteran's pituitary condition affected reproductive symptoms. Throughout the period on appeal, the Veteran has complained that the removal of her pituitary and subsequent radiation have affected her hormonal regulation, leading to loss of menstruation and sexual arousal. On concurrent examination, the examiner reported diagnoses of amenorrhea and female sexual arousal disorder. Amenorrhea is rated under 38 C.F.R. § 4.116, Diagnostic Code 7615. Indeed, the note to Diagnostic Code 7615 specifically states that "for the purpose of VA disability evaluation, a disease...affecting the menstrual cycle, such as dysmenorrhea and secondary amenorrhea, shall be rated under [D]iagnostic [C]ode 7615." Diagnostic Code 7615 evaluates the severity of the symptoms by whether and how they are controlled. For symptoms that do not require continuous treatment, a noncompensable rating is warranted. To warrant a 10 percent rating, there must be symptoms that require continuous treatment. To warrant a 30 percent rating, there must be symptoms that are not controlled by continuous treatment. Here, the examiner found that the Veteran's symptoms of amenorrhea do not require continuous treatment. Additionally, there is no evidence in the Veteran's medical records that demonstrate continuous treatment for amenorrhea. Therefore, a noncompensable rating is appropriate under the Diagnostic Code. Female sexual arousal disorder is rated under 38 C.F.R. § 4.116, Diagnostic Code 7632. The only rating under Diagnostic Code 7632 for female arousal disorder is a noncompensable rating. However, Diagnostic Code 7632 notes that VA should review the symptoms for entitlement to special monthly compensation under 38 C.F.R. § 3.350. With regard to special monthly compensation, as was discussed above, the AOJ awarded special monthly compensation for loss of use of a creative organ, effective May 5, 2021the date of the Veteran's gynecological conditions examination. However, VA received the Veteran's claim for an increased rating for residuals of her pituitary condition on March 5, 2016. Throughout the pendency of this claim, the Veteran has complained of loss of sexual function due to her service-connected pituitary condition. The Board finds that the Veteran, as a layperson, is competent to observe and describe the symptoms of sexual dysfunction, therefore the evidence demonstrates that special monthly compensation for is warranted since the date of the claim. See 38 C.F.R. § 3.400(o). The Board has considered whether it is appropriate to award such an increased rating during the one-year period prior to the Veteran's submission of the claim, as is allowed under 38 C.F.R. §3.400(o). However, the evidence does not specifically show that it is factually ascertainable the increase occurred during this period. Accordingly, an award of special monthly compensation prior to March 5, 2016 is not warranted. Thus, the preponderance of the evidence is against a finding that an increased rating is warranted for amenorrhea or female sexual arousal disorder under the schedular diagnostic codes. As the preponderance of the evidence is against this finding, the "benefit of the doubt" rule is not applicable and the Board must deny those claims. However, the evidence does demonstrate that an award of special monthly compensation for loss of use of a creative organ is warranted since the date of the Veteran's increased rating claim. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Giaquinto, 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.