Citation Nr: 21013732 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 07-17 848 DATE: March 10, 2021 ORDER Entitlement to compensation under 38 U.S.C. § 1151 for hypopituitarism as a result of radiation therapy from July 10, 1997 to August 27, 1997 at the Hines VA Medical Center (VAMC) is denied. Entitlement to compensation under 38 U.S.C. § 1151 for brain damage as a result of radiation therapy from July 10, 1997 to August 27, 1997 at the Hines VAMC is denied. Entitlement to compensation under 38 U.S.C. § 1151 for an endocrine disorder as a result of radiation therapy from July 10, 1997 to August 27, 1997 at the Hines VA Hospital is denied. Entitlement to compensation under 38 U.S.C. § 1151 for erectile dysfunction (ED) as a result of radiation therapy from July 10, 1997 to August 27, 1997 at the Hines VAMC is denied. Entitlement to compensation under 38 U.S.C. § 1151 for water retention as a result of radiation therapy from July 10, 1997 to August 27, 1997 at the Hines VA Hospital is denied. Entitlement to compensation under 38 U.S.C. § 1151 for hypertension as a result of radiation therapy from July 10, 1997 to August 27, 1997 at the Hines VAMC is denied. Entitlement to compensation under 38 U.S.C. § 1151 for right ear hearing loss as a result of radiation therapy from July 10, 1997 to August 27, 1997 at the Hines VAMC is denied. FINDINGS OF FACT 1. The competent and probative evidence weighs against a finding that the proximate cause of the Veteran’s hypopituitarism, brain damage, an endocrine disorder, ED, water retention, and hypertension was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing radiation treatment from July to August 1997, or an event not reasonably foreseeable. 2. The preponderance of the competent and credible evidence of record does not show that an additional disability of right ear hearing loss resulted from VA radiation treatment from July to August 1997. CONCLUSIONS OF LAW 1. The criteria for compensation benefits under 38 U.S.C. § 1151 for hypopituitarism due to VA medical treatment are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 2. The criteria for compensation benefits under 38 U.S.C. § 1151 for claimed additional disability of brain damage due to VA medical treatment are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 3. The criteria for compensation benefits under 38 U.S.C. § 1151 for an endocrine disorder due to VA medical treatment are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 4. The criteria for compensation benefits under 38 U.S.C. § 1151 for ED due to VA medical treatment are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 5. The criteria for compensation benefits under 38 U.S.C. § 1151 for claimed additional disability of water retention due to VA medical treatment are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 6. The criteria for compensation benefits under 38 U.S.C. § 1151 for hypertension due to VA medical treatment are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 7. The criteria for compensation benefits under 38 U.S.C. § 1151 for claimed additional disability of right ear hearing loss due to VA medical treatment are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1970 to May 1972. This case comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned Veterans Law Judge at an April 2011 hearing; a transcript of the hearing is of record. The Board then remanded the issues on appeal for further development in August 2011 and December 2012. On remand, and in a January 2017 rating decision, the AOJ granted compensation under 38 U.S.C. § 1151 for schizoaffective disorder, rated 100 percent disabling from May 8, 2008. The AOJ also determined that the Veteran was permanently and totally disabled under 38 U.S.C. § 1151 from that date. These issues are not in appellate status. In February 2018, the Board requested a specialist medical opinion from the Veterans Health Administration (VHA) as to the remaining claims under 38 U.S.C. § 1151, and a VHA opinion was obtained in July 2018. In correspondence dated in July 2018, the Veteran was provided a copy of the letter and given an opportunity to respond. In a December 2018 decision, in pertinent part, the Board denied entitlement to service connection for bilateral hearing loss and tinnitus, and remanded the issues of compensation under 38 U.S.C. § 1151 for additional development, including a VA medical opinion and medical records. The Veteran then appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a January 2020 Joint Motion for Partial Remand (Joint Motion), the Court, the parties (the Veteran and the Secretary of VA) requested that the Board decision be vacated only as to the issues of entitlement to service connection for left ear hearing loss and tinnitus, and these issues remanded. The parties stated that the appellant did not challenge the Board’s denial of service connection for right ear hearing loss. In a February 2020 order, the Court granted the Joint Motion and remanded the claims for action consistent with the terms of the Joint Motion. The appeal as to the remaining issue (service connection for right ear hearing loss) was dismissed. In June 2020, the Board remanded the claims of service connection for left ear hearing loss and tinnitus to the AOJ for additional development. On remand, and in a September 2020 rating decision, the AOJ granted service connection for left ear hearing loss and tinnitus, and these issues are no longer in appellate status. The issues of compensation under 38 U.S.C. § 1151 for left ear hearing loss and tinnitus are not in appellate status as service connection is the greater benefit. The case was subsequently returned to the Board. 1151 Eligibility A Veteran who suffers disability or death resulting from hospital care or medical or surgical treatment or examination provided by a VA employee or in a VA facility is entitled to compensation for the additional disability in the same manner as if such additional disability were service-connected, if the additional disability was not the result of willful misconduct and was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing that treatment or an event not reasonably foreseeable. 38 U.S.C. § 1151 (a)(1)(A), (B); 38 C.F.R. § 3.361 (a)-(d); Viegas v. Shinseki, 705 F.3d 1374, 1377-78 (Fed. Cir. 2013). The causation element of § 1151 is satisfied not only when an injury is “directly” or “actually” caused by the actions of VA employees, but also where an injury occurs in a VA facility resulting from VA’s negligence. Viegas v. Shinseki, 705 F.3d 1374, 1378 (Fed. Cir. 2013). 38 U.S.C. § 1151 does not extend to the remote consequences of the hospital care or medical treatment provided by the VA. See Viegas, at 1383. To determine whether a Veteran has additional disability, VA compares the Veteran’s condition immediately before the beginning of the hospital care, medical or surgical treatment, or examination to the Veteran’s condition after such care, treatment, or examination has stopped. 38 C.F.R. § 3.361 (b). VA considers each involved body part or system separately. Id. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the Veteran’s additional disability. 38 C.F.R. § 3.361 (c)(1). Merely showing that a Veteran received care, treatment, or examination, and that the Veteran has additional disability, does not establish cause. Id. Hospital care, medical or surgical treatment, or examination cannot cause the continuation or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361 (c)(2). Additional disability caused by a Veteran’s failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361 (c)(3). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361 (d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran’s additional disability, it must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran’s additional disability and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran’s or, in appropriate cases, the Veteran’s representative’s, informed consent. 38 C.F.R. § 3.361 (d)(1). Whether the proximate cause of a Veteran’s additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361 (d)(2). The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. Id. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361 (d)(2). According to the applicable regulations, “informed consent” means consent that is freely given after a careful explanation by a medical practitioner of a proposed diagnostic or therapeutic procedure or course of treatment. See 38 C.F.R. §§ 3.361, 17.32. The practitioner must explain in language understandable to the patient the nature of a proposed procedure of treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and anticipated results if nothing is done. Id. A failure to provide information to a patient about a potential adverse effect does not defeat a finding of informed consent if a reasonable person faced with similar circumstances would have proceeded with the treatment. McNair v. Shinseki, 25 Vet. App. 98, 107 (2011). 1. Entitlement to compensation under 38 U.S.C. § 1151 for hypopituitarism 2. Entitlement to compensation under 38 U.S.C. § 1151 for brain damage 3. Entitlement to compensation under 38 U.S.C. § 1151 for an endocrine disorder 4. Entitlement to compensation under 38 U.S.C. § 1151 for ED 5. Entitlement to compensation under 38 U.S.C. § 1151 for water retention 6. Entitlement to compensation under 38 U.S.C. § 1151 for hypertension The Veteran contends that he has multiple disabilities due to radiation treatment at the Hines VAMC in 1997, including hypopituitarism, brain damage, an endocrine disorder to include decreased testosterone, impotence (ED), water retention, hypertension, and right ear hearing loss. He has also contended that his hypopituitarism was caused by the radiation treatment and then caused the other claimed disabilities. He contends that the radiation treatment was unnecessary, and therefore an error in judgment, and that the amount of radiation he received was excessive. He contends that his hearing loss was aggravated by the radiation treatment. See his statements dated in June 2007, May 2008, June 2008, February 2010 and May 2010, and Board hearing testimony. In June 2007, the Veteran filed his original claim for compensation under 38 U.S.C. § 1151 for panhypopituitarism due to VA radiation treatment. In June 2008, he claimed that the radiation treatment caused depression, anxiety, worry, poor concentration, memory loss, aggravation of hearing loss, hypertension, brain damage, a damaged pituitary gland causing impotence, weight gain, retaining water, and damage to his endocrine system. He said that he had to wear testosterone patches and take water pills because of pituitary gland damage, and that after the radiation, he had extreme head pain that lasted for six to eight months. At the April 2011 Board hearing, the Veteran testified that the chemotherapy seemed to clear up his T-cell lymphoma cancer, but medical providers talked him into getting 32 days of unnecessary radiation therapy to his head, which caused the damage. See April 2011 Board hearing transcript. He admitted signing a consent form for the radiation treatment but said they talked him into it without explaining the risks. See hearing transcript, pages 6, 10; Veteran’s February 2012 statement. He also contended that there was definitely brain damage during the radiation treatment because he could smell his flesh burning after ten days, and he had “exploding” head pain for six months. He stated that he was told he had a brain tumor by treatment providers, but later they told him he did not have one. He said his brain damage included memory loss, emotional numbness, impaired concentration, depression and delusions. He also contended that the radiation damaged his pituitary gland, causing a lack of testosterone, which caused impotence and water retention under his arms, stomach and lower abdomen. He testified that hypertension was first diagnosed after the radiation treatment. In February 2021, the Veteran's representative contended that he is entitled to “service connection” for right ear hearing loss and hypopituitarism under the provisions of 38 U.S.C. § 1151, and is entitled to compensation for brain damage, hypertension, impotence, an endocrine system disorder and water retention as secondary to hypopituitarism under 38 C.F.R. § 3.310. Initially, the Board notes that the issues on appeal pertain to entitlement to compensation under 38 U.S.C. § 1151, not service connection (38 U.S.C. § 1110), and that 38 C.F.R. § 3.310 pertains to secondary service connection. There are three elements required to establish benefits pursuant to 38 U.S.C. § 1151: an additional disability, a causal nexus between the VA treatment and the additional disability, and a finding of fault or a finding of an unforeseen circumstance. As discussed in detail below, the evidence weighs against the Veteran’s claims, and the claims must be denied. VA medical records reflect that in April 1997, the Veteran was diagnosed with T-cell lymphoma of the nasal cavity and seen in initial consultation at the Loyola-Hines Department of Radiotherapy of Loyola University Medical Center and Hines VAMC. It was noted that he had a history of chronic sinusitis and a three-month history of recurrent sinus infection including nasal congestion and occasional headaches. He previously presented to the ear, nose, and throat (ENT) clinic on March 5, 1997 where he was found to have perforation of the nasal septum with extensive crusting and surrounding granulation tissue in addition to bilateral cervical lymphadenopathy, and obstruction of the nasal cavity secondary to tumor. He was treated with cyclophosphamide (CHOP) chemotherapy beginning in April 1997. The Veteran received radiation therapy to the nasal cavity and left maxillary sinus at a VA facility from July 10, 1997 to August 27, 1997. An August 1997 report of final consultation reflects that he received a full course of radiation therapy, during which a good clinical response was noted, but he continued to complain of congestive symptoms. He had less obstruction in the midline tumor masses involving the septum. During treatment he developed significant pain secondary to irritation of the mucosa. The Board notes that there is a gap in treatment from late 1997 to 1999. An initial VA psychology note dated in September 1999 reflects that the Veteran reported that he previously had cancer, which was last treated in 1997, and then he went into some degree of isolation, using cocaine and alcohol in his house; he was diagnosed with cocaine dependence, in early full remission. In October 1999, the Veteran denied a history of hypertension, and in May 2001, his blood pressure was 132/74. A May 2000 VA oncology note reflects that the Veteran denied nasal stuffiness and headaches; the physician indicated that he was doing well with no evidence of disease. Low testosterone was diagnosed in August 2000, which the oncologist indicated was questionably secondary to hypopituitarism, and referred him to endocrinology. A September 2000 VA magnetic resonance imaging (MRI) scan of the brain was performed for hypopituitary hypogonadism, to rule out a pituitary tumor, and showed findings questionable for a small pituitary microadenoma. A February 2001 endocrinology note indicated that the results of pituitary stimulation testing showed that the Veteran required testosterone replacement and growth hormone. A December 2002 endocrinology note shows diagnoses of pituitary microadenoma, and hypogonadotropic hypogonadism likely secondary to radiation. A January 2003 brain MRI showed a stable pituitary microadenoma, but a September 2004 brain MRI was normal, with no mass seen. In February 2005, he was diagnosed with ED. A June 2010 brain MRI showed that the pituitary gland was normal in size and demonstrated normal enhancement; no definite focal pituitary lesion was identified. The Board finds that that the threshold element for compensation under 38 U.S.C. § 1151, the presence of additional disability, has been met with regard to the claims for hypopituitarism, brain damage, an endocrine disorder, ED, and hypertension. Medical records on file show that the Veteran did not have hypopituitarism, pituitary microadenoma, hypogonadism, decreased testosterone, ED, or hypertension prior to the radiation treatment in 1997. Hypopituitarism, pituitary microadenoma, hypogonadism, decreased testosterone, and ED were diagnosed a few years after the radiation treatment, but hypertension was not diagnosed until July 2004, seven years later. See VA medical records dated from 2000 to 2004. Medical records reflect that the Veteran was taking hydrochlorothiazide for hypertension in 2005. A November 2007 VA outpatient treatment record reflects that the Veteran stopped taking his blood pressure medications and thought he was retaining more water since stopping hydrochlorothiazide. In June 2011, the Veteran said he was retaining water. In April 2013, the Veteran requested a prescription for his water pill Furosemide. The physician noted that he was not taking Furosemide. The Veteran then said that he wanted the medication so he could lose ten pounds. The Board now turns to the causation element of these claims. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the Veteran’s additional disability. 38 C.F.R. § 3.361 (c)(1). Merely showing that a Veteran received care, treatment, or examination, and that the Veteran has additional disability, does not establish cause. Id. The claims file contains multiple medical opinions weighing for and against the causation elements of the claims for hypopituitarism, pituitary microadenoma, hypogonadism, decreased testosterone, ED, water retention, and hypertension. Evidence weighing in favor of the causation element of these claims includes a December 2001 VA endocrinology note reflecting that the physician opined that the Veteran’s partial hypopituitarism was probably due to irradiation from nasal T-cell lymphoma, but an MRI showed microadenoma as well. The physician added that because there were slight elevations of luteinizing hormone (LH) and prolactin (PRL), the whole picture was not explained by irradiation. A December 2002 endocrinology note shows diagnoses of pituitary microadenoma, and hypogonadotropic hypogonadism likely secondary to radiation. On VA examination in May 2005, the examiner opined that hypopituitarism was secondary to radiation for T-cell lymphoma, but did not provide a supporting rationale, which reduces the probative value of the opinion. In a June 2008 VA endocrine diseases examination and a September 2011 addendum opinion, the examiner, a nurse practitioner, opined that the Veteran's partial hypopituitarism is as likely as not to be related in part to irradiation from nasal T-cell lymphoma. The opinion was based on the timing of symptoms and signs to the irradiation treatment, but the examiner stated that all of the effects could not be explained solely by irradiation, noting that an initial pituitary MRI showed microadenoma, but a repeat MRI in 2004 was normal. There were also slight elevations in LH and prolactin and TSH which was not explained by irradiation, and his prolactin, LH and TSH had since normalized. His testosterone was normalized but required supplementation. In January 2020, Dr. P. opined that it is as likely as not that hypopituitarism was caused by the VA treatment at issue, and the rationale was that the Veteran had surgical excision, chemotherapy and radiation therapy for nasal T-cell lymphoma and thereafter developed hypopituitarism. Dr. P. opined that it is at least as likely as not that brain damage is a result of the VA treatment at issue. The rationale was that the Veteran had loss of memory, lack of focus and concentration after the treatment. Dr. P. opined that it is at least as likely as not that hypertension is a result of the VA treatment at issue, because the diagnosis of hypertension started after treatment for nasal lymphoma and his blood pressure was at goal after the treatment. Dr. P. opined that it is at least as likely as not that an endocrine disorder (hypothyroidism secondary to hypopituitarism) is a result of the VA treatment at issue. The rationale was that the treatment of nasal lymphoma with surgery and radiation resulted in hypopituitarism. Dr. P. opined that it is at least as likely as not that water retention is a result of the VA treatment at issue. The rationale was that treatment of nasal lymphoma with surgery and radiation therapy caused hypothyroidism [sic] which resulted in hypothyroidism causing water retention. Evidence weighing against the causation element of these claims includes a July 2020 VA medical opinion by Dr. G., a medical oncologist, who opined that the Veteran's pituitary dysfunction was not caused by his CHOP chemotherapy, and that CHOP chemotherapy is an appropriate treatment for T-cell lymphoma. He opined that none of the above listed problems including hypopituitarism, brain damage, hypertension, etc., are permanent side effects of CHOP chemotherapy. Dr. G. did not provide an opinion as to whether or not the Veteran's radiation therapy was more or less likely than not to have caused pituitary dysfunction. With regard to the claim for impotence (ED), in January 2020, Dr. P. opined that it is less likely than not that impotence is secondary to hypopituitarism or caused by the treatment at issue, because impotence predated treatment for nasal lymphoma in 1997. Dr. P. also noted that the Veteran had low testosterone after treatment for nasal lymphoma. July 2018 and November 2020 VHA expert medical opinions from a VA radiation oncologist, Dr. V., weigh against the causation element of the claims. In July 2018, he opined that it is less likely than not that the Veteran has additional disability resulting from VA radiation treatment for T-cell lymphoma of the nasal cavity in 1997. The rationale was that pituitary dysfunction is more likely due to microadenoma because pituitary dysfunction would likely need the entire dose from all 3 beams to converge onto the pituitary which would have about a 5-10% risk of pituitary dysfunction. He stated that a review of the medical records showed that two of the three beams based on the drawing did not deliver a dose to the pituitary. In November 2020, he opined that it is less likely that the Veteran’s claims of disability (of hypopituitarism, brain damage, hypertension, an endocrine disorder, impotence, water retention, hearing loss, and tinnitus) resulted from VA radiation therapy in the treatment of his T‐cell lymphoma of the nasal cavity in 1997 because both the daily dose given as well as the total dose are outside established guidelines for this to occur. With regard to the causation element under 38 U.S.C. § 1151 as to these claims, the evidence is in relative equipoise. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the probative evidence shows that hypopituitarism, pituitary microadenoma, hypogonadism, decreased testosterone, ED, water retention, and hypertension are proximately due to the 1997 VA radiation treatment. With regard to the third element, the Board finds that the Veteran has not established there was carelessness, negligence, lack of proper skill, error in judgment or other instance of fault on VA’s part in the radiation treatment. To this end, it must be shown either that VA failed to exercise the degree of care expected by a reasonable treatment provider or furnished the medical treatment at issue without his informed consent. See 38 C.F.R. § 3.361 (d)(1). This has not been demonstrated. Although VA psychiatrists Dr. B. and Dr. S. provided opinions in September 2011, February 2013 and July 2016, that it is as likely as not that the Veteran's schizoaffective disorder was likely due to “excessive” radiation to the pituitary due to an error in judgment or a failure to exercise the degree of care expected by a reasonable health care provider, the Board finds that these psychiatrists’ opinions are less probative than those of Dr. V. and Dr. G., due to their greater expertise as a radiation oncologist and oncologist, respectively. The Board notes that in July 2016, Dr. S. stated that her opinion that reasonable standards of care were not exercised was based on the “fact” that excessive radiation was used, and it was with speculation only that she opined that reasonable standards of care were not exercised. Neither Dr. B. nor Dr. S. provided any support for their finding that the radiation used in 1997 was excessive. In contrast, Dr. V., a radiation oncologist, reviewed the radiation treatment records and opined that it is less likely than not that such additional disability was directly caused by carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on VA’s part in furnishing treatment, or was an event not reasonably foreseeable. In November 2020, he opined that it is less likely that the Veteran’s claims of disability (of hypopituitarism, brain damage, hypertension, an endocrine disorder, impotence, water retention, hearing loss, and tinnitus) resulted from VA radiation therapy in the treatment of his T‐cell lymphoma of the nasal cavity in 1997 because both the daily dose given as well as the total dose are outside established guidelines for this to occur. The other VA examiners consistently opined that it is less likely than not that such additional disability was directly caused by carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on VA’s part in furnishing treatment, or was an event not reasonably foreseeable. See June 2008, September 2011 VA medical opinions. The rationale was that the location of lymphoma was in proximity to the pituitary and there was no evidence of negligence. Therefore, the proximate cause of hypopituitarism is due to an event that was reasonably foreseeable. In January 2020, Dr. P. opined that it is less likely as not that the additional disability resulted from attending personnel’s failure to follow an appropriate standard of care. The rationale was that the Veteran received chemotherapy as prescribed in oncology standards, and radiation treatment as properly based on radiation standards. Radiation exposure included the pituitary gland that received some of the radiation treatment and chemotherapy resulting in hypopituitarism. It is less likely than not that the additional disability resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider. Hypopituitarism was anticipated and diagnosed and treated promptly including sequelae. The examiner opined that it is less likely than not that failure on part of VA to timely diagnose the disease allowed it to continue to progress. The rationale was that hypopituitarism was diagnosed soon after treatment of nasal lymphoma and appropriate treatment started, and currently the only manifestation of hypopituitarism is low testosterone. In July 2020, Dr. G., a medical oncologist, opined that after reviewing his prior medical oncology treatment (CHOP chemotherapy) and radiation treatment that it is less likely than not that his disability is the result of carelessness or negligence. CHOP chemotherapy and consolidation with radiation is an appropriate treatment for stage 2e nasal T-cell lymphoma, and there is nothing in the record to say that the method in which those therapies was administered was inappropriate. Radiation treatment does carry some risk of permanent damage to the targeted area and nearby areas. In addition, there is a radiation consent form signed by the patient and radiation oncologist listing numerous potentially permanent side effects of radiation treatment including damage to irradiated organs. The radiation dose given to this Veteran is in line with published guideline dosages for definitive therapy in aggressive non-Hodgkin T-cell lymphomas (40-55gy) [Journal of Radiation Oncology, Biology, Physics, 2014-05-01, Volume 89, Issue 1, Pages 49-58] and does not to me seem “excessive.” Dr. G. stated that he was not able to reconcile the prior psychiatry opinion that his psychosis may have been exacerbated by his radiation treatment, and he did not believe the Veteran's cancer therapy was “excessive” based on the records provided. The VA medical opinions by Dr. G. and Dr. V. are highly probative, because they are based on an accurate medical history and review of medical records, and provide explanations that contain clear conclusions and supporting data, including the radiation dosage and the location of the beams during the treatment, and with citation to medical references. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, VA treatment records contain a June 1997 informed consent for radiation therapy, signed by the Veteran. He was advised that radiation treatments will usually accomplish what is intended with minimal or acceptable side-effects or after-effects, however there can be no guarantees that radiation will be successful and that he would suffer no damage from radiation. If damage occurs, corrective surgery might be needed. He was informed that temporary side effects of the treatment included reaction of the lining of the nose and possible throat (sore throat), skin reaction, effect of radiation on inner part of eyes, and permanent after-effects included dryness of the nose. Possible complications included damage to irradiated organs, e.g. damage to nose cartilage which may need surgery. Therefore, the Board finds the evidence demonstrates fulfillment of the informed consent requirements of 38 C.F.R. § 17.32 for the surgery in question. The Board acknowledges the Veteran’s sincerely held beliefs that VA radiation therapy from July to August 1997 caused his current hypopituitarism, brain damage, an endocrine disorder, ED, water retention, and hypertension due to fault on the part of VA. The Veteran is not competent to provide a medical opinion in this case. This issue is also medically complex, as it requires specialized medical education, knowledge of the interaction between multiple organ systems in the body, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Since there is no probative evidence that the proximate cause of hypopituitarism, brain damage, an endocrine disorder, ED, water retention, and hypertension was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, to include medical and surgical treatment, or an event not reasonably foreseeable, the claim for entitlement to compensation under 38 U.S.C. § 1151 is denied. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 7. Entitlement to compensation under 38 U.S.C. § 1151 for right ear hearing loss The Veteran contends that VA radiation treatment aggravated his right ear hearing loss. As will be discussed below, the Board finds that that the threshold element for 38 U.S.C. § 1151 compensation, the presence of a qualifying additional disability, has not been met. A hearing loss disability in the right ear was noted on service entrance examination in January 1970. 38 C.F.R. § 3.385. In other words, his right ear hearing loss existed prior to service, and existed for decades prior to his VA radiation treatment in 1997. The Veteran contends that his hearing loss was aggravated by the radiation treatment. In September 2008, the Veteran stated that he had hearing problems from 1973 to 1995. In a February 2008 VA audiological examination, the Veteran complained of longstanding hearing difficulties bilaterally, progressively worse especially after 32 days of radiation treatment to his head. The examiner diagnosed sensorineural hearing loss and stated that acoustic reflexes were absent in all conditions, which was likely due to his history of cranial radiation. The examiner stated that the claims file was not available, and based the opinion on the remoteness of complaint from service (35 years after discharge), as well as his history of radiation and chemotherapy, both of which can be highly ototoxic to high-frequency hearing. The Board finds that this opinion has low probative value since the examiner did not review the Veteran's claims file or medical records. In a June 2008 VA audiology examination, the examiner opined that none of the medications in the CHOP chemotherapy regimen list a side effect of ototoxicity, and stated that if radiation treatment causes hearing loss, it is typically a conductive hearing loss due to swelling and can be medically treatable. Given that there are no audiological assessments prior to treatment nor in the near aftermath of treatment, the examiner could not determine if his condition became worse as a result of VA treatment without speculation. In July 2018, Dr. V., a radiation oncologist, considered the Veteran's contention that he has additional hearing loss due to VA radiation treatment in 1997, and opined that it is less likely than not that the Veteran has additional disability resulting from VA radiation treatment for T-cell lymphoma of the nasal cavity in 1997. The rationale was that pituitary dysfunction is more likely due to microadenoma because pituitary dysfunction would likely need the entire dose from all 3 beams to converge onto the pituitary which would have about a 5-10% risk of pituitary dysfunction. After a review of the medical records, two of the three beams based on the drawing did not deliver a dose to the pituitary. In January 2020, Dr. P. opined that it is less likely than not that the claimed disability of hearing loss was caused or made worse by treatment of nasal lymphoma. The rationale was that the diagnosis of hearing loss predated treatment of nasal lymphoma and hearing loss was not made worse by treatment of nasal lymphoma. The VA medical opinions by Dr. V. and Dr. P. are highly probative, because they are based on an accurate medical history and review of medical records, and provide explanations that contain clear conclusions and supporting data, including the radiation dosage and the location of the beams during the treatment. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges the Veteran’s sincerely held beliefs that the 1997 VA radiation treatment aggravated his preexisting right ear hearing loss. The Veteran is not competent to provide a medical opinion in this case. This issue is also medically complex, as it requires specialized medical education, knowledge of the interaction between multiple organ systems in the body, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. As the most probative evidence of record shows that the Veteran did not incur an additional right ear hearing loss disability, or an increase in the severity of such disability as a result of proper and appropriate VA treatment, the benefit of the doubt rule is not for application with respect to this claim. Therefore, the Board finds compensation under 38 U.S.C. § 1151 for right ear hearing loss is not warranted. See 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. L. Wasser, 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.