Citation Nr: 0006188 Decision Date: 03/08/00 Archive Date: 03/17/00 DOCKET NO. 97-27 917 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for mitral valve prolapse prior to January 12, 1998. 2. Entitlement to an evaluation in excess of 60 percent for mitral valve prolapse since January 12, 1998. 3. Entitlement to an increased evaluation for Graves' disease, currently evaluated as 10 percent disabling. 4. Whether new and material evidence has been submitted to reopen a claim for service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Douglas E. Massey, Associate Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. The veteran, who had active, service from May 1986 to June 1991, appealed that decision to the Board. The Board notes that the veteran's representative argues, in a January 2000 informal hearing presentation, that the evidence of record raises an inferred claim for a psychological problem secondary to service-connected Graves' disease. This claim is REFERRED to the agency of original jurisdiction. FINDINGS OF FACT 1. The veteran's mitral valve prolapse is productive of paroxysmal tachycardia and a left ventricular ejection fraction of 40 to 45 percent, but is not productive of enlargement of the heart, dyspnea on slight exertion, or signs of congestive failure; at 4 METs of exertion, there is no evidence of dyspnea, fatigue, angina, dizziness, or syncope. 2. The veteran's is clinically euthyroid and Graves' disease is not productive of fatigability, constipation, or mental sluggishness. 3. An unappealed November 1991 rating decision denied service connection for hearing loss. 4. The evidence associated with the claims file subsequent to the November 1991 rating decision does not tend to establish any material fact which was not already of record at the time of that rating decision and is not so significant that it must be considered in order to fairly decide the merits of the claim. CONCLUSIONS OF LAW 1. The veteran's mitral valve prolapse meets the criteria for a 60 percent evaluation prior to January 12, 1998. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.104, Diagnostic Code 7000 (prior to January 12, 1998). 2. The criteria for an evaluation in excess of 60 percent for the veteran's mitral valve prolapse have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.104, Diagnostic Code 7000 (1999); 38 C.F.R. § 4.104, Diagnostic Code 7000 (prior to January 12, 1998). 3. The criteria for an evaluation in excess of 10 percent for the veteran's Graves' disease have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.119, Diagnostic Codes 7900 and 7903 (1999). 4. The November 1991 rating decision which denied service connection for hearing loss is final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. §§ 3.104, 3.385, 20.302, 20.1103 (1999). 5. The evidence received since the November 1991 rating decision is not new and material, and the veteran's claim for that benefit is not reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Evaluation of Service-Connected Disabilities As a preliminary matter, the Board finds that the veteran's claims for increased ratings are plausible and capable of substantiation and are therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a). A claim that a service- connected condition has become more severe is well grounded where the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). The Board also is satisfied that all relevant facts have been properly developed and no further assistance to the veteran is required in order to comply with the duty to assist. See 38 U.S.C.A. § 5107(a). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). A. Mitral valve prolapse The evidence shows that the veteran was diagnosed with mitral valve prolapse during his period of active military service. As a result, a November 1991 rating decision granted service connection for mitral valve prolapse with chest pain and assigned a 30 percent disability evaluation from June 1991. The veteran filed a claim in October 1996 requesting an increased evaluation for this service-connected disability. In connection with his claim, the RO considered private July 1996 reports showing treatment for complaints of chest pain and a rapid heart rate. On admission, the veteran reported discomfort in his left upper chest that radiated to the left shoulder. It was noted that the veteran had a history of mitral valve prolapse. Physical examination showed a blood pressure reading of 125/72 with a pulse of 96. The heart had a regular rate and rhythm with no murmurs heard. A 12-lead electrocardiogram (EKG) showed a normal sinus rhythm with a ventricular rate of 97. There was no evidence of ischemic changes or preexcitation. Pulse rate intervals were normal, and chest X-rays were unremarkable. The physician's impression was history of intermittent rapid heart rates. The physician commented that he was unable to determine the cause of the veteran's rapid heart rate, but indicated that his symptoms were not primarily due to cardiac ischemia. VA outpatient treatment reports dated from September 1995 to October 1996 show that the veteran continued to seek treatment for chest pain and heart palpitations. These reports reflect that, at least at times, the veteran's cardiac symptoms were related to anxiety. An August 1996 entry, for instance, noted that the veteran's only abnormality on laboratory testing was an increased level of dioxide due to hyperventilating from anxiety. The diagnoses were anxiety disorder and depression. The veteran was seen later that month for complaints of chest pain, palpitations, nausea, and numbness of the legs. After Holter testing showed "nothing too abnormal," a cardiologist determined that the veteran's symptoms were due to anxiety. In October 1996, the veteran was diagnosed with supraventricular tachycardia and mitral valve prolapse. Overall, these reports consistently showed that the veteran's heart had a regular rate and rhythm. The veteran underwent a VA cardiac examination in January 1997 to determine the nature and manifestations of his mitral valve prolapse. A report from that examination noted that the veteran had not lost any weight. Physical examination showed a blood pressure reading of 110/70 and a pulse of 84 and regular. The cardiac size was indeterminate. There was an intermittent "clicky" quality to the first heart sound (S1) and a very faint grade 1/2 to 1 early systolic murmur in the supine position. The murmur could not be heard while the veteran was sitting or squatting. Cardiac tones were regular. The systole and diastole were predominately clear. The examiner noted that, although he thought a mid-systolic click was present when examined last August, no such click was heard on current examination. No evidence of congestive heart failure was observed. A transthoracic EKG disclosed that the left ventricular ejection fraction was 40 to 45 percent. Based on these findings, the examiner concluded that the veteran had mitral valve prolapse, diagnosed in 1990, of no hemodynamic significance. The examiner commented that findings with respect to this diagnosis would fluctuate, as a click or murmur may be heard one day, with no such abnormality detected on the following day. The examiner stated that he did not hear a loud, large crescendo blowing systolic murmur consistent with significant mitral insufficiency. The examiner also diagnosed the veteran with history of supraventricular tachycardia with fairly normal Holter monitor. The examiner added that the veteran's Graves' disease had been a factor with his palpitations and supraventricular tachycardia, which appeared to be controlled. The examiner did not believe that the supraventricular tachycardia was related to the mitral valve prolapse. He also indicated that the mitral valve prolapse was of no significant consequence, as there had never been any infection of the valve or evidence of shortness of breath. It was further noted that the veteran's palpitations could be explained, in part, by his hypothyroidism, and that exogenous factors such as caffeine intake were contributing to palpitations and other symptoms. The examiner opined that the veteran's mitral valve prolapse had not progressed. After reviewing the foregoing evidence, the RO issued a rating decision in April 1997 denying the veteran's claim of entitlement to an evaluation in excess of 30 percent for his service-connected mitral valve prolapse. The veteran responded by perfecting a substantive appeal. In his VA Form 9 (Appeal to Board of Veterans' Appeals) submitted in January 1997, the veteran challenged the finding that his heart palpitations were related to anxiety. Private clinical records dated in October 1997 reflect that the veteran sought treatment for complaints of transient episodes of a rapid heart rate and numbness in the left side of his neck, left shoulder, and both calf areas. It was noted that the veteran was on Cardizem. His blood pressure was 139/91 and pulse was 71 and regular. The heart had a regular rhythm with a grade 2/6 to 3/6 systolic murmur heard, which was more pronounced along the left sternal border and at the apex, with some transmission to the left. The physician noted that the veteran's slightly diminished sensation over both calf areas involved both S1 and S2 dermatome distributions, which was somewhat unusual with no other involvement. A 12-lead EKG was normal. The veteran was diagnosed with transient tachyarrhythmia, subjective hypesthesia of both calf areas, and mitral valve prolapse. The veteran testified before a hearing officer at the RO in November 1997 concerning the severity of his mitral valve prolapse. The veteran maintained that this condition was productive of symptoms consistent with a heart attack, such as palpitations, nausea, hot flashes, a sensation of tightness in his chest, and numbness in his extremities. He stated that he would experience symptoms after just several hours of working at his job, which involved manual labor. According to the veteran, a physician recommended that he get a job which did not require manual labor. The veteran continued to seek VA treatment for cardiac symptoms from November 1996 to June 1997. The veteran was seen in December 1996, at which time his heart had a regular rhythm and rate. It was noted that the supraventricular tachycardia was stable. A February 1997 entry noted that the veteran may have angina. An April 1997 report indicated that the veteran was seen for atypical chest pain. In June 1997, it was reported that the veteran had complaints associated with non-cardiac chest pain, depression and continued shortness of breath. The veteran was hospitalized at a VA medical center in February 1997 for complaints of intermittent left chest discomfort. The veteran reported that he had been suffering from episodes of chest pain two to three times a week for the past three and a half years. The pain was described as a stabbing, squeezing sensation in the left area of the chest. This pain had been treated with Diltiazem and Paroxetine. The veteran explained that he had experienced nine such episodes three days prior to admission. He said these episodes lasted from 5 to 15 minutes and ranged in severity from 3 to 5 on a pain scale of 0 to 10. He said that pain and numbness would occasionally radiate to his left arm. He also reported episodes of sweating and palpitations, but denied nausea, vomiting, weakness, and shortness of breath. The veteran related that he did not have to stop his activities during these episodes. On cardiovascular examination, the veteran's heart demonstrated a regular rate and rhythm. The chest was clear to auscultation bilaterally. An EKG showed normal sinus rhythm. Stress thallium testing was negative. The physician concluded that the most likely etiology of the veteran's chest pain continued to be mitral valve prolapse. It was also noted that there was no evidence of ischemia on the thallium testing. The assigned diagnoses were (1) atypical chest pain, status post negative thallium, double product showed no signs of ischemia, non-cardiac etiology likely; and (2) mitral valve prolapse, diagnosed by echocardiogram. An April 1998 VA cardiology examination report included a medical opinion that the veteran's paroxysmal tachycardia was clearly related to his mitral valve prolapse as opposed to his thyroid disease. This opinion was based on the fact that tachycardia episodes had persisted through the years and occurred at rest and with exercise. The veteran explained that these episodes had been decreasing in frequency, from two to three times a week in the past to only two to four times a month currently. However, the episodes had been increasing in intensity. He also said that the tachycardia would last anywhere from 5 to 15 minutes, with a pulse in the range of 140 to 150. It also was noted that the veteran experienced episodes of atypical chest pain of a squeezing nature which would last up to 5 minutes and occur approximately twice a week. These episodes were described as exertional in character, but would occur at rest from time to time. The veteran added that he was still able to play golf and take walks, but said he would not participate in any vigorous activities for fear of developing either chest pain or tachycardia. On physical examination, the veteran's chest was clear to percussion and auscultation. The heart was not enlarged. There was a mid-systolic click, but no third heart sound (S3) or edema. The examiner diagnosed with veteran with (1) mitral valve prolapse; and (2) atypical chest pain and paroxysmal tachycardia, both existing as manifestations of mitral valve prolapse, Functional Class II, according to the New York Heart Association. The examiner indicated that the veteran was up to 4 METs of exertion. On VA examination in June 1999, the veteran's blood pressure was 138/84 with a pulse of 84. Cardiac examination revealed a Grade I to IV systolic murmur most pronounced along the left lower sternal border but also audible at the apex. No third or forth heart sounds were present, and no jugular venous distention was observed. X-rays of the chest were unremarkable. As this was an examination for the veteran's thyroid condition, no cardiac diagnosis was provided. In a September 1999 rating decision, the RO determined that the hearing officer's decision issued in May 1998 constituted clear and unmistakable error by not assigning a 60 percent evaluation for the veteran's mitral valve prolapse, effective as of January 12, 1998. The RO determined that findings contained in the January 1997 examination report were consistent with a 60 percent evaluation under the new criteria pertaining to the cardiovascular system. The RO assigned January 12, 1998, as the effective date of increase because this was the date that VA issued new regulations for evaluating cardiac conditions. As the effective date of increase did not go back to the date of claim, two issues must be adjudicated. The Board must determine whether the veteran's mitral valve prolapse warrants an evaluation in excess of 30 percent prior to January 12, 1998, and, determine whether this condition warrants an evaluation in excess of 60 percent since January 12, 1998. 1. Evaluation prior to January 12, 1998 The RO evaluated the veteran's service-connected mitral valve prolapse by analogy under Diagnostic Code 7000 for rheumatic heart disease. Prior to January 12, 1998, this diagnostic code provided a 30 percent evaluation after termination of an established service episode of rheumatic fever, or its subsequent recurrence, with cardiac manifestations, during the episode or recurrence, for three years, or diastolic murmur with characteristic EKG manifestations or definitely enlarged heart. A 60 percent evaluation was assigned where the heart was definitely enlarged; or if there was severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal tachycardia; or where more than light manual labor was precluded. Finally, a 100 percent evaluation was provided where there was definite enlargement of the heart confirmed on x-ray and clinically; dyspnea on slight exertion; rales, pretibial pitting at the end of the day or other definite signs of beginning congestive failure; or, if more than sedentary employment was precluded. 38 C.F.R. § 4.104, Diagnostic Code 7000 (Prior to January 12, 1998). Applying the criteria to the facts of this case, the Board finds that a 60 percent evaluation is warranted for the veteran's mitral valve prolapse prior to January 12, 1998. As noted, a 60 percent evaluation is assignable under the former criteria where the heart is definitely enlarged, or if there is severe dyspnea on exertion, elevation of systolic blood pressure, or with such arrhythmias as paroxysmal tachycardia; or where more than light manual labor is precluded. Here, the April 1998 VA examination report contained a medical opinion that the veteran's paroxysmal tachycardia was clearly related to his service-connected mitral valve prolapse. Based on this opinion, the Board finds that a 60 percent evaluation is warranted under Diagnostic Code 7000 for the veteran's mitral valve prolapse for the period prior to January 12, 1998. In reaching this decision, the Board also finds that an evaluation higher than 60 percent is not warranted for this condition prior to January 12, 1998. Here, the clinical evidence contradicts of finding of definite enlargement of the heart, dyspnea on slight exertion, rales, pretibial pitting at the end of the day or other definite signs of beginning congestive failure, or that more than sedentary employment is precluded. VA examination in April 1998 specifically found that the veteran's heart was not enlarged. The evidence also does not show that the veteran has experienced dyspnea on slight exertion. The January 1997 VA examination report noted that there had never been any evidence of shortness of breath. The veteran also stated at his April 1998 VA examination that he was still able to play golf and take walks, which is inconsistent with a finding of dyspnea on slight exertion. In addition, the January 1997 VA examination report noted that there was no evidence of congestive heart failure. Finally, the evidence does not reflect that the veteran is precluded from performing more than sedentary employment, as the veteran is currently employed part-time in customer service at an airport and works part-time as a private investigator. In short, the preponderance of the evidence is against an evaluation in excess of 60 percent for the veteran's mitral valve prolapse for the period prior to January 12, 1998. 2. Evaluation after January 12, 1998 By regulatory amendment effective January 12, 1998, VA issued new regulations for the evaluation of cardiovascular disorders, as set forth in 38 C.F.R. § 4.104, Diagnostic Codes 7000-7017. See 61 Fed. Reg. 65207-65244 (1998). Where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas v Derwinski, 1 Vet. App. 308, 312-313 (1991). The effective date rule established by 38 U.S.C.A. § 5110(g), however, prohibits the application of any liberalizing rule to a claim prior to the effective date of such law or regulation. Id.; Rhodan v. West, 12 Vet. App. 55, 57 (1998). Therefore, as observed by the RO, any increase in the veteran's mitral valve prolapse based on the revised criteria cannot become effective prior to January 12, 1998. Under the revised criteria, a 60 percent evaluation is warranted where there is more than one episode of acute congestive heart failure in the past year; or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Finally, a 100 percent evaluation is assigned where there is documented coronary artery disease resulting in: chronic congestive heart failure; or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. 4.104, Diagnostic Code 7000 (1999). Under the new criteria, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner may be used. Id. For the period since January 12, 1998, the Board finds that the preponderance of the evidence is against an evaluation in excess of the currently assigned 60 percent under both sets of criteria listed in Diagnostic Code 7000. The medical evidence of record simply does not show that the veteran has ever suffered from coronary artery disease resulting in chronic congestive heart failure. The record also does not document that a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope. The April 1998 VA examination report, for instance, disclosed that the veteran was up to 4 METs of exertion, at which time no evidence of dyspnea, fatigue, angina, dizziness, or syncope was reported. The Board further points out that a transthoracic EKG performed in January 1997 revealed a left ventricular ejection fraction of 40 to 45 percent, which is obviously greater than 30 percent as listed in the criteria for a 100 percent evaluation. Accordingly, a 100 percent evaluation is not warranted under either set of criteria pursuant to Diagnostic Code 7000. 3. Conclusion In conclusion, the Board finds that the evidence supports a 60 percent evaluation for mitral valve prolapse, for the period from the date of the submission of the veteran's claim in October 1996, to January 12, 1998. However, the preponderance of the evidence is against an evaluation in excess of 60 percent at any time during the period at issue, either prior to or following January 12, 1998. In denying an evaluation higher than 60 percent, the Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the veteran's claim, the doctrine is not for application. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-56. B. Graves' disease In a November 1991 rating decision, the RO granted service connection for Graves' disease and assigned a 10 percent disability evaluation as of June 1991. An April 1997 rating decision denied the veteran's claim for an increased evaluation for this condition. The veteran disagreed with that decision, and this appeal ensued. In denying an increased evaluation, the RO considered VA outpatient treatment reports dated from September 1995 to October 1996. These reports essentially show treatment for the veteran's thyroid condition, for which he was taking various medications. An April 1996 entry noted that the veteran's blood pressure was 121/55, with a pulse of 68 beats per minute. These treatment reports also show that the veteran was treated for depression, anxiety and chest pain. When seen in October 1996, a clinician noted that the veteran's Graves' disease was stable. In connection with this claim, the veteran was afforded a VA compensation examination in January 1997. On examination, blood pressure was 110/70 and pulse was 84 and regular. The veteran's height was 74 inches and his weight was 229 pounds. The thyroid was not enlarged, no tremor of the extended hands was observed, and no muscle weakness was present. The veteran appeared to move quickly and exhibited a normal affect. Based on these findings, the pertinent diagnosis was Graves' disease, status post presumptive propylthiouracil therapy and then radioactive iodine therapy with subsequent hypothyroidism, controlled. The examiner opined that laboratory thyroid hormone levels were at the upper limits of normal. The examiner also noted a diagnosis of history of supraventricular tachycardia with fairly normal Holter monitor. He stated that the veteran's Graves' disease had been a factor regarding palpitations and supraventricular tachycardia, which appeared to be controlled. In an April 1997 notice of disagreement, and at his hearing held in November 1997, the veteran reported symptoms of sluggishness, fatigability and mental disturbance. The veteran testified that he suffered from mental sluggishness in that he was unable to remember instructions at work. He also said that he suffered from chronic fatigue. He related that he almost fell asleep at the wheel while driving to the hearing. He said that he would get up at 7:00 a.m., but would have to take a nap by 11:00 a.m. due to exhaustion. He also took three-hour naps in the afternoon and went to bed at 11:00 p.m. The veteran also explained that he often got "edgy" at home with his family. Private Emergency Department records in October 1997 disclosed that the veteran's blood pressure was 139/91 and his pulse was 71 and regular. The neck was supple without adenopathy or thyromegaly. The heart had a regular rhythm with a grade 2/6 to 3/6 systolic murmur heard best along the left sternal border and at the apex with some transmission to the left. No muscle weakness was present, as his major muscle groups demonstrated a 5/5 muscle function throughout. The treating physician's assessment included "transient tachyarrhythmia, consider excess exogenous thyroid replacement medication." The veteran was hospitalized at a VA medical center in February 1997 for complaints of intermittent left chest discomfort. The veteran reported episodes of occasional sweating and palpitations. He denied nausea, vomiting, weakness, and shortness of breath. Examination of the neck showed no thyromegaly or nodules. Cardiovascular examination was normal with a regular rate and rhythm. The diagnosis were (1) atypical chest pain, non-cardiac etiology likely; (2) history of depression, treated on Paroxetine; (3) mitral valve prolapse; (4) Graves' disease, diagnosed in 1986, on Synthroid, status post ablation; and (5) reflux esophagitis. Additional VA treatment reports show continued treatment for the veteran's thyroid condition from November 1996 to June 1997. A December 1996 entry noted that the veteran's depression, hypothyroidism and supraventricular tachycardia were stable. A February 1997 report noted that the veteran continued to smoke one and a half packs of cigarettes a day. When seen in March 1997, the veteran was observed to be alert. In June 1997, the veteran reported complaints of non- cardiac chest pain, depression and continued shortness of breath. The veteran was also treated for depression by the VA from June 1997 to May 1999. The veteran underwent an additional VA examination in June 1999 for his thyroid condition. At that time, the veteran reported a thirty year history of smoking one pack of cigarettes a day. He said that he worked as a private investigator. Physical examination revealed a blood pressure reading of 138/84 and a pulse of 84 and regular. His weight was 252 pounds. The neck was supple without adenopathy and the thyroid gland was not palpable. The extremities showed no evidence of cyanosis, clubbing, or edema, but a tremor was present. Laboratory testing included the following thyroid function studies: the free levothyroxine thyroxine (T4) was 1.46 (normal), the total triiodothyronine (T3) was 106.5 (normal), and the thyroid-stimulating hormone (TSH) was 6.96 (acceptable). Anti-thyroglobulin antibody titers and anti- microsomal antibody titers were negative. Based on these findings, the examiner concluded with a diagnosis of "history of Graves' disease, clinically euthyroid at present." The examiner also commented that the veteran's depression was only partially related to his hypothyroidism. He observed that the veteran's past difficulties with depression were more related to being either hyperthyroid or hypothyroid as a result of medications. The examiner explained, however, that the veteran was currently euthyroid and not complaining of depressive symptoms that were as severe as had been in the past. The veteran's service-connected Graves' disease has been evaluated under the criteria for evaluating the endocrine system. 38 C.F.R. § 4.119, Diagnostic Codes 7900, 7903. Diagnostic Code 7900 pertains to hyperthyroidism. Under this code provision, a 10 percent evaluation is warranted for hyperthyroidism with tachycardia, which may be intermittent, and tremor. A 10 percent evaluation is also assignable when continuous medication is required for control. A 30 percent evaluation is warranted for hyperthyroidism with tachycardia, tremor, and increased pulse pressure or blood pressure. A 60 percent evaluation is appropriate when hyperthyroidism causes emotional instability, tachycardia, fatigability, and increased pulse pressure or blood pressure. A 100 percent evaluation is provided where there is thyroid enlargement, tachycardia (more than 100 beats per minute), eye involvement, muscular weakness, loss of weight, and sympathetic nervous system, cardiovascular or gastrointestinal symptoms. 38 C.F.R. § 4.119, Diagnostic Code 7900. Diagnostic Code 7903 pertains to hypothyroidism, which provides a 10 percent rating for hypothyroidism manifested by fatigability, or continuous medication required for control; a 30 percent rating for fatigability, constipation, and mental sluggishness; a 60 percent rating for muscular weakness, mental disturbance, and weight gain; and a 100 percent rating for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia, and sleepiness. 38 C.F.R. § 4.119, Diagnostic Code 7903. Applying the above criteria to the facts of this case, the Board finds that the preponderance of the evidence is against an evaluation in excess of 10 percent for the veteran's Graves' disease. Initially, the Board points out that the veteran's Graves' disease has not been productive of hyperthyroidism while this claim has been pending. Consequently, the Board need only apply the provisions of Diagnostic Code 7903 (hypothyroidism) without consideration of Diagnostic Code 7900 (hyperthyroidism). The Board notes that application of Diagnostic Code 7900 would not result in a rating in excess of 10 percent, as the criteria for the 30 percent evaluation requires manifestation of three symptoms (tachycardia, tremor, and increased pulse pressure or blood pressure), of which the veteran manifests one, tremor. The Board notes that, while paroxysmal tachycardia has been diagnosed, that symptom has been specifically attributed, by medical opinion of record, to the veteran's service-connected mitral prolapse, and has been considered in the veteran's evaluation under Diagnostic Code 7000. Thus, that symptom may not be considered under Diagnostic Code 7900. 38 C.F.R. § 4.14. As noted, a 30 percent evaluation for hypothyroidism requires a showing of fatigability, constipation, and mental sluggishness. The veteran testified at his hearing that he suffered from both mental sluggishness and fatigability. While the veteran's testimony that he becomes tired is certainly credible, the Board notes that the medical evidence of record does not confirm that the veteran has "fatigability" for purposes of evaluation of Graves' disease. For example, the medical examinations reflect that the veteran does not have lid lag. The veteran's assertions that tiredness which precluded further employment as a heavy equipment operator is due to Graves' disease have not been confirmed by the clinical evidence of record. None of the clinical evidence in connection with this claim has shown the veteran to be objectively sluggish or fatigued. In fact, a VA examiner in January 1997 stated that the veteran appeared to move quickly and displayed a normal affect. Moreover, the clinical evidence does not show, nor has the veteran alleged, that he suffers from constipation. Thus, the evidence does not show that the veteran's hypothyroidism meets the criteria for a 30 percent evaluation under Diagnostic Code 7903. The Board observes that the veteran suffers from some form of mental disturbance and that he has gained weight during the pendency of this appeal, both of which are noted in the criteria for a 60 percent evaluation under Diagnostic Code 7903. In particular, the veteran has been treated for depression and anxiety, and his weight appears to have increased from 229 pounds in January 1997 to 252 pounds in June 1999. Nevertheless, no evidence has attributed this weight gain to the veteran's Graves' disease. In addition, the June 1999 VA examination report included the examiner's opinion that only part of the veteran's depression was attributable to hypothyroidism. As such, the Board need not attribute all of the veteran's depression to his Graves' disease. Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of the service- connected condition from a nonservice-connected condition, such signs and symptoms be attributed to the service- connected condition). The Board also emphasizes that the veteran's hypothyroidism appears to be well controlled on medication. For example, an October 1996 VA treatment report noted that the veteran's hypothyroidism was stable. Likewise, the January 1997 VA examination report noted that this condition was well controlled, while the June 1999 VA examination report noted that the veteran had a history of Graves' disease that was clinically euthyroid. Given these findings, the veteran's Graves' disease is most consistent with a 10 percent evaluation under Diagnostic Code 7903. In conclusion, the Board finds that the preponderance of the evidence is against the veteran's claim for an evaluation in excess of 10 percent for his service-connected Graves' disease. Consequently, the doctrine of reasonable doubt need not be considered. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-57. C. Consideration of an extra-schedular evaluation The Board also finds, as did the RO, that the evidence of record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating standards." See 38 C.F.R. § 3.321(b)(1). There is no objective evidence indicating that either service-connected disability at issue has caused marked interference with his earning capacity or employment status (i.e., beyond that contemplated in the assigned ratings), necessitated frequent periods of hospitalization, or otherwise rendered impracticable the application of the regular schedular standards. The record shows that the veteran has been employed as a private investigator, and has been hospitalized for a total of six days during the pendency of these claims. Under these circumstances, the Board determines that further development for an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell, 9 Vet. App. at 239; Shipwash v. Brown, 8 Vet. App. at 227. II. New and Material Evidence The veteran claims that he currently suffers from bilateral hearing loss as a result of noise exposure in service. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R § 3.303(a). Before service connection may be granted for hearing loss, that loss must be of a particular level of severity. For the purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). In this case, the RO denied the veteran's claim of entitlement to service connection for bilateral hearing loss in a November 1991 rating decision. That decision was based on a finding that there was no hearing loss disability for VA purposes. The veteran was notified of that decision and of his appellate rights that same month but failed to seek appellate review within one year of notification. Therefore, that decision is final and is not subject to revision upon the same factual basis. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104(a), 20.302, 20.1103. However, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. See 38 U.S.C.A. § 5108. Reviewing a final decision based on new and material evidence is potentially a three-step process. See Elkins v. West, 12 Vet. App. 209, 214-9 (1999). First, the Board must determine whether the evidence submitted since the prior decision is new and material, which will be discussed below. If "the Board finds that no such evidence has been offered, that is where the analysis must end." Butler v. Brown, 9 Vet. App. 167, 171 (1996). Second, if new and material evidence has been presented, the claim is reopened and must be considered based upon all the evidence of record, to determine whether it is well grounded. See Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995). Finally, if the claim is well grounded, and if VA's duty to assist under 38 U.S.C.A. § 5107(a) has been fulfilled, the Board may evaluate the merits of the claim. See Winters v. West, 12 Vet. App. 203, 206-7 (1999). The question of whether evidence is "new and material" is analyzed under 38 C.F.R. § 3.156(a), and also requires a three-step analysis. The first step requires determining whether the newly presented evidence "bears directly and substantially upon the specific matter under consideration," i.e., whether it is probative of the issue at hand. Cox v. Brown, 5 Vet. App. 95, 98 (1993). Evidence is probative when it "tend[s] to prove, or actually prov[es] an issue." Routen v. Brown, 10 Vet. App. 183, 186 (1997), citing Black's Law Dictionary 1203 (6th ed. 1990). Second, the evidence must be shown to be actually "new," that is, not of record when the last final decision denying the claim was made. See Struck v. Brown, 9 Vet. App. 145, 151 (1996). The third and final question is whether the evidence "is so significant that it must be considered in order to fairly decide the merits of the claim." Hodge v. West, 155 F.3d 1356, 1359 (Fed. Cir. 1998), citing 38 C.F.R. § 3.156(a). This need not mean that the evidence warrants a revision of the prior determination, but is intended to ensure the Board has all potentially relevant evidence before it. See Hodge, 155 F.3d at 1363, citing "Adjudication; Pensions, Compensation, Dependency: New and Material Evidence; Standard Definition," 55 Fed. Reg. 19088, 19089 (1990). New evidence will be presumed credible at this point solely for the purpose of determining whether a claim should be reopened. Justus v. Principi, 3 Vet. App. 510, 513 (1992). If all three tests are satisfied, the claim must be reopened. The November 1991 rating decision which denied service connection for hearing loss is final, as it was the last disposition in which the claim was finally disallowed on any basis. The relevant evidence at that time consisted of the veteran's service medical records and a report of a VA audiological evaluation report performed in October 1991. Consequently, the evidence that must be considered in determining whether the claim may be reopened based on new and material evidence is that added to the record since the November 1991 rating decision. Since that rating decision, the pertinent clinical evidence includes two VA examination reports. A report from a VA ear examination performed in May 1997 included the examiner's statement that the veteran had normal hearing bilaterally through 4000 Hz, and mild to moderate hearing loss at 6000 and 8000 Hz. Normal speech discrimination was demonstrated bilaterally. The Board notes, however, that no audiological findings are associated with this examination report. Therefore, no hearing loss disability for VA purposes can be confirmed by this report. The veteran also submitted a VA audiological evaluation report dated in April 1998. Findings from that evaluation revealed bilateral pure tone thresholds of 5 decibels at the 500, 1000, 2000, and 3000 Hz levels and 20 decibels at the 4000 Hz level, for an average of 9. Speech recognition was 98 percent for the right ear and 94 percent for the left. The Board finds that both of these reports are new, as they were not of record at the time of the November 1991 rating decision. Nevertheless, neither report shows that the veteran has a hearing loss disability for VA purposes, as required under 38 C.F.R. § 3.385. Thus, neither of these reports is probative of the central issue in this case. See 38 C.F.R. § 3.156. For this reason, the Board finds that neither of the reports submitted since the November 1991 rating decision "is so significant that it must be considered in order to fairly decide the merits of the claim." Hodge, 155 F.3d at 1359. The Board has also considered the veteran's own lay statements in support of his claim, including testimony presented at his November 1997 hearing. The Board finds, however, that these statements cannot be deemed material as defined under 38 C.F.R. § 3.156. As discussed above, evidence is probative when it tends to prove, or actually proves, an issue. See Routen, 10 Vet. App. at 186, citing Black's Law Dictionary 1203 (6th ed. 1990). To be material, the evidence also should be so significant that it must be considered in order to fairly decide the merits of the claim. See 38 C.F.R. § 3.156(a). These lay statements fail to meet both of these tests. The Court has held that where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet. App. 492 494-95 (1991. Here, the record does not reflect that the veteran possesses the medical training and expertise necessary to render an opinion as to either the cause or presence of a hearing loss disability. Hence, these statements, unsupported by medical evidence, are neither probative to the central issue in this case nor so significant that they must be considered in order to fairly decide the merits of the claim. As a whole, the evidence received since the November 1991 rating decision, when viewed either alone or in light of all of the evidence of record, does not tend to show that the veteran has a current hearing loss disability for VA purposes, as required under 38 C.F.R. § 3.385. Therefore, it follows that new and material evidence has not been submitted subsequent to the November 1991 rating decision to reopen the claim of entitlement to service connection for bilateral hearing loss. Because the veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen his finally disallowed claim, the benefit-of-the-doubt doctrine may not be applied in this case. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). As the foregoing explains the need for competent evidence demonstrating that he currently suffers from a hearing loss disability for VA purposes, the Board views its discussion as sufficient to inform the veteran of the elements necessary to reopen his claim for service connection for this disability. See Graves v. Brown, 8 Vet. App. 522, 524 (1996). ORDER Subject to the laws and regulations governing the award of monetary benefits, a 60 percent evaluation is granted for mitral valve prolapse for the period from the date of submission of the claim prior to January 12, 1998. An evaluation in excess of 60 percent for mitral valve prolapse is denied. An evaluation in excess of 10 percent for Graves' disease is denied. New and material evidence not having been submitted to reopen a claim for service connection for bilateral hearing loss, the appeal is denied. TRESA M. SCHLECHT Acting Member, Board of Veterans' Appeals