Citation Nr: 0708974 Decision Date: 03/28/07 Archive Date: 04/09/07 DOCKET NO. 02-09 360 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for service-connected post-traumatic stress disorder (PTSD). 2. Entitlement to an initial disability rating in excess of 10 percent for service-connected hypertension. 3. Entitlement to an initial disability rating in excess of 30 percent for service-connected status post triple coronary artery bypass grafting, prior to January 4, 2006. 4. Entitlement to a disability rating in excess of 60 percent for service-connected status post triple coronary artery bypass grafting, from May 1, 2006. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Orfanoudis, Counsel INTRODUCTION The veteran had active service from March 1967 to March 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2001 rating decision of the Montgomery, Alabama, Department of Veterans Affairs (VA), Regional Office (RO), which granted service connection for PTSD and status post triple coronary artery bypass grafting with hypertension. The veteran has appealed the assigned disability ratings for these disabilities. During the pendency of this appeal, by rating action dated in November 2005, the RO increased the disability ratings for the veteran's PTSD and status post triple coronary artery bypass grafting with hypertension, each to 30 percent effective from May 10, 2001. By rating action dated in June 2006, the RO increased the disability rating for the veteran's status post triple coronary artery bypass grafting with hypertension to 100 percent from January 4, 2006, and 30 percent from May 1, 2006. In October 2006, the RO increased the disability rating for the status post triple coronary artery bypass grafting to 60 percent, effective as of May 1, 2006; and awarded a separate disability rating of 10 percent for the veteran's hypertension, effective as of May 10, 2001. FINDINGS OF FACT 1. The veteran's PTSD is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to moderate symptoms; it is not productive of occupational and social impairment with reduced reliability and productivity. 2. The veteran's hypertension is not characterized by diastolic blood pressure of predominantly 110 or more, or systolic blood pressure of predominantly 200 or more. 3. Prior to January 4, 2006, the veteran's status post triple coronary artery bypass grafting was productive of coronary artery disease with symptoms of fatigue and shortness of breath, and an unclear ejection fraction. 4. From May 1, 2006, the veteran has been diagnosed with chronic congestive heart failure. CONCLUSIONS OF LAW 1. The schedular criteria for the assignment of an initial disability rating greater than 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Codes 9411, 9440 (2006). 2. The schedular criteria for the assignment of an initial disability rating greater than 10 percent for hypertension have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2006). 3. The schedular criteria for the assignment of an initial disability rating greater than 30 percent for status post triple coronary artery bypass grafting prior to January 4, 2006, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 4.7, 4.104, Diagnostic Codes 7005, 7017 (2006). 4. The schedular criteria for the assignment of a 100 percent disability rating for status post triple coronary artery bypass grafting from May 1, 2006, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 4.7, 4.104, Diagnostic Codes 7005, 7017 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist VA has specified duties to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. With few exceptions, the regulations implementing this law are applicable to all claims filed on or after the date of enactment, or filed before the date of enactment and not yet final as of that date. Veterans Claims Assistance Act (VCAA); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). In this case, VA's duties have been fulfilled. VA must notify the veteran of evidence and information necessary to substantiate his claim and inform him whether he or VA bears the burden of producing or obtaining that evidence or information. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The veteran was notified of the information necessary to substantiate his increased disability rating claims. The RO sent the veteran letters in May 2002, March 2006, October 2006, and December 2006 in which he was informed of what was required to substantiate his claims and of his and VA's respective duties, i.e., that VA would attempt to get any additional records that he identified as being helpful to his claims. He was also asked to submit evidence and/or information, which would include that in his possession, to the RO. Since the veteran's claims for increased disability ratings for PTSD, hypertension, and status post triple coronary artery bypass grafting, prior to January 4, 2006, were denied by the RO and are also being denied by the Board, as discussed herein, there is no potential effective date or disability rating issue that would warrant additional notice as to those issues. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As to the issue of an increased disability rating for status post triple coronary artery bypass grafting, from May 1, 2006, the Board grants the veteran's claim herein. The RO will be responsible for addressing any notice defect with respect to the rating and effective date elements when effectuating the award. Id. at 473. The Board finds no prejudice to the veteran in proceeding with the issuance of a final disposition in those issues that the Board is presently deciding. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). There is no indication that the outcome of the case has been affected, and the veteran has been provided a meaningful opportunity to participate effectively in the processing of his claims. The content of the subsequent notice provided to the veteran fully complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). The veteran's relevant service, VA and private medical treatment records have been obtained, as discussed below. There is no indication of any additional, relevant records that the RO failed to obtain. Assistance shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The veteran was afforded VA examinations in August 2001, September 2001, December 2003, November 2004, May 2005, November 2005, and July 2006. These examinations were thorough in nature, many based upon a review of the veteran's entire claims file, and provided relevant findings that are deemed to be more than adequate. Under such circumstances, there is no duty to provide another examination or to obtain an additional medical opinion. Id. Accordingly, the requirements of the VCAA have been met by the RO to the extent possible. Having determined that the duty to notify and the duty to assist have been satisfied, the Board turns to an evaluation of the veteran's claims on the merits. Increased Disability Ratings Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, 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. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2006). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2006); Peyton v. Derwinski, 1 Vet. App. 282 (1991). However, there is a distinction between an appeal of an original or initial rating and a claim for an increased rating, and this distinction is important with regard to determining the evidence that can be used to decide whether the original rating on appeal was erroneous. Fenderson v. West, 12 Vet. App. 119, 126 (1999). For example, the rule articulated in Francisco v. Brown, 7 Vet. App. 55, 58 (1994) -- that the present level of the veteran's disability is the primary concern in a claim for an increased rating and that past medical reports should not be given precedence over current medical findings -- does not apply to the assignment of an initial rating for a disability when service connection is awarded for that disability. Fenderson, 12 Vet. App. at 126. Instead, where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson, 12 Vet. App. at 126. If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). PTSD The veteran's service-connected PTSD is currently rated as 30 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2006). Anxiety disorders, which include PTSD, are rated under the criteria set forth in Diagnostic Code 9440. Under diagnostic code provision, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when occupational and social impairment is found with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A maximum 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. It should also be noted that use of terminology such as "moderate" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2005). A VA PTSD examination report dated in July 2001 shows that the veteran reported having worked 11 years in law enforcement, followed by 14 years in the fire department, and was currently working in a corporation as a safety director. He described symptoms including intrusive thoughts, insomnia, irritability, depression, and anxiety. Mental status examination revealed that he was pleasant and cooperative. His psychomotor function was within normal limits, mood was nervous, affect ranged widely, and speech was regular. His memory was fair, and he reported no auditory or visual hallucinations. He reported no suicidal or homicidal ideations, delusions, obsessions, or compulsions. He had no flight of ideas and no thought blocking. He was oriented to time, person, and place. The diagnosis was PTSD of moderate severity. A GAF code of 65 was assigned. A letter from B. Kopyta, M.D., dated in July 2001, shows that the veteran had multiple medical problems, including depression. VA outpatient treatment records dated from July 2001 to March 2002 show intermittent treatment for symptoms associated with PTSD. The veteran described suspiciousness, nightmares, flashbacks, panic attacks, chronic sleep impairment, mild memory loss, anxiety, irritability, and depression. A VA outpatient treatment record dated in September 2001 shows that the veteran reported intrusive thoughts, violent nightmares, flashbacks, irritability, anxiety, low frustration tolerance, and difficulty in situations involving crowds of people. Mental status examination revealed an anxious mood, depressed and anxious affect, and periods of irritability. His thoughts were unremarkable for harmful ideation, plan, or intent, and he had no symptoms of psychosis. The diagnosis was anxiety, not otherwise specified, rule out PTSD. A GAF code of 50 was assigned. In September 2002, the veteran testified at a personal hearing over which a hearing officer of the RO presided. The veteran reported that he received treatment for his PTSD through VA, attending group sessions. He described experiencing nightmares and problems with crowds. He also noted having problems with his temper and anger. He added that he was employed at a job that allowed him to leave when he felt it necessary. A VA PTSD examination report dated in December 2003 shows that the veteran reported subjective complaints of nightmares every night, problems with depression, feelings of detachment, and exaggerated startle response. He added that he had no friends, but that he got along well with co- workers. It was noted in the examination report that he was a safety director for a grocery distributing center. Mental status examination revealed that he was cooperative, anxious, and alert and oriented times four with good eye contact. His affect was anxious, and his thought process was coherent with no flight of ideas or looseness of association. Thought content was negative for suicidal or homicidal ideations. There was no overt psychosis seen. Insight and judgment were adequate. The diagnosis was chronic PTSD. A GAF code of 51 was assigned. VA outpatient treatment records dated from March 2003 to November 2005 show continued intermittent treatment for symptoms associated with PTSD. In May 2004, he was assigned a GAF of 55 and in November 2004 a GAF of 60. A VA outpatient treatment record dated in May 2005, shows that the veteran denied any acute problems, adding that his psychotropic medications were working fairly well. He noted that he was sleeping pretty well. Mental status examination revealed that the veteran was cooperative with good eye contact. He interacted appropriately and exhibited no abnormal mannerisms. His speech was clear, coherent, appropriate, and goal directed. His mood appeared fairly euthymic, and affect was full range and congruent. His thought process was significant for absence of any overt lethal ideation, paranoia, or delusions. There were no perceptual abnormalities in terms of any hallucinations. Cognitively he was alert and oriented times three. Short and long term memory was intact. Concentration, judgment, and attention span were fairly good and intact. There was no evidence of any language or gait abnormalities, and no evidence of any abnormal voluntary or involuntary motor movements. Fund of general knowledge was good. The diagnosis was PTSD, depressive disorder, and rule out obstructive sleep apnea. A GAF of 65 was assigned. A VA PTSD screening report dated in July 2005, shows that the veteran indicated that in the preceding month, he had not been bothered by repeated memories, thoughts or images of one or more of the stressful events experienced previously. He also denied feeling distant or cut off from other people, or being "super alert," watchful, or on guard in the preceding month. A VA outpatient treatment record dated in November 2005, shows that the veteran was cooperative with good eye contact. His speech was clear, coherent, appropriate, and goal directed. His mood appeared mildly anxious, and affect was congruent. His thought process was significant for absence of any overt lethal ideation, paranoia, or delusions. There were no perceptual abnormalities in terms of any audio or visual hallucinations. Cognitively he was alert and oriented times three. Short and long term memory was intact, as was judgment. A GAF of 60 to 65 was assigned. A VA outpatient treatment record dated in March 2006 shows that the veteran was seen in the mental health clinic for follow up of his PTSD. His mood appeared somewhat anxious, and his thought process was significant for absence of any overt lethal ideation, paranoia or delusions. A GAF of 65 was assigned. A VA PTSD examination report dated in July 2006 shows that the veteran's affect was full, and his mood dysphoric. He was oriented to person, time, and place. His thought process and content were unremarkable, and he had no delusions or hallucinations. He did not exhibit inappropriate, obsessive, or ritualistic behavior. He described experiencing panic attacks when in a crowd. He had no homicidal thoughts, but did have fleeting suicidal thoughts on occasion due to pain. He had good impulse control with no episodes of violence. Remote and immediate memory were normal. Recent memory was moderately impaired. He had nightly nightmares, wherein he would wake up in a sweat. He would no longer sleep in the same bed with is wife. The diagnosis was PTSD, depressive disorder, and panic disorder. The examiner explained that the depressive disorder was likely due to the veteran's chronic health problems. The panic disorder onset was co- morbid with PTSD symptoms, suggesting the two disorders were highly related. A GAF of 54 was assigned. The examiner opined that the PTSD signs and symptoms were transient or mild and would decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. A VA outpatient treatment record dated in September 2006 shows that the veteran reported having had left elbow and right shoulder surgery, and that he had been depressed thereafter, that he felt better. He added that he felt tired at the end of his work day. His mood appeared euthymic, but there were no perceptual abnormalities. A GAF of 70 was assigned. In examining the evidence in this case, the Board concludes that the findings do not approximate the criteria for the assignment of a higher disability rating. The VA treatment records set forth above reveal that the veteran's overall symptoms were generally of moderate severity, and that he was able to function relatively well in his social and work environment. Although the veteran was provided a GAF of 50 in September 2001, a GAF of 51 in December 2003, a GAF of 55 in March 2004, and a GAF of 54 in July 2006 which would suggest moderate difficulty in social, occupational, or school functioning, he was provided a GAF of 65 in July 2001, a GAF of 60 in November 2004, a GAF of 65 in May 2005, a GAF of 60 to 65 in November 2005, a GAF of 65 in March 2006, and a GAF of 70 in September 2006. A GAF of 61 to 70 is indicative of some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. The GAF of 70 suggests some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. The VA examiners have consistently reported that the veteran's thought process and content were unremarkable, and he had no delusions or hallucinations. He did not exhibit inappropriate, obsessive, or ritualistic behavior. He had no homicidal thoughts, and exhibited good impulse control with no episodes of violence. Remote and immediate memory were normal, though recent memory was moderately impaired. Although the veteran reported difficulty sleeping, episodes of depression, a desire to be alone, and some difficulty with anger, he has reported and is noted to be able to continue with his employment and had good relations with his colleagues. He was also still able to maintain a personal relationship with his spouse. This type of symptomatology is already contemplated by the currently assigned 30 percent disability rating. The competent medical evidence of record does not establish flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. As such, the schedular criteria for a 50 percent disability rating have not been met. The veteran is competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must only consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). To the extent that the veteran argues or suggests that the clinical data supports an increased evaluation or that the rating criteria should not be employed, he is not competent to make such an assertion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992) (holding that a witness must be competent in order for his statements or testimony to be probative as to the facts under consideration). The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher disability rating. The preponderance of the evidence is against a disability rating higher than 30 percent for the veteran's PTSD. Thus, the benefit-of-the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hypertension The veteran's service-connected hypertension is currently rated 10 percent disabling under Diagnostic Code 7101 which provides the criteria for evaluating hypertensive vascular disease (hypertension and isolated systolic hypertension). Under this diagnostic code provision, a 10 percent rating is assigned for hypertension when diastolic pressure is predominately 100 or more; or when systolic pressure is predominantly 160 or more; or when there is a history of diastolic pressure predominantly 100 or more and continuous medication for control is required. A 20 percent rating is assigned when diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. A 40 percent rating is assigned when diastolic pressure is predominantly 120 or more. A maximum 60 percent rating is assigned when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2006). As indicated above, to receive the next higher rating of 20 percent, the veteran's diastolic pressure, i.e., the bottom number of his blood pressure reading, must be predominantly 110 or more, or his systolic pressure, i.e., the top number of his blood pressure reading, must be predominantly 200 or more. The evidence in this case demonstrates that the veteran's diastolic pressure is predominantly below 110, and his systolic pressure is predominantly below 200, and thus his hypertension is no more than 10 percent disabling. VA and private medical treatment records dated from August 2000 to August 2006 show that the veteran's blood pressure had been read on several occasions. Specifically, in August 200, the veteran's blood pressure was 122/88. In April 2001, blood pressure was 122/82; in June 2001, it was 158/80; in August 2001 it was 132/83; in December 2001, it was 144/86; in January 2002, it was 144/89; in February 2002, it was 138/80; in May 2002, it was 132/90; in June 2002, it was 126/83; in September 2002, it was 131/84; and in November 2002, it was 130/80. In June 2003, blood pressure was 135/81; in October 2003, it was 140/78; in December 2003, it was 128/78; in January 2004, it was 117/70; in May 2004, it was 120/64; and in December 2004, it was 124/62. In July 2005, blood pressure was 132/78; in October 2005, it was 130/68; in November 2005 it was 130/68; in February 2006 it was 113/75; in July 2006 it was 128/58; and in August 2006, it was 126/75. The treatment records show the veteran continued to take medication for control of his hypertension. The veteran's hypertension is not shown to be more than 10 percent disabling. The medical reports show systolic readings which have been entirely below 200 and diastolic readings which have been entirely below 110. Hence, the Board finds that the currently assigned evaluation of 10 percent is appropriate. The Board has considered the veteran's assertions that he is entitled to a higher disability rating for his service- connected hypertension. However, as noted, the Board is limited to those factors that are included in the rating criteria provided by regulations for rating that disability. To do otherwise would be error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). The pertinent criteria for rating hypertension in this case involves an assessment of the predominant systolic and diastolic pressure readings of record. See 38 C.F.R. § 4.104, Diagnostic Code 7101. Accordingly, the documented blood pressure readings of record were the only medical findings which could be considered in concluding that an increased disability rating for hypertension is not appropriate. The preponderance of the evidence is against the claim for a disability rating greater than 10 percent for the service- connected hypertension. Thus, the benefit-of-the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 49 (1990). Status post triple coronary artery bypass grafting, prior to January 4, 2006 The veteran's service-connected status post triple coronary artery bypass grafting is rated as 30 percent disabling prior to January 4, 2006, pursuant to Diagnostic Codes 7005 for arteriosclerotic heart disease and 7017 for coronary bypass surgery. 38 C.F.R. § 4.104, Diagnostic Codes 7005, 7017 (2006). Pursuant to both of the above Diagnostic Codes, a 30 percent disability rating is warranted where the evidence reveals more than one episode of acute congestive heart failure in the past year, or; workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent disability rating is warranted where the evidence reveals more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent disability rating is warranted where the evidence reveals chronic congestive heart failure, or a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or there is left ventricular dysfunction with an ejection fraction of less than 30 percent. Additionally, pursuant to Diagnostic Code 7017, a 100 percent is also warranted for three months following hospital admission for coronary artery bypass surgery. Note (2) to 38 C.F.R. § 4.104 indicates that 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 of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Private medical records dated in May 2000 reveal a history of the veteran having undergone a triple coronary artery bypass graft in 1995. He was said to be currently stable on therapy and was to continue with regular follow-up visits. A private medical record from Dr. Kopyta dated in July 2001 shows that the veteran was said to have coronary artery disease, hypertriglyceridemia, and dyslipidemia. Private medical records from Gadsden Regional Medical Center dated in August 2001 show that the veteran reported that he felt all right. He reported no dyspnea or angina. There were no murmurs noted, and there was no edema. Pulses were positive. He was reported to be stable. A VA examination report dated in August 2001 shows the veteran reported no further cardiac symptoms. Physical examination revealed that he weighed 285 pounds. His chest was clear to percussion and auscultation. The diagnosis was post operative status coronary heart disease and triple coronary bypass surgery. During his September 2002 RO hearing, the veteran reported that he had a nuclear stress test done along with heart catheterization and the 1995 bypass surgery. He added that he was taking medication, that he would get tired and fatigued easily, and that he would have some shortness of breath requiring rest. A private medical record from Dr. Kopyta dated in August 2002 shows that the veteran was said to have coronary artery disease, ischemic cardiomyopathy, and congestive heart failure. A private medical record from P. M. Szeto. M.D., dated in January 2003 reveals that the veteran was said to have been under his care since 1995, for a history of coronary artery disease treated with bypass surgery. He added that the veteran had developed congestive heart failure due to cardiomyopathy. He was said to be on medical therapy including Coreg 6.25 milligrams twice a day. A VA examination report dated in December 2003 shows that the veteran reported being troubled by fatigue. He added that he had been taking Coreg, which was said to be a congestive heart failure medication. He noted that he had been told his ejection fraction was 51 percent. The examiner indicated that an echocardiogram would be ordered to verify ejection fraction. Cardiac examination revealed that a soft S1 and S2 rhythm heard. There were no murmurs or gallops. The impression, in pertinent part, was coronary artery disease with unclear ejection fraction. A VA cardiology consult dated in December 2003 shows that left ventricular function was normal with segmental abnormalities. Right heart function was also normal. A poor acoustic window was noted. VA outpatient treatment records dated from May 2005 to January 2006 reveal that the veteran reported no chest pain or palpitations. There was no shortness of breath, cough, or congestion. His heart rate was 78 beats per minute. The treatment records show coronary artery disease, hypertension, and blood pressure, stable. The Board has reviewed the competent evidence of record and finds no support for assignment of the next higher 60 percent disability rating under any cardiac diagnostic code provision prior to January 4, 2006. There is no demonstration of more than one episode of acute congestive heart failure in the preceding years. Although Dr. Szeto had indicated in January 2003 that the veteran had developed congestive heart failure due to cardiomyopathy, there was no indication that it was chronic and he was said to be on medical therapy. The various VA examination reports of record do not provide a diagnosis of chronic congestive heart failure. The competent evidence of record also fails to show that a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope. In fact, during the December 2003 VA examination, the veteran reported that he had been told his ejection fraction was at 51 percent. The competent evidence of record fails to reveal left ventricular dysfunction with an ejection fraction of 30 to 50 percent. To the contrary, the December 2003 cardiology consult showed that left and right ventricular functions were normal. The Board has considered the veteran's complaints of significant symptomatology related to his coronary artery disease. During his September 2002 RO hearing he described becoming fatigued easily, and having some shortness of breath. However, the Board finds that his disability picture prior to January 4, 2006 is appropriately reflected by the 30 percent disability rating currently in effect. No other diagnostic code provisions are applicable to the veteran's heart disorder. In conclusion, the evidence of record fails to support the veteran's claim of entitlement to a rating in excess of 30 percent for the veteran's status post triple coronary artery bypass grafting, prior to January 4, 2006. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Status post triple coronary artery bypass grafting, from May 1, 2006 Private medical records from the Gadsden Regional Medical Center dated in January 2006 show that the veteran was admitted due to unstable angina. He then underwent an additional triple coronary artery bypass graft operation to correct the prior graft. As a result, the veteran was awarded a 100 percent disability rating effective from January 4, 2006 to May 1, 2006. The evaluation of 100 percent was assigned for three months following hospital admission for coronary bypass surgery. A VA examination report dated in August 2006 shows that the veteran reported a history of chronic congestive heart failure since 2004 and a history of hypertensive heart disease since 1968. A pharmacological stress test revealed post-stress ejection fraction was 42 percent. The rest ejection fraction was 46 percent. The diagnosis was coronary artery disease, class III angina symptoms; congestive heart failure; and hypertension. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. However, under the "benefit-of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). As indicated above, pursuant to both Diagnostic Codes 7005 and 7017, a 100 percent disability rating is warranted where the evidence reveals chronic congestive heart failure, or a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or there is left ventricular dysfunction with an ejection fraction of less than 30 percent. As the veteran has been diagnosed with chronic congestive heart failure, the Board finds that the schedular criteria have been met, and a 100 percent disability rating is warranted, effective from May 1, 2006. As of that point, while the veteran's cardiac disorder may have been subject to minor variances in its severity, further medical inquiry is not required to ascertain that congestive heart failure is near constant. Because the mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. In this matter, the Board is of the opinion that this point has been attained. Because a state of relative equipoise has been reached in this case, the benefit of the doubt rule will therefore be applied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown, 5 Vet. App. 413, 421 (1993). Although the veteran provided a history of congestive heart failure dating back to 2004, there is no evidence of record to set forth the onset at that time, and the examiner did not provide a basis for this statement. A medical diagnosis is only as credible as the history on which it was based. See Reonal v. Brown, 5 Vet. App. 458, 460 (1993); see also Elkins v. Brown, 5 Vet. App. 474, 478 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993) [ a diagnosis "can be no better than the facts alleged by the appellant."]. The medical evidence of record does not establish a diagnosis of chronic congestive heart failure prior to January 4, 2006. As such, the effective date of the effective date of the award of the 100 percent disability rating is to be from May 1, 2006. ORDER Entitlement to an initial disability rating in excess of 30 percent for service-connected PTSD is denied. Entitlement to an initial disability rating in excess of 10 percent for service-connected hypertension is denied. Entitlement to an initial disability rating in excess of 30 percent for service-connected status post triple coronary artery bypass grafting, prior to January 4, 2006, is denied. A disability rating of 100 percent for service-connected status post triple coronary artery bypass grafting, from May 1, 2006, is granted subject to controlling regulations governing the payment of monetary benefits. ____________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs