Citation Nr: 0014807 Decision Date: 06/06/00 Archive Date: 06/15/00 DOCKET NO. 98-08 915A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased disability rating for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, currently rated as 60 percent disabling. 2. Entitlement to an increased disability rating for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, evaluated as 60 percent prior to December 18, 1997. 3. Entitlement to an increased disability rating for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, evaluated as 30 percent disabling prior to April 10, 1997. 4. Entitlement to a temporary total rating under the provisions of 38 C.F.R. § 4.29 for hospitalization from August 11, 1999 to September 8, 1999. 5. Entitlement to a total disability rating based on individual unemployability, due to service connected disabilities. REPRESENTATION Appellant represented by: Bobby Vance, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. L. Wight, Associate Counsel INTRODUCTION The veteran served on active duty from November 1961 to June 1965. This case comes before the Board of Veterans' Appeals (Board) by means of a May 1995 rating decision rendered by the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA) wherein service connection for a cardiovascular disability as secondary to rheumatic fever was denied. The veteran appealed this decision. During the pendency of this appeal, a March 1997 rating action established service connection for a valvular disability with a history of rheumatic fever and rheumatic heart disease and a 30 percent disability evaluated was assigned. The veteran appealed this decision. The veteran also appeals a August 1999 rating action wherein a total disability evaluation based on individual unemployability was denied and a November 1999 rating action wherein a temporary total evaluation because of hospital treatment in excess of 21 days for a service-connected condition was denied. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's claims has been developed. 2. In March 1994, the veteran filed a claim for service connection for a cardiovascular disability, as secondary to rheumatic fever and rheumatic heart disease. 3. During the pendency of the veteran's appeal, the diagnostic criteria for the rating of cardiovascular and heart disabilities were modified effective January 18, 1998. 4. With respect to his claim that his service connected cardiovascular disability is more severe than currently evaluated, the Board finds that the old and new criteria are equally favorable to the veteran. 5. The veteran is currently unemployable due to his service connected cardiovascular disability secondary to rheumatic fever and rheumatic heart disease. 6. The veteran's cardiovascular disability is currently manifested by complaints of chest pain, fatigue, and dyspnea with objective findings of 3-5 METs. 7. The evidence shows that the veteran was unemployable prior to December 18, 1997 due as a result of his valvular disease. 8. Prior to April 10, 1997, the veteran's cardiovascular disease was manifested by subject complaints of chest pain and objective findings of a systolic heart murmur. 9. Prior to April 10, 1997, the evidence did not show that the veteran's service connected cardiovascular disease was manifested by an enlarged heart; severe dyspnea on exertion; elevation of systolic blood pressure; paroxysmal auricular fibrillation or flutter; paroxysmal tachycardia; or preclusion of more than light manual labor. 10. The appellant's period of VA hospitalization from August 11, 1999 to September 8, 1999, included treatment and evaluation of his service-connected cardiovascular disability. CONCLUSIONS OF LAW 1. The criteria for an increased schedular disability rating of 100 percent for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.104, Diagnostic Codes 7000-7123 (1997 & 1999). 2. The criteria for an increased schedular disability rating of 100 percent for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, prior to December 18, 1997, are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1997); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.104, Diagnostic Codes 7000-7123 (1997 & 1999). 3. The criteria for an increased schedular disability for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, rated as 30 percent disabling prior to April 10, 1997, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1997); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.104, Diagnostic Codes 7000-7123 (1997). 4. The criteria for establishing a total disability rating based on individual unemployability (TDIU) are not met. 38 C.F.R. § 4.16 (1999). 5. The criteria for a temporary total rating for a period of VA hospitalization from August 11, 1999 to September 8, 1999, have been met. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999); 38 C.F.R. § 4.29 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The threshold question that must be resolved with regard to each claim is whether the appellant has presented evidence that each claim is well grounded; that is, that each claim is plausible. If he has not, the appeal fails as to that claim, and the Board is under no duty to assist him in any further development of that claim, since such development would be futile. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); Murphy v. Derwinski, 1 Vet. App. 78 (1990). I. Claims for Increased Disability Ratings Generally, claims for increased evaluations are considered to be well grounded. A claim that a condition has become more severe is well grounded where the condition was previously service connected and rated, and the claimant subsequently asserts that a higher rating is justified due to an increase in severity since the original rating. Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992). Accordingly, the Board finds that the veteran's claims for increased disability ratings are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); that is, he has presented claims that are plausible. He has not alleged that any records of probative value that may be obtained and which have not already been associated with his claims folder are available. The Board accordingly finds that the duty to assist him, as mandated by 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999), has been satisfied. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (1999). The percentage ratings in the Schedule for Rating Disabilities represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1 (1999). Moreover, each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (1999). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (1999). It should also be noted that use of terminology such as "mild" or "moderate" by VA examiners and others, 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 (1999). Service connection for a valvular disability was denied by means of a May 1995 rating action. The veteran appealed this decision. During the pendency of his appeal, service connection for a valvular disability with a history of rheumatic fever and rheumatic heart disease was established by means of a March 1997 rating action as post service medical records indicate that the veteran's cardiovascular disability was etiologically related to an inservice rheumatic fever. The evidence also showed that the veteran underwent valve replacement and coronary artery bypass grafting on April 4, 1994. A 100 percent disability rating was assigned effective March 25, 1994, the date of claim on appeal. A 30 percent disability evaluation was assigned effective June 1, 1995, as such rating is the minimum rating assigned following heart valve replacement. The veteran appealed the assignment of this disability rating. By means of an April 1998 rating decision, the disability evaluation for the veteran's cardiovascular disability was increased to 60 percent disabling, effective April 10, 1997. Additionally, a 100 percent disability rating was assigned from December 19, 1997 to April 1, 1998, due to hospitalization over 21 days; and a 100 percent disability rating was also assigned from April 1, 1998 to February 28, 1999 based on surgical or other treatment necessitating convalescence. Effective March 1, 1999, the veteran's cardiovascular disability was increased to 60 percent disabling. Diseases of the heart are currently rated under Diagnostic Codes 7000 to 7123 of the Schedule. 38 C.F.R. § 4.104 (1999). The veteran's current disability may be evaluated under Diagnostic Codes 7000, 7016, or 7017. (The Board notes that the relevant rating criteria are the same under these three diagnostic codes.) Under these criteria a 30 percent disability rating is appropriate for a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent disability rating contemplates more than one episode of acute congestive heart failure in the past year; a workload of greater than 3 but no greater than 5 METs resulting 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 appropriate for chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. During the pendency of this appeal, the schedular criteria for evaluating cardiovascular disabilities were modified. Under the criteria effective prior to January 12, 1998, a 30 percent disability evaluation is warranted for inactive rheumatic heart disease from the termination of an established service episode of rheumatic fever, or its subsequent recurrence with cardiac manifestations during the episode or recurrence for 3 years; or a diastolic murmur with characteristic EKG manifestation or definitely enlarged heart. A 60 percent disability rating contemplates definite heart enlargement; severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; or preclusion of more than light manual labor. A 100 percent disability evaluation is appropriate for definite enlargement of the heart clinically confirmed by roentgenogram; dyspnea on slight exertion; rales, pretibial pitting at end of day or other definite signs of beginning congestive failure; or preclusion of more than sedentary employment. 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997). In addition, prior to January 12, 1998, Diagnostic Code 7016 provides for a 100 percent disability rating for one year following implantation of a prosthetic heart valve; thereafter, rated as rheumatic heart disease with a minimum rating of 30 percent. Similarly, Diagnostic Code 7017 provides for a 100 percent disability rating for one year following coronary artery bypass surgery; thereafter, rated as arteriosclerotic heart disease with a minimum rating of 30 percent. Under Diagnostic Code 7005 arteriosclerotic heart disease is rated 30 percent disabling following typical coronary occlusion or thrombosis; or with history of substantiated anginal attack with ordinary manual labor feasible. A 60 percent disability rating is warranted following a typical history of acute coronary occlusion or thrombosis; or with history of substantiated repeated anginal attacks with more than light manual labor not feasible. A 100 percent disability rating is warranted during and for 6 months following acute illness from coronary occlusion or thrombosis, with circulatory shock, etc. A 100 percent disability rating is also warranted for arteriosclerotic heart disease after 6 months, with chronic residual findings of congestive heart failure or angina on moderate exertion or preclusion of more than sedentary employment. 38 C.F.R. § 4.104 (1997). The United States Court of Appeals for Veterans Claims, formerly the United States Court of Veterans Appeals, (Court) has held that for the purpose of appeals, where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant should be applied unless provided otherwise by statute. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). Similarly, VA General Counsel has held that when a provision of the Rating Schedule is amended while a claim for an increased rating under that provision is pending, the Board should first determine whether the amended regulation is more favorable to the claimant. VAOPGCPREC 3-00 (April 10, 2000). The Board notes that it may be necessary to separately apply the pre-amendment and post-amendment version of the regulation to the facts of the case in order to determine which provision is more favorable to the appellant, unless it is clear from a facial comparison of both versions that one version is more favorable. Id. VA Adjudication Manual, M21-1, Part VI, Chapter 5, paragraph 11.18f(2) (August 26, 1996) (hereinafter "M21-1, para. 11.18f(2)") states that "if verified rheumatic heart disease has been demonstrated, the effect of subsequent onset of hypertensive or arteriosclerotic heart disease which may also produce heart muscle changes and congestive failure cannot be satisfactorily dissociated from the rheumatic changes." The combined cardiac disability is to be evaluated as one entity under the service-connected rheumatic heart disease code. Recently, the VA General Counsel has determined that this provision of VA Manual M21-1 is substantive and binding on the Board. VAOPGPREC 6-2000 (May 19, 2000). A. Increased Rating greater than 60 percent In the present case, the most recent medical evidence shows that the veteran is currently precluded from working due to his cardiovascular disability. A October 1997 VA outpatient treatment record indicates that while the veteran has pulmonary disabilities, the limiting factor in his ability to return to work as a pipe fitter is not his lungs, but the chronic anti-coagulation required for his prosthetic heart valve. The VA physician stated that the veteran should not work in any environment where he is at risk for even mild physical trauma. Similarly, a November 1997 statement from Dr. William L. Holman indicates that, because of the veteran's chronic need for anti-coagulation and sternal instability, he is not physically able to do any type of work in the work force and should be considered permanently disabled. An April 1999 VA heart examination report indicates that the veteran complained of daily chest pain. He takes from 1-7 nitroglycerin daily; however, his use had increased recently. He indicated that he develops chest pain if he walks too fast and that he can only walk 50-60 yards before he is limited due to leg pain, chest pain, and shortness of breath. He could not exercise due to chest pain. While he did not have a history of dizziness or syncope, he complained of extreme fatigue, lack of energy, and dyspnea. Cardiac examination revealed a regular rate with crisp valve sounds, nor murmur, rub or gallop. PMI was not displaced and his precordium was not hyperactive. He had a well-healed sternal scar and right thoracotomy scar. There was no peripheral edema. A diagnosis of rheumatic valvular heart disease, status post aortic valve replacement, status post mitral valve replacement, status post myocardial infarction, with history of hypertension (3-5 METS) was rendered. In November 1999, a VA physician reviewed the veteran's claims folder and medical records. The examiner concluded that the veteran was presently unemployable; however, the examiner opined that this unemployability was not related to valvular disease, but rather to coronary artery disease. At the time the veteran was hospitalized in the intensive care unit and on a respiratory secondary to heart condition related to the arterial supply to the heart rather than to his valves. The Board notes that VA Adjudication Manual, M21-1, Part VI, Chapter 5, paragraph 11.18f(2) (August 26, 1996) (VA Manual M21-1) states that "if verified rheumatic heart disease has been demonstrated, the effect of subsequent onset of hypertensive or arteriosclerotic heart disease which may also produce heart muscle changes and congestive failure cannot be satisfactorily dissociated from the rheumatic changes." The combined cardiac disability is to be evaluated as one entity under the service-connected rheumatic heart disease code. Recently, the VA General Counsel has determined that this provision of VA Manual M21-1 is substantive and binding on the Board. VAOPGPREC 6-2000 (May 19, 2000). Accordingly, the Board finds that, giving the veteran the benefit of the doubt, it is prudent to evaluate his cardiac disability as one entity. After a review of both the rating criteria currently in effect and the rating criteria in effect prior to January 12, 1998, the Board finds that both sets of criteria are equally favorable to the veteran. With respect to the old criteria, a 100 percent disability rating is warranted for rheumatic heart disease with preclusion of more than sedentary employment. As indicated above, the evidence shows that the veteran was unable to work due to his cardiovascular condition and was thus unable was precluded from even sedentary employment. Accordingly, a 100 percent disability rating is currently warranted based on the old criteria. Likewise, a 100 percent disability rating is currently warranted under the new rating criteria as the evidence shows a workload of 3 METs resulting in dyspnea, fatigue and dizziness. Accordingly, the preponderance of the evidence is for an increased disability rating of 100 percent, but no greater, for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease disability. Accordingly, a 100 percent disability rating is granted, as the diagnostic criteria for an increased rating for this disability are satisfied. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.104, Diagnostic Codes 7000-7123 (1997 & 1999). B. Increased Rating greater than 60 percent prior to December 18, 1997 With respect to this claim for an increased rating, as the aforementioned changes in the diagnostic criteria were established subsequent to the time period in question, the Board will consider this claim based on the criteria in effect prior to January 12, 1998. After a review of the evidence, the Board finds that that the veteran's contentions are supported by the evidence and that an increased disability is, therefore, warranted. As stated previously, an October 1997 VA outpatient treatment record indicates that while the veteran has pulmonary disabilities, the limiting factor in his ability to return to work as a pipe fitter is not his lungs, but the chronic anti- coagulation required for his prosthetic heart valve. The VA physician stated that the veteran should not work in any environment where he is at risk for even mild physical trauma. Similarly, a November 1997 statement from Dr. William L. Holman indicates that because of the veteran's chronic need for anti-coagulation and sternal instability, he is not physically able to do any type of work in the work force and should be considered permanently disabled. Accordingly, as the evidence shows that the veteran was unemployable due to his chronic need for anti-coagulation medication and more than sedentary employment was precluded as a result of his service connected cardiovascular disability, the Board finds that the criteria for a disability rating of 100 percent, but no greater, are met for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease disability, prior to December 18, 1997. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1997); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.104, Diagnostic Codes 7000-7123 (1997). C. Increased Rating Greater than 30 Percent Prior to April 10, 1997 With respect to this claim for an increased disability rating greater than 30 percent, prior to April 10, 1997, as the aforementioned changes in the diagnostic criteria were established subsequent to the time period in question, the Board will consider this claim based on the criteria in effect prior to January 12, 1998. After a review of the evidence, the Board finds that that the veteran's contentions are not supported by the evidence and that an increased disability is, therefore, not warranted. In March 1994, the veteran underwent a right and left heart catheterization with coronary angiography. The VA operation report indicates that the veteran had near critical aortic valve stenosis and single vessel coronary artery disease. The hospital summary shows that the veteran was hospitalized from March 1994 to April 1994. The veteran reported chest discomforted described as a heaviness with less than 15 minutes duration that is relieved by rest. Physical examination revealed a regular heart rate and rhythm. The veteran had a III/VI systolic ejection murmur and a mild diastolic rumble with radiation of the murmur to the left axilla and to the carotids bilaterally. His pulses were 2+ and equal throughout. There was no cyanosis present and the point of maximal intensity was normal. Similarly there was no thrill detected. Diagnoses of rheumatic heart disease, hypertension, and coronary artery disease were rendered. In April 1994, the veteran underwent an aortic valve replacement and coronary artery bypass grafting. He tolerated the surgery well and had a normal convalescence prior to his hospital discharge. VA outpatient treatment records from April 1994 to July 1994 indicate that the veteran received postoperative follow-up treatment. A July 1994 record shows that his valve sounds were "O.K." He was doing well and had no cardiovascular complaints. In July 1994, the veteran was afforded a VA diseases of arteries/veins examination. The examination report indicates that the veteran reported a seven to eight year history of his legs giving out and hurting after going up ten to fifteen stairs. The examiner found mild peripheral vascular disease with no history of an acute embolic episode and no history of known atrial fibrillation, both of which could contribute to the likelihood of artery blockage caused by rheumatic fever. A July 1994 VA disease of the heart examination report indicated that the veteran reported a history of rheumatic fever during active service in December 1961 or 1962. He complained of pressure in his chest especially on exertion. He also reported three episodes of rapid heartbeat since his prior heart surgery. Cardiac examination revealed a regular rate with a crisp heart valve sounds. There was no apparent murmur or gallop. His PMI was not displaced and his precordium was not hyperactive. There was no peripheral edema. There was a well-healed 22 cm sternal scar and a donor scar down his left leg medially. His lungs were clear to auscultation and percussion without rales, rhonchi, or wheezes. An EKG was within normal limits and a chest x-ray revealed that his heart was not enlarged. No acute pulmonary infiltrates were seen. In additional a complete blood count was completely within normal limits. Electrolyte and renal function were normal with the exception of a slight elevated chloride of 114. Cardiac ECHO revealed aortic valve replacement, normal left ventricular systolic function, mild mitral regurgitations and moderate to severe aortic insufficiency. Diagnoses of a history of rheumatic fever and status post valve replacement and one coronary artery bypass for coronary artery disease were rendered. The examiner opined that the veteran's coronary artery disease and peripheral vascular disease were not caused by his rheumatic fever. A July 1994 VA radiology report shows the veteran's heart was not enlarged. There was not evidence of acute pulmonary infiltrates. In August 1994, the veteran was seen for a second opinion relative to his prior VA examination. The veteran's temperature was recorded as afebrile. His pulse was 74 and regular and his respiratory rate was 14. His blood pressure was 130/70. He was described as a well-developed, well- nourished man who was in no apparent distress. He was oriented and cooperative. Examination of his heart found that his PMI was not displaced. His S1-S2 was normal with a physiologic splitting of S2. He had a grade 1/6 systolic ejection murmur in the aortic area. There was no diastolic murmur and no gallop or rub. His pulses were described as full and synchronous except in both legs where the pulses were faintly palpable below the femorals. An August 1994 VA radiology report indicates that the veteran's heart was within "range of normal size." An impression of bilateral chronic obstructive pulmonary disease was noted. In January 1995, the veteran underwent a dental restoration at a VAMC. The hospitalization records indicate that he had a "stable heart, lobe dry." His heart had a normal rhythm with a crisp prosthetic click. He also had a grade 2/6 systolic murmur at the apex. A February 1995 VA medical record shows that the veteran was seen with complaints of a one week history of sharp pain in his left chest with radiation down his left arm. His cardiovascular system displayed a normal heart rhythm with a systolic ejection murmur. There was no aortic regurgitation and normal valve sounds. His chest was nontender and there was no edema. A May 1995 follow-up VA outpatient treatment record shows that the veteran had "no real angina." He had good valve clicks with no congestive heart failure. A January 1996 letter from Dr. William L. Holman, a private physician, indicates that the veteran underwent aortic valve replacement. Dr. Holman opined that the veteran's previous attacks of rheumatic fever are related to his aortic valve disease and that his rheumatic disease injured both his mitral and aortic valves. From April to May 1994, the veteran was hospitalized at a VAMC for sinus surgery. The discharge summary indicates that the veteran's heart had a regular rate and rhythm with evidence of mechanical valve clicks. The remainder of the examination was unremarkable. A VAMC discharge summary covering a period of hospitalization from July 1996 to September 1996 indicates that the veteran was hospitalized complaining of a four day history of fever and chills. On examination, his heart displayed an "aortic click." A CT of the chest showed a possible hematoma versus an abscess in the right upper lobe located in the general area wherein a chest tube was placed. The veteran remained afebrile during his hospital stay and had no respiratory distress. A primary diagnosis of ehrlichiosis with acute respiratory stress syndrome and sepsis was rendered. Additional diagnoses included rheumatic heart disease, chronic sinusitis, chronic obstructive pulmonary disease, hypertension, urinary tract infection, foot neuropathy, and anemia were also rendered. The report of an October 1996, VA chest CT scan indicates that a previously noted infiltrate in the left lower lobe had almost completely cleared with minimal residual changes persisting. Similarly, an infiltrate in the right lower lung anteriorly also appeared less prominent. The examination report is silent for any cardiovascular pathology. In November 1996, the veteran was afforded a personal hearing before a regional office hearing representative. The veteran stated that he had a rheumatic fever during his active military service. He indicated that he underwent heart surgery to correct problems that his doctor had told him were related to his inservice rheumatic fever. As indicated previously, Diagnostic Code 7016 provides for a 100 percent disability rating for one year following implantation of a prosthetic heart valve; thereafter, rated as rheumatic heart disease with a minimum rating of 30 percent. Under Diagnostic Code 7000, inactive rheumatic heart disease from the termination of an established service episode of rheumatic fever or its subsequent recurrence with cardiac manifestations during the episode or recurrence for 3 years; or diastolic murmur with characteristic EKG manifestation or definitely enlarged heart warrants a 30 percent disability rating. A 60 percent disability rating contemplates definite heart enlargement; severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; or preclusion of more than light manual labor. 38 C.F.R. § 4.104 (1997). An increased disability is not warranted, as the evidence does not show that the veteran's disability met the schedular criteria for an increased disability rating prior to April 10, 1997. On the contrary, the evidence does not show that the veteran's disability was manifested by a definite heart enlargement. Similarly, the evidence does not show severe dyspnea on exertion, elevation of systolic blood pressure or paroxysmal auricular fibrillation, flutter or paroxysmal tachycardia. Additionally, the clinical evidence does not show that the veteran was precluded from more than light manual labor prior to April 10, 1997. Accordingly, based on the evidence, the Board must find that any functional impairment resulting from the veteran's service connected cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease disability was consistent with the rating code provisions for a 30 percent rating in effect prior to April 10, 1997. In brief, the preponderance of the evidence is against the veteran's claim for an increased rating for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, prior to April 10, 1997. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1997); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.104, Diagnostic Codes 7000-7123 (1997). II. Total Disability Rating based upon Individual Unemployability As set forth above, the veteran's disability rating for his service-connected cardiovascular disability as a result of his rheumatic fever and rheumatic heart disease has been increased to 100 percent. Total disability based upon individual unemployability contemplates a schedular rating less than total. 38 C.F.R. § 4.16(a) (1999). Since the veteran in this case is entitled to a 100 percent schedular rating, he is not eligible for a TDIU evaluation. See Vettese v. Brown, 7 Vet App. 31 (1994) ("claim for TDIU presupposes that the rating for the condition is less than 100 percent"); Holland v. Brown, 6 Vet App. 443 (1994). In essence, a TDIU rating is moot as the veteran has a total rating based on his service connected disability. Therefore, as a matter of law, the veteran's claim for TDIU fails. III. Temporary Total Rating for a Period of VA Hospitalization from August 11, 1999 to September 8, 1999 The appellant asserts that he is entitled to a temporary total rating for the period of VA hospitalization from August 11, 1999, to September 8, 1999, because he received treatment and evaluation for his service connected cardiovascular disability during that time. VA regulations provide that a total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established that a service- connected disability has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days, or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29 (1999). The report concerning the period of hospitalization in question indicates that the appellant was admitted to a VA medical center (VAMC) from August 11, 1999 to September 1999 for treatment for coronary artery disease, coronary obstructive pulmonary disease, congestive heart failure, peripheral vascular disease, and hypertension. VA Adjudication Manual, M21-1, Part VI, Chapter 5, paragraph 11.18f(2) (August 26, 1996) (VA Manual M21-1) states that "if verified rheumatic heart disease has been demonstrated, the effect of subsequent onset of hypertensive or arteriosclerotic heart disease which may also produce heart muscle changes and congestive failure cannot be satisfactorily dissociated from the rheumatic changes." The combined cardiac disability is to be evaluated as one entity under the service-connected rheumatic heart disease code. Recently, the VA General Counsel has determined that this provision of VA Manual M21-1 is substantive and binding on the Board. VAOPGPREC 6-2000 (May 19, 2000). While the evidence shows that the veteran's mitral valve and aortic valve prosthesis were operating normally during his admission to the VAMC, the VA hospitalization report indicates that he received intensive treatment and evaluation for cardiovascular symptoms. These symptoms cannot be "satisfactory dissociated from his rheumatic changes." The Board notes that the appellant has been hospitalized several times for treatment involving his service connected cardiovascular disability, and for which he was awarded temporary total ratings. When, after consideration of all the evidence and material of record in a case before VA with respect to benefits under laws administered by the Secretary of VA, there is an approximate balance of the positive and negative evidence regarding the merits of an issue material to a determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (b). In this case, the Board, after careful and thorough evaluation of the evidence pertaining to the period of hospitalization in question, has determined that it is approximately balanced. Therefore, extending the benefit of the doubt to the appellant, the Board finds that the appellant's period of VA hospitalization from August 11, 1999 to September 8, 1999, was required for treatment of his service- connected cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, and, thus warrants the assignment of a temporary 100 percent rating under the provisions of 38 C.F.R. § 4.29 (1999). ORDER A 100 percent evaluation, is granted for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, subject to the laws and regulations governing the award of monetary benefits. A 100 percent evaluation prior to December 18, 1997, is granted for a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, subject to the laws and regulations governing the award of monetary benefits. An increased disability rating from a cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease, rated as 30 percent disabling prior to April 10, 1997, is denied. A temporary total disability rating is granted for the veteran's period of VA hospitalization from August 11, 1999 to September 8, 1999, for treatment of his service- connected cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease. The veteran's claim for TDIU is denied in light of his 100 percent evaluation for service connected PTSD. A temporary total disability rating is granted for the veteran's period of VA hospitalization from August 11, 1999 to September 8, 1999, for treatment of his service- connected cardiovascular disability, to include valvular heart disease with a history of rheumatic fever and rheumatic heart disease. MARK W. GREENSTREET Member, Board of Veterans' Appeals