Citation Nr: 1228045 Decision Date: 08/14/12 Archive Date: 08/21/12 DOCKET NO. 04-11 931A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and in excess of 60 percent from March 26, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The appellant served on active duty from February 1991 to September 1998. This matter originally came to the Board of Veterans' Appeals (Board) on appeal from a November 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied a rating in excess of 30 percent for hypertension with cardiomegaly. Before the appeal was certified to the Board, in a February 2006 rating decision, the RO in St. Petersburg, Florida, reduced the rating for hypertension with cardiomegaly to zero percent, effective July 1, 2006. In September 2006, the appellant testified before a Veterans Law Judge at a Board hearing at the RO in connection with his appeal. In a January 2007 decision, the Board denied a rating in excess of 30 percent for hypertension with cardiomegaly for the period prior to July 1, 2006, and a compensable rating for hypertension with cardiomegaly from July 1, 2006. The appellant appealed the Board's decision to the U.S. Court of Appeals for Veterans Claims (Court). In a December 2008 memorandum decision, the Court let stand that portion of the Board's January 2007 decision denying a rating in excess of 30 percent for hypertension with cardiomegaly prior to July 1, 2006. The Court vacated that part of the Board's January 2007 decision denying a compensable rating for hypertension with cardiomegaly for the period from July 1, 2006, finding that the appellant had submitted a timely notice of disagreement with the February 2006 rating decision which reduced the rating for hypertension with cardiomegaly to zero percent, effective July 1, 2006. The Court directed VA to issue a Statement of the Case regarding the rating reduction issue and further held that the issue of entitlement to a compensable rating for hypertension with cardiomegaly from July 1, 2006, was inextricably intertwined with the rating reduction issue. In August 2009, the Board remanded the matter to the RO for compliance with the Court's remand instructions. While the matter was in remand status, the appellant perfected an appeal with the rating reduction issue and elected to attend another Board hearing in connection with the appeal. In May 2010, the appellant testified before another Veterans Law Judge at a Board hearing at the RO. In an August 2010 decision, the Board restored the 30 percent disability rating for hypertension with cardiomegaly effective July 1, 2006. The Board remanded the remaining issue on appeal-entitlement to a rating in excess 30 percent for hypertension with cardiomegaly for the period from July 1, 2006-for additional evidentiary development. In April 2011 and again in March 2012, the Board remanded the matter for additional evidentiary development. While the matter was in remand status, in a May 2012 rating decision, the RO increased the rating assigned for the appellant's hypertension with cardiomegaly to 60 percent, effective March 26, 2012. Although an increased rating was granted, the issue remains in appellate status, as the maximum schedular rating has not been assigned nor has the appellant withdrawn his appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Moreover, given the procedural history of this issue, adjudication of the claim now requires evaluation during two distinct time periods, as set forth above on the cover page of this decision. As noted above, during the pendency of this appeal, the appellant has testified before two different Veterans Law Judges. Thus, review of this matter has been assigned to a panel of three Veterans Law Judges, in accordance with 38 C.F.R. § 20.707 (2011). Both Veterans Law Judges who conducted hearings in this case are on the panel and will participate in making the decision on the claim. In a December 2011 letter, the Board offered the appellant the opportunity to testify before the third member of the panel. See Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). The appellant was advised that if he did not respond to the letter within 30 days, the Board would proceed with his appeal on the assumption that he did not wish to attend a third hearing. Having received no response from the appellant, the Board will proceed with consideration of his appeal. Please note that in September 2006, the appellant submitted a motion to advance his case on the Board's docket, claiming to be in financial hardship. In December 2006, the Board granted the motion and advanced the appeal on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2011). FINDINGS OF FACT 1. For the period from July 1, 2006, to March 25, 2012, the appellant's diastolic blood pressure readings were consistently below 100, his systolic blood pressure readings were consistently below 160, and his hypertension did not require medication for control. 2. For the period from March 26, 2012, the appellant's diastolic pressure has been below 100, his systolic pressure has been below 160, and he requires a small dose of medication for control of his hypertension. 3. For the period from July 1, 2006, to March 25, 2012, repeated examination consistently showed no evidence of congestive heart failure; repeated diagnostic testing consistently showed that the appellant exhibited normal left ventricular function, with an ejection fraction of no less than 55 to 60 percent; and the most probative evidence showed that the appellant's estimated METs level was between 5 and 7. 4. For the period from March 26, 2012, the appellant's cardiac disability has not been productive of chronic congestive heart failure, left ventricular dysfunction with an ejection fraction of less than 30 percent, or a workload of 3 METs or less. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and in excess of 60 percent from March 26, 2012, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.16, 4.104, Diagnostic Codes 7007, 7101 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. In February 2001, February 2006, and June 2006 letters, VA notified the appellant of the information and evidence needed to substantiate and complete his claim, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2011). The June 2006 letter also included the additional notification requirements imposed by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Since the issuance of these letters, the RO has reconsidered the appellant's claim on several occasions, most recently in the May 2012 Supplemental Statement of the Case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). In addition to these notification letters, in prehearing conferences conducted prior to the September 2006 and May 2010 Board hearings, and during the hearings themselves, the undersigned Veterans Law Judges discussed the issue on appeal with the appellant and his representative, both of whom acknowledged full understanding of all matters discussed. 38 C.F.R. § 3.103 (2011); see also Bryant v. Shinseki, 23 Vet. App. 488 (2010). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). The appellant has not argued otherwise. The appellant's service treatment records are on file, as are all available post-service clinical records which the appellant has specifically identified and authorized VA to obtain, including VA clinical records dated to April 2012. 38 U.S.C.A. § 5103A(c) (West 2002); 38 C.F.R. § 3.159(c)(2), (3) (2011). The appellant has also been afforded VA medical examinations in connection with his claim, most recently in April 2012. 38 C.F.R. § 3.159(c) (4) (2011). The Board finds that the April 2012 examination is adequate. The opinion was provided by a qualified medical professional and was predicated on a full reading of all available records. The examination report also includes reference to the pertinent schedular criteria. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds that the evidence is adequate to decide the issue on appeal and further notes that neither the appellant nor his representative has challenged the adequacy of any of the examinations obtained. Sickels v. Shinseki, 643 F3d 1362 (Fed. Cir. 2011) (holding that in the absence of a challenge, the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2011). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary on the issue now being decided. Background The record on appeal shows that in October 1998, shortly after his separation from active service, the appellant submitted an original application for VA compensation benefits seeking service connection for multiple disabilities, including a cardiac condition, bifascicular block. In connection with his claim, the appellant was afforded a VA medical examination in December 1998 at which he reported a history of an incidental finding of bifascicular block on an EKG during service. The examiner noted, however, that all subsequent testing had been normal. In connection with the examination, the appellant underwent an echocardiogram and a treadmill test, both of which were normal, with the appellant achieving more than 13 METS. The diagnoses included moderate hypertension. In an August 1999 rating decision, the RO granted service connection for hypertension with cardiomegaly and assigned an initial 30 percent disability rating, effective September 13, 1998. In March 2001, the appellant again underwent VA medical examination at which blood pressure readings of 110/80, 110/80, and 108/80 were recorded. The examiner indicated that there was no clinical evidence of congestive heart failure. The diagnosis was mild essential hypertension with a previous EKG showing bifascicular and right bundle branch block which was probably not significant in view of normal echocardiogram testing on two subsequent occasions. At a May 2004 VA medical examination, the appellant claimed that he had recently been denied employment due to a chest X-ray which had shown cardiomyopathy. He indicated that he had previously been told that he had hypertension, although he indicated that he never initiated medical therapy of had persistent elevation of his blood pressure. The examiner noted that the appellant did not require any type of antihypertensive therapy nor did he participate in any special maneuvers for blood pressure control. On examination, blood pressure readings of 128/80, 115/75 and 120/81 were recorded. An EKG was normal with an ejection fraction of 55-60 percent. There was no evidence of cardiomegaly, including on X-ray. The impression of the examiner was no evidence of cardiomegaly or cardiovascular disease on evaluation nor evidence of essential hypertension. The examiner noted that although the appellant had a history of previous evidence of cardiomegaly on chest X-ray, this could have been due to pericardial effusion and/or a radiographic abnormality resulting from the placement of the chest X-ray. At the time of the examination, however, he indicated that there was no evidence of cardiovascular dysfunction including cardiomegaly or essential hypertension. Subsequent clinical records show that in July 2004, the appellant sought emergency treatment with complaints of chest pain. He reported a history which included hypertension, chronic right bundle branch block on EKG, cardiomyopathy, and anxiety disorder. The appellant's blood pressure was 124/92. The impressions included atypical chest pain, possibly chronic bifascicular block on EKG, history of pulmonary hypertension not confirmed objectively, and anxiety disorder. In August 2004, the appellant underwent an exercise stress test at a private hospital. The maximum level achieved was 7 METS before testing was discontinued due to attainment of 100 percent of the maximum predicted heart rate, dyspnea, and fatigue. The appellant again underwent VA hypertension examination in June 2005. It was noted that he was on no medication for blood pressure. He claimed that he had an enlarged heart but denied any symptoms other than occasional chest pain which the examiner noted had been evaluated several times with negative results. During the examination, blood pressure readings of 120/88 and 118/84 were recorded. Chest X-ray was stable, with no interval change. The impression was history of borderline hypertension since 1997 but not on any medications. At a June 2005 VA heart examination, the appellant's blood pressure was measured as 120/88 and 120/84. The diagnosis was atypical chest pain with negative cardiac workup in the past including EKG showing normal left ventricular function. The examiner noted that the appellant had a history of cardiomegaly with slight prominent heart shown on present X-ray, stable since the last examination. He also noted that a stress test showed that the appellant had no ischemia, achieving a METS of 8.5. In a June 2005 addendum, another VA physician concurred in the findings and indicated that there was no evidence of cardiomegaly or hypertensive heart disease. At a September 2006 Board hearing, the appellant testified that since his separation from active service, he had experienced symptoms such as a rapid heart rate with chest pain, fatigue, dizziness, and trouble sleeping. He claimed that his job options were limited because his bosses did not think he could handle stress. In support of the appellant's claim, the RO obtained VA clinical records dated from June 2004 to November 2009. These records are entirely negative for complaints or findings pertaining to hypertension or cardiomegaly. In May 2005, the appellant's blood pressure was noted to be 131/88. In an August 2009 note, a private nurse practitioner indicated that the appellant had an abnormal EKG with a right bundle branch block and left anterior fascicular block. At his May 2010 Board hearing, the appellant testified that he was now receiving his medical care from VA. He indicated that he was not on any medication for his cardiac condition, although he took medication for his agoraphobia. At the hearing, the appellant submitted a May 2010 document entitled "EXPERT INDEPENDENT MEDICAL EVALUATION (IME)" from Craig N. Bash, M.D. Dr. Bash indicated that he had reviewed the appellant's "medical records/testimony/lay statements/personnel records, imaging based medical examination . . . and an in-person history/clinical interview." He described himself as being "exquisitely well trained" to interpret imaging studies "as they represent a form of patient examination akin to an in person face to face exam because objective data is obtained form both processes." Dr. Bash indicated that it was his opinion that the record documented a consistent trend of progressive serious cardiac disease which began in service with chest pain, EKG changes, and hypertension and had progressed to "cardiomeglia [sic] with persistent EKG block changes with new left axis deviation which resulted in chronic intermittent chest pain with exertion." Dr. Bash indicated that it was his opinion that the appellant's cardiac function had likely declined since his last evaluation in June 2005 where he reached a level of 8.5 METS. He indicated that it was his medical opinion that the appellant should be assigned a 30 percent rating under Diagnostic Code 7005, as it most closely described the appellant's chronic cardiac problems. In pertinent part, additional VA clinical records show that at a physical examination in August 2010, the appellant's blood pressure was 114/81. He reported a history of post prandial chest tightness and a right bundle branch block and indicated that he took nitroglycerin as needed. The examiner recommended cardiac work-up, including an exercise treadmill test and an echocardiogram. A chest X-ray was performed in August 2010 in connection with the appellant's report that he had cardiomegaly. The heart was determined to be along the upper limits normal for size, possibly slightly accentuated due to shallow inspiration. The radiologist noted that there was no evidence of congestive failure, a pulmonary consolidation, or pleural effusion. In October 2010, the appellant underwent myocardial perfusion imaging which showed normal left ventricular systolic function with an estimated ejection fraction of 55-60 percent. The appellant was advised that he was being scheduled for a "chemical stress test" as he had been unable to satisfactorily complete an exercise stress test. In November 2010, the appellant underwent VA medical examination at which he reported a history of cardiomegaly. The examiner noted that the appellant was on no medication for hypertension or heart disease. The appellant reported that he currently attended graduate school full time. On examination, the appellant's blood pressure was 122/79. The examiner indicated that there was no clinical evidence of congestive heart failure or pulmonary hypertension. He noted that an October 2010 echocardiogram had shown normal left ventricular systolic function with an estimated ejection fraction of 55 to 60 percent. The examiner also noted that during a Bruce stress test performed in October 2010, the appellant had exercised for 1:38 minutes with maximum work attained of 3.50 METS, but that the test results were totally unsatisfactory due to the appellant's claimed chest discomfort and limited exercise tolerance. Thus, a Lexiscan myocardial perfusion imaging study had been scheduled. After examining the appellant and reviewing the available record, the examiner diagnosed the appellant as having hypertension, stable, on no medication; and history of cardiomegaly with no current objective evidence on chest X-ray or echocardiogram. The examiner indicated that the appellant's cardiac condition had no effect on his occupation or daily activities. In December 2010, the appellant underwent the Lexiscan stress test without chest pain, shortness of breath, or significant arrhythmias. The impression was essentially unremarkable EKG response to Lexiscan challenge. In an April 2011 addendum, a VA examiner indicated that he had reviewed the appellant's medical records and claims file thoroughly as well as the new Lexiscan results. He noted that the prior exercise stress test had been determined by the examining cardiologist to be unsatisfactory due to dyspnea. He noted that the follow up study had shown normal myocardial perfusion with a resting left ventricular ejection fraction of 62 percent. He indicated that based on a personal interview with appellant in November 2010, he estimated that the appellant's true METs score was at least between 5-7. He indicated that the appellant had been diagnosed as having hypertension and cardiomegaly that had not required pharmacologic treatment thus far and that an echocardiogram in October 2010 had confirmed no functional or structural abnormalities of the heart. The impression was normal left ventricular systolic function with estimated ejection fraction of 55-60%. The examiner further indicated that it was likely that the appellant was able to obtain and maintain gainful employment in the physical and sedentary sector without limitations. He explained that this was possible, given that the appellant had exhibited a normal myocardial perfusion scan and echocardiogram. He also noted that the appellant's cardiologist had indicated that the prior stress test was unsatisfactory and hence had no weight on his cardiac status. Finally, he noted that the appellant was currently on no medical therapy for heart disease only for a mood disorder. Additional VA clinical records show that in January 2011, the appellant was seen in the cardiology clinic for an evaluation for possible cardiac catheterization. He reported a history of episodes of chest tightness and dyspnea not related to activity. He indicated that nitroglycerin controlled his chest pain. The examiner noted that echocardiogram had been unremarkable and that a recent myocardial perfusion imaging study performed the month prior had shown no ischemia. The appellant reported that he had undergone cardiac catheterization about two years prior which showed "some inflammation." The examiner noted, however, that unfortunately the appellant did not bring the record with him. On examination, the appellant's blood pressure was 130/74. The evaluation was deferred pending review of the appellant's cardiac catheterization records. In a January 2011 addendum, the examiner noted that a review of the records provided by the appellant indicated that he had undergone a left heart catheterization in February 2009 which showed no angiographic evidence of coronary artery disease, no global or regional wall motion abnormality with a 60 percent ejection fraction, and no aortic stenosis. Based on these findings and the recent negative myocardial perfusion imaging study, the appellant's cardiologist concluded that no further catherization was necessary. In February 2011, the appellant underwent a blood pressure check which showed a reading of 110/64. In March 2011, the appellant was seen in connection with his reports being very stressed from graduate school. It was noted that he had a history of atypical chest pain and that a recent myocardial perfusion imaging study had been negative, as had a cardiac catherization two years prior. The impression was benign atypical chest pain for which he takes nitroglycerin a couple times monthly. In January 2012, the appellant sought emergency treatment, claiming to be suffering from a reaction to medication he had been taking for his anxiety disorder and agoraphobia. He indicated that he had been under a lot of stress lately while pursuing a graduate degree in psychology. On examination, his blood pressure was 128/87. On follow-up later that month, the appellant claimed that he had been suffering from frequent panic attacks since his discharge from service. During these episodes, he claimed to experience sweating, chest pain, palpitations, tightness, an inability to concentrate. On examination, the appellant's blood pressure was 126/74. The impressions included panic attacks by history and atypical chest pain with negative cardiac workup. The appellant underwent VA medical examination in April 2012. [The RO has listed the date of the examination as March 26, 2012, although the electronic records contained in the appellant's Virtual VA file appear to indicate that the examination and diagnostic tests were conducted on April 10, 2012]. During the examination, the appellant reported a history of an enlarged heart and abnormal EKG. The examiner noted that the appellant did not have a history of diastolic blood pressure elevation to predominantly 100 or more but that his current treatment plan included taking Metoprolol and nitroglycerin. During the examination, the following blood pressure readings were recorded: 128/91, 113/82, and 116/79. The examiner indicated that the appellant exhibited no other complications nor did his hypertension impact his ability to work. Cardiac exam revealed a regular rate and rhythm. There was no murmur, rub or gallop. In connection with the examination, the appellant underwent a chest X-ray which showed that his cardiomediastinal silhouette was within normal limits. A note was made to the effect that the appellant made a shallow inspiratory effort during the study. The appellant also participated in a Bruce exercise EKG stress test in connection with the examination. He achieved a work level of maximum METS of 4.60 before the test was stopped due to his complaints of feeling dizzy. The impression was nondiagnostic exercise EKG stress test secondary to not attaining maximum target heart rate. Finally, in connection with the examination, an echocardiogram was performed which was normal, with a left ventricular ejection fraction of 55-60 percent. After examining the appellant, reviewing the results of diagnostic testing, and considering the claims folder in detail, the examiner indicated that it was his opinion that the appellant had mild hypertension which is controlled with a small dose of Metoprolol. She indicated that the appellant was capable of gainful sedentary or physical employment. Applicable Law Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2011). Separate diagnostic codes identify the various disabilities. 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 (2011). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10 (2011). In considering the severity of a disability, it is essential to trace the medical history of the claimant. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2011). 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 (2011); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The RO has rated the appellant's service-connected hypertension with cardiomegaly under 38 C.F.R. § 4.104, Diagnostic Codes 7101 and 7007. Hypertensive vascular disease (hypertension and isolated systolic hypertension) is evaluated under Diagnostic Code 7101. Those rating criteria provide for the assignment of a 10 percent rating when diastolic pressure is predominantly 100 or more; or systolic pressure is predominantly 160 or more; or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 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 60 percent rating is warranted when diastolic pressure is predominantly 130 or more. Hypertensive heart disease is evaluated under Diagnostic Code 7007. Under those rating criteria, a 30 percent evaluation is assigned when a workload greater than 5 METs (metabolic equivalents) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness or syncope; or when there is evidence of cardiac hypertrophy or dilatation on electrocardiogram (EKG), echocardiogram (echo) or X-ray. A 60 percent rating is assigned when there is more than one episode of acute congestive heart failure in the past year or workload that is greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness or syncope; or when there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned where there is chronic congestive heart failure, or a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET 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. 38 C.F.R. § 4.104, Note (2). The Board notes that effective October 6, 2006, the rating criteria were revised to provide that hypertension is to be rated separately from hypertensive heart disease or other types of heart disease. See 71 Fed. Reg. 52,457-60 (Sept. 6, 2006) (codified at 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (3) (2011)). These amended rating criteria, however, apply only to applications for benefits received by VA on or after October 6, 2006. Id. ("The provisions of this final rule shall apply to all applications for benefits received by VA on or after the effective date of this final rule."). As the appellant's claim was received prior to that date, the revised criteria are not applicable. In any event, as set forth in more detail below, the evidence of record shows that the criteria for a compensable rating under Diagnostic Code 7101 have not been met at any time since July 1, 2006. Given the evidence, a separate compensable rating would not have been warranted even with application of the amended criteria. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Analysis Applying the facts in this case to the criteria set forth above, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and in excess of 60 percent from March 26, 2012. With respect to the period from July 1, 2006, to March 25, 2012, the Board has carefully reviewed the entire record, with particular attention to the VA clinical records, private clinical records, and VA and private examination reports corresponding to this period. Without exception, this evidence shows that the appellant's diastolic blood pressure readings were consistently below 100, his systolic blood pressure readings were consistently below 160, and his hypertension did not require medication for control. Indeed, the appellant has never contended otherwise. Under these circumstances, the Board finds that the criteria for a rating in excess of 30 percent under Diagnostic Code 7101 have not been met at any time between July 1, 2006, and March 25, 2012. Indeed, these findings would not warrant a compensable rating under Diagnostic Code 7101 during this period. Similarly, the Board finds that the record does not warrant the assignment of a rating in excess of 30 percent under Diagnostic Code 7007 during the period from July 1, 2006, to March 25, 2012. In that regard, the record shows that repeated examination has consistently shown that the appellant exhibited no evidence of congestive heart failure during this period, or indeed at any time since service. For example, in August 2010, a VA radiologist specifically determined that an X-ray study was negative for evidence of congestive failure and during a November 2010 VA medical examination, the examiner expressly concluded that there was no evidence of congestive heart failure on examination. In addition, the Board notes that repeated diagnostic testing consistently showed that during the period from July 1, 2006, to March 25, 2012, the appellant exhibited normal left ventricular function, with an ejection fraction of no less than 55 to 60 percent. For example, an October 2010 myocardial perfusion imaging study showed normal left ventricular systolic function with an estimated ejection fraction of 55-60 percent. In April 2012, the appellant underwent an echocardiogram which was again normal, with a left ventricular ejection fraction of 55-60 percent. Finally, the Board notes that during the period from July 1, 2006, to March 25, 2012, the most probative evidence showed that the appellant's estimated METs level was between 5 and 7. For example, in May 2010, Dr. Bash indicated that based on his review of the record and an examination of the appellant, as well as his exquisite training and experience, it was his opinion that the appellant's cardiac function had declined from a level of 8.5 METS to the level set forth in the criteria for a 30 percent rating under Diagnostic Code 7005, i.e. between 5 and 7 METS. Similarly, in an April 2011 opinion, a VA examiner indicated that based on a personal interview with appellant and a review of the record, he estimated that the appellant's true METs score was at least between 5 and 7. The Board has considered the findings of the November 2010 Bruce stress test, but notes that medical examiners consistently concluded that the results of that test were unsatisfactory, requiring an estimation of the appellant's METS level during the period in question. The Board finds that there is no basis upon which to conclude that the appellant exhibited a lower METS level during this period. Indeed, a follow-up Lexiscan stress test performed in December 2010 was essentially unremarkable. Under these circumstances, the Board assigns far more probative weight to the findings of the medical professionals in this case, both of whom agree that the appellant's METs score was between 5 and 7 during the period in question. In view of these findings, the Board finds that the criteria set forth in Diagnostic Code 7007 for a rating in excess of 30 percent from July 1, 2006, to March 25, 2012, have not been met. As set forth above, as of March 26, 2012, the RO has assigned a 60 percent rating for the appellant's hypertension with cardiomegaly under Diagnostic Codes 7101 and 7007. After carefully reviewing the record, the Board finds that the criteria for a rating in excess of 60 percent from March 26, 2012, have not been met. As a preliminary matter, the Board notes that the rating criteria set forth in Diagnostic Code 7101 do not provide a basis for a rating in excess of 60 percent. A 60 percent rating is the maximum available under that provision. In any event, given the appellant's blood pressure reading history, i.e. diastolic blood pressure readings consistently below 100 and systolic blood pressure readings consistently below 160, there is no basis upon which to conclude that the criteria for a compensable rating under Diagnostic Code 7101 have been met, even with the recent notation that the appellant now takes a small dose of medication for blood pressure control. With respect to the rating criteria set forth in Diagnostic Code 7007, the evidence does not show, nor has the appellant contended, that his hypertension with cardiomegaly has been manifested since March 26, 2012, by chronic congestive heart failure, left ventricular dysfunction with an ejection fraction of less than 30 percent, or a workload of 3 METs or less. Indeed, the Board observes that VA clinical records and the April 2012 VA medical examination report indicate that the appellant has no complications from his hypertension, it had no impact on his ability to work, and a chest X-ray and echocardiogram were both normal. During an exercise stress test, the appellant achieved 4.6 METS before the test was stopped due the appellant's claims that he felt dizzy. Given this evidence, the Board can find no basis upon which to conclude that the criteria for a rating in excess of 60 percent under Diagnostic Code 7007 have been met from March 26, 2012. In reaching its decision, the Board has also considered whether the appellant may be entitled to an extraschedular rating pursuant to 38 C.F.R. § 3.321 (2011). Under 38 C.F.R. § 3.321, in exceptional cases where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent period of hospitalizations as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2011); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). After reviewing the record, however, the Board finds no basis for further action on this question as there is no indication of an exceptional or unusual disability picture such that the schedular criteria for the appellant's service-connected hypertension with cardiomegaly are inadequate. As discussed above, the symptoms associated with the appellant's service-connected disability are specifically contemplated by the Rating Schedule. Moreover, the appellant's service-connected hypertension with cardiomegaly has not necessitated frequent periods of hospitalization and he has not contended otherwise. Finally, the Board finds that the appellant's service-connected hypertension with cardiomegaly has not been shown to cause marked interference with employment beyond that contemplated by the schedular criteria. Again, the appellant has not argued otherwise. Although he claims to feel limited in his ability to obtain employment due to a perception that he is unable to handle stress, the record contains no indication that his service-connected hypertension with cardiomegaly causes marked interference with employment beyond the schedular criteria. Further, in recognition of the industrial impairment caused by his service-connected hypertension with cardiomegaly, the appellant has already been awarded a 30 percent disability rating from July 1, 2006, and a 60 percent rating from March 26, 2012. Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The record otherwise contains no indication that there are factors causing marked interference with employment beyond that contemplated by the schedular criteria. Under these circumstances, the Board finds no evidence to indicate referral for extraschedular consideration. Thun v. Peake, 22 Vet. App. 111 (2008). The Board has also considered the Court's decision in Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In this case, however, the record on appeal contains no indication that the appellant is unemployable as a result of his service-connected hypertension with cardiomegaly and the appellant has not contended otherwise. Indeed, as delineated in more detail above, VA examiners have repeatedly and consistently concluded that the appellant's service-connected hypertension with cardiomegaly does not prevent him from obtaining or maintaining substantially gainful employment. For example, in November 2010, a VA medical examiner indicated that the appellant's cardiac condition had no effect on his occupation or daily activities. In April 2011, a VA examiner indicated that the appellant was able to obtain and maintain gainful employment in the physical and sedentary sector without limitations. In April 2012, a VA medical examiner indicated that the appellant was capable of gainful sedentary or physical employment. In summary, the Board finds that the record does not show, nor has the appellant alleged, that he is unable to secure and follow a substantially gainful occupation solely by reason of his service-connected hypertension with cardiomegaly. Under these circumstances, there is no basis for the assignment of a total rating based on individual unemployability due to service-connected disability. For the reasons and bases discussed above, the Board finds that the preponderance of the evidence is against the claim. The benefit of the doubt doctrine is not for application as the weight of the evidence is against the claim. 38 U.S.C.A. § 5107(b) ; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Entitlement to a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and in excess of 60 percent from March 26, 2012, is denied. L. Howell Barbara B. Copeland Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals __________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs