Citation Nr: 1310261 Decision Date: 03/26/13 Archive Date: 04/02/13 DOCKET NO. 02-18 741 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an increased rating for coronary artery disease, currently rated as 30 percent disabling prior to July 11, 2012. 2. Entitlement to an increased rating for anxiety disorder, currently rated as 30 percent disabling prior to June 14, 2011, and as 50 percent disabling since June 14, 2011. ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from March 1948 to March 1952. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, that continued both the Veteran's 10 percent rating for coronary artery disease and his 30 percent rating for anxiety disorder. In March 2007, the Veteran filed a Notice of Disagreement. The RO furnished the Veteran a Statement of the Case in October 2007, and the Veteran filed a Substantive Appeal (VA Form 9) in November 2007. The Board notes that the Veteran was previously represented by an unaccredited representative. A March 2008 letter was sent to the Veteran explaining to him that the unaccredited representative could not represent him. The Veteran was provided with a list of approved service organizations at that time. Subsequently, in May 2008, the Veteran appeared for a Decision Review Officer (DRO) hearing with the same unaccredited representative. At that time, the DRO explained to the Veteran that he could not have this attorney represent him in that capacity. It was explained to the Veteran that he could proceed with the attorney as a witness, he could proceed alone, or he could postpone the hearing until he had another representative. Ultimately, the Veteran canceled the hearing, stating that he would not proceed without this individual representing him. The Veteran was later scheduled for and presented for a November 2011 videoconference hearing before a Veterans Law Judge. However, the Veteran again appeared for the hearing with the unaccredited representative, and chose to cancel the hearing again upon being informed that he could not proceed at the hearing being represented by the unaccredited representative. No further requests for a hearing have been received from the Veteran. A June 2011 rating decision increased the disability rating for coronary artery disease, from 10 percent to 30 percent, effective April 8, 2004, and increased the disability rating for anxiety disorder from 30 percent to 50 percent, effective June 14, 2011. However, as these grants do not represent total grants of benefits sought on appeal, the claims for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). In a January 2005 rating decision, the Veteran was granted service connection for coronary artery disease, effective November 26, 1999. He did not submit additional evidence within a year of the rating decision, and therefore the rating decision became final. See 38 C.F.R. § 3.156(b) (2012). The Veteran filed a claim for increased rating for coronary artery disease in November 2006. During the pendency of the current appeal, in a May 2011 rating decision, the RO granted an earlier effective date of October 18, 1999 with respect to the date of service connection for coronary artery disease. However, regardless of the earlier effective date for the grant of service connection, the original January 2005 rating decision granting service connection for coronary artery disease remains final because the Veteran did not submit evidence within a year of the rating decision, and therefore, the Veteran's claim remains a claim for increased rating. See 38 C.F.R. § 3.156(b); Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, the Board notes that in a December 2012 rating decision, the Veteran was granted a 100 percent rating for coronary artery disease, effective July 11, 2012, which represents a full grant of benefits as of that date. The Board has therefore recharacterized the Veteran's claim for coronary artery disease as reflected on the title page. The Board remanded these claims for additional development in June 2012. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Prior to July 11, 2012, the Veteran's coronary artery disease was manifested, at worst, by dyspnea, fatigue, and angina brought on by a workload of 6 metabolic equivalents (METs). He had an ejection fraction of 60 percent, and there was no evidence of any episodes of acute congestive heart failure. 2. Prior to June 14, 2011, the Veteran's symptoms of anxiety disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to anxiety, panic attacks (weekly or less often), chronic sleep impairment, and a Global Assessment of Functioning score of 61 to 70. 3. Since June 14, 2011, the Veteran's anxiety disorder has been manifested by occupational and social impairment with reduced reliability and productivity due to panic attacks more than once a week, difficulty in understanding complex commands, impairment of short-term memory, disturbances of motivation and mood, and Global Assessment of Functioning scores of 61 to 70 and 49. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for coronary artery disease have not been met prior to July 11, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.104, Diagnostic Code 7017 (2012). 2. The criteria for a rating in excess of 30 percent for anxiety disorder have not been met prior to June 14, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9413 (2012). 3. The criteria for a rating in excess of 50 percent for anxiety disorder have not been met since June 14, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9413 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the appellant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The Veteran was provided VCAA notice in a December 2006 letter. This letter advised the Veteran of what information and evidence is needed to substantiate his claims for a higher rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter also advised the Veteran of the necessity of providing medical or lay evidence demonstrating the level of disability and the effect that the disability has on his employment. The notice also provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The letter further advised the Veteran of how effective dates are assigned, and the type of evidence which impacts those determinations. The claim was last readjudicated in December 2012. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. Specifically, the information and evidence that have been associated with the claims file include service treatment records, VA medical records, VA examination reports, and the Veteran's statements. Additionally, the prior remand instructions were substantially complied with. Instructions pertinent to the claims being decided included scheduling the Veteran for VA examinations for both of his claims. In response, the RO/AMC scheduled the Veteran for a June 2012 VA psychiatric examination and a July 2012 VA cardiac examination. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The appellant was notified and aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran has been an active participant in the claims process by reporting for VA examinations, responding to notices, and submitting evidence and argument. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Conway, supra; Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Coronary Artery Disease Prior to July 11, 2012 The Veteran contends that he is entitled to a higher disability rating for his coronary artery disease. Such disability has been rated under 38 C.F.R. § 4.104, Diagnostic Code 7017, as 30 percent disabling prior to July 11, 2012. Diagnostic Code 7017 provides ratings for coronary bypass surgery. For three months following hospital admission for surgery, a 100 percent rating is assigned. Thereafter, status post coronary bypass surgery resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication is required, is rated 10 percent disabling. Status post coronary bypass surgery resulting in 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 dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. Status post coronary bypass surgery resulting in 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, is rated 60 percent disabling. Status post coronary bypass surgery resulting in chronic congestive heart failure, or; 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, is rated 100 percent disabling. 38 C.F.R. § 4.104, Diagnostic Code 7017 (2012). VA medical records dated from November 2005 to September 2011 show that the Veteran received intermittent treatment for his coronary artery disease. Although the Veteran reported in June 2009 that he had been hospitalized for coronary symptoms while on vacation in Spain, the evidence otherwise indicates that the Veteran had no active chest pain/angina, shortness of breath, or exercise intolerance. Indeed, his disease was found to be stable. In June 2008, there was evidence of a new heart murmur. A June 2008 echocardiogram revealed normal left ventricular size and function and dilated right atrium with moderate degree of tricuspid regurgitation. There was pulmonary artery systolic pressure of 55 mmHg, which was consistent with moderate pulmonary hypertension. On VA examination in January 2007, the Veteran complained that he had experienced angina 3 to 4 times over the past year. He denied dyspnea at rest, but reported getting dyspnea with exertion about 3 times a week when he engaged in light exercise. He stated that he suffered from daily fatigue that developed in the evenings but denied dizziness or syncopal episodes. The Veteran indicated that he had not had a stress test done within the past year. He also maintained that his cardiac condition had a significant effect on his daily activities because he was unable to engage in strenuous activity. Examination revealed a regular heart with occasional ectopic beats. There was 2/6 systolic ejection murmur that was best heard at the left upper sternal border. Cardiac size was difficult to determine clinically. There was no radiation or cardiac S3 or S4. A chest x-ray showed peribronchial interstitial thickening of the left lower lobe, but there was otherwise no evidence of heart failure. A Dobutamine stress echocardiogram was negative for ischemia 120 percent maximum predicted heart rate and for ischemia. An electrocardiogram was found to be abnormal with non-specific ST abnormality and sinus rhythm with marked sinus arrhythmia. The examiner diagnosed the Veteran with coronary artery disease, status post coronary artery bypass graft of four coronary vessels in 1999. The Veteran was found to have had a good response to his coronary artery bypass graft, but he had also experienced 3 or 4 chest pain episodes over the past year. The examiner noted that the Veteran was prevented from engaging in strenuous activity, but that he did engage in light exercise to try to maintain his cardiac health. In a February 2007 VA addendum, the examiner found that the estimated METs was 6, as the Veteran had reported being able to do light gardening, moderate carpentry, light downhill skiing, walking at about a 5 mph pace, lawn mowing, dirt shoveling, light backpacking, bicycling at about 10 mph, pneumatic tool-using, and golfing (with walking and carrying of his own bag). A May 2007 CT of the abdomen revealed extensive atherosclerotic change of the aorta with an ectasia of the upper abdominal aorta at the hiatus. Relatively dense atherosclerotic change of the abdominal aorta and iliac vessels was noted as well. A June 2007 sonogram of the aorta showed atherosclerotic change and ectasia of the abdominal aorta measuring up to 2.7 cm. This was not considered to be aneurysmal. At a June 2011 VA examination, the Veteran denied any history of cardiac trauma, cardiac neoplasm, myocardial infarction, rheumatic fever, hypertensive heart disease, heart rhythm disturbance, valvular heart disease (including prosthetic valve), congestive heart failure, other heart disease, angina, dizziness, syncope, fatigue, dyspnea, non-productive or productive cough, wheezing, non-anginal chest pain, hemoptysis, fever, anorexia, or night sweats. He was noted to have a history of hypertension, and continuous medication was required for control of both his hypertension and heart disease. Examination revealed regular heart rhythm and size. Heart sounds were present in S1 and S2. There was no evidence of congestive heart failure, pulmonary hypertension, or abnormal breath sounds. The Veteran was noted to be well-developed, well-nourished, fit, tall, and thin with normal posture. He was negative for deformities and was in no acute distress. He looked very good and vigorous for his age. Stress test results showed 10 METs, which was found to be age appropriate. The examiner indicated that the Veteran was active with great vigor, and stated that per his review, the previous VA examination appeared to have underestimated the METs. A chest x-ray demonstrated stable peribronchial thickening in the left lower lobe and added density projecting over the lower thoracic spine on the lateral projection, degenerative changes versus parenchymal abnormality. The examiner diagnosed the Veteran with coronary artery disease status post bypass. He noted the negative history of myocardial infarction, age appropriate METs that were greater than 10, and prior echocardiogram ejection fraction of 60 percent. He found that the Veteran's disability had no effects on his usual daily activities. The Board finds that a rating in excess of 30 percent is not warranted under Diagnostic Code 7017. The evidence does not show that he has more than one episode a year of acute congestive heart failure; a workload of greater than 3 METs but not greater than 5 METS which results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 38 C.F.R. § 4.104, Diagnostic Code 7017. While the Board acknowledges that during the January 2007 VA examination, the Veteran complained of having angina 3 to 4 times over the past year, dyspnea with exertion about 3 times a week when he engaged in light exercise, and daily fatigue, the overall medical evidence is devoid of findings of dyspnea, fatigue, angina, dizziness or syncope attributable to the coronary artery disease. Indeed, VA medical records consistently showed that the Veteran's coronary artery disease was stable. Moreover, even considering the Veteran's complaints of angina, dyspnea, and fatigue, the objective evidence shows that, at worst, the Veteran's METs were measured as 6 during the period under consideration. Additionally, the Veteran has denied a history of congestive heart failure, and the objective medical evidence also fails to show any congestive heart failure. Finally, the Veteran's ejection fraction was shown to be no less than 60 percent for the period under consideration. Therefore, the Board finds that a rating in excess of 30 percent for the Veteran's coronary artery disease is not warranted for the period under consideration. Accordingly, the criteria for a rating in excess of 30 percent for service-connected coronary artery disease are not shown to have been more nearly approximated, and the claim is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Anxiety Disorder The Veteran contends that he is entitled to a higher disability rating for his anxiety disorder. Such disability has been rated under 38 C.F.R. § 4.130, Diagnostic Code 9413, as 30 percent disabling prior to June 14, 2011, and as 50 percent disabling since June 14, 2011. Under Diagnostic Code 9413, which is governed by a General Rating Formula for Mental Disorders, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). A 30 percent rating is warranted for 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; and/or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment 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; and/or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for 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 work-like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF score of 61 to 70 indicates some mild symptomatology (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, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2012). 1. Prior to June 14, 2011 VA medical records dated from November 2005 to June 2011 show that the Veteran met regularly with a Korean War group for psychotherapy treatment sessions. The evidence indicates that the Veteran was an active participant in these therapy sessions and generally did not exhibit any suicidal ideation or intent. On VA examination in January 2007, the Veteran described having good interpersonal relations with his friends and family. He stated that he had close friends and was very close to his family. He indicated that he felt that his support system was adequate. He reported being very actively involved with his grandchildren and stated that he went swimming on a regular basis. He maintained that he was very positive and optimistic and wanted to live as long as he could to enjoy his family. He stated that he was dealing well with his widow status of 8 years and indicated that he had been in a very close and loving relationship with his wife. The Veteran did complain that he was currently more tense and anxious than he would normally feel, as he was forced to reminisce about his Korean War experiences during the holidays and cold weather. He reported having nightmares that focused on the theme of helplessness of being at war. He stated that although he put tremendous effort into putting war memories into the past, he still had some intrusive thoughts that came and went, mostly in the context of symbolic reminders. He indicated that he felt psychological distress when thinking about these things, but denied any psychological reactive symptoms. He maintained that he had chronic sleep impairment. He reported that he did not like loud noises, but stated that he did not really jump when he heard them. He stated that he had periodic panic attacks that occurred typically in the context of a specific thought. The examiner noted that a review of the Veteran's file indicated no problems with bipolar disorder, mood disorder, or depression. Examination revealed that the Veteran was casually dressed and groomed, appearing to be in no acute distress. He was alert and oriented and noted to be a reliable and honest historian. He provided good eye contact and remained polite and respectful during the examination. He denied any active or passive suicidal thoughts and described his mood as euthymic. The examiner noted that the Veteran's affect was definitely not restricted, as the Veteran had warm, loving, and compassionate feelings towards others. There was no evidence of clear hypervigilant symptoms, startle problems, anger problems, outbursts of clinical significance, clear cognitive difficulties, psychogenic amnestic symptoms, anhedonia, detachment issues, major concentration disturbances, or memory disturbances. Thought process was clear, coherent, goal-directed, and logical. Thought content was free of any obsessions, compulsions, delusions, or hallucinations. Judgment and insight were felt to be pretty good. The Veteran had no avoidance beyond watching movies, listening to the Star-Spangled Banner, or events that caused direct symbolic associations. Based on the Veteran's report, the examiner found that the Veteran continued to feel anxious, but it did not appear to be extreme. He stated that the anxiety seemed to fall mostly in the mild range with some periods of moderate intensity and rarely periods of high intensity. The examiner diagnosed the Veteran with anxiety disorder, not otherwise specified and assigned a GAF score of 61 to 70. He explained that the Veteran had a clinical presentation of anxiety, and that while he had features of both generalized anxiety and posttraumatic stress disorder (PTSD), he did not meet the criteria for PTSD. The Veteran was noted to not really acknowledge apprehensive expectation or worry types of symptoms. He also did not feel that he had trouble controlling worries or calming himself down. The examiner found that typically, the Veteran did not meet the criteria for generalized anxiety disorder with his current presentation because his symptoms had been ameliorated significantly by his psychiatric and pain medications. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that for the period prior to June 14, 2011, the Veteran's anxiety disorder is appropriately evaluated as 30 percent disabling. As outlined above, the Veteran maintained good social interactions with family members and friends and had interests. He was generally positive and optimistic and expressed a desire to live as long as possible to enjoy time with his family. The Veteran did exhibit anxiety, nightmares, sleep difficulty, and occasional intrusive thoughts, but he had no problems with suicidal or homicidal ideation, flattened affect, hallucinations, delusions, incoherent speech or thought process, cognitive impairment, memory disturbance, or impaired judgment. Although he reported periodic panic attacks, these were shown to arise in the context of a specific thought and did not occur more than once a week. The GAF score during this period was 61 to 70, which is indicative of some mild symptomatology or difficulty in social functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. The Board finds that the symptomatology during this time period does not more nearly approximate the criteria for a higher rating. The Veteran is retired and has been able to maintain effective social relationships. He indicated that he had an adequate support system and that he had no trouble controlling his worries or calming himself down. The January 2007 VA examiner noted that the Veteran did not even meet the criteria for generalized anxiety disorder with his current presentation because his medication had significantly ameliorated his symptoms. Accordingly, the 30 percent rating assigned for the period prior to June 14, 2011 adequately addresses the Veteran's psychiatric symptoms. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 2. Since June 14, 2011 On VA examination in June 2011, the Veteran reported that his wife had died of cancer at age 62, and he had been living alone ever since. He stated that he had periods of depression and loneliness. He complained of panic attacks, periods of irritability, and loss of concentration. He indicated that it was very difficult for him to listen to the Star-Spangled Banner and that it brought tears to his eyes. He maintained that he avoided people during Memorial Day and the Fourth of July. He stated that without his religious faith, he would not have made it out alive. The examiner noted that the Veteran did not meet all the criteria for generalized anxiety disorder because he denied having nightmares and flashbacks. Examination revealed the Veteran to be alert, oriented, cooperative, casually dressed, fit, and spontaneous and clear in speech. There was no evidence of excessive anxiety or psychosis. The Veteran had average intelligence with mild visual memory, attention, and concentration. The Veteran passed the Mini Mental State Examination relative to recall after delay, attention, registration, and abstraction from similarities. His anxiety appeared to be stable, and he was able to perform his daily activities of living, drive a car, and function within normal limits for his current age of 81. His sleep was fitful and disturbed. Affect was restricted, but the Veteran had adequate insight and judgment. He attributed his good health to his resilience and flexibility. Neuropsychological test results showed problems with the perception of human speech sounds and rhythm as well as with tap and grip, but the examiner noted that these problems may be related to sensory organ decline. The Veteran also demonstrated impaired parallel processing, but there was no evidence of depression or seizure suggestion. His working memory was within average limits for his current age. He qualified as having severe anxiety on the Beck Anxiety Index, but did not meet the full criteria for PTSD. He had no emotional numbness, did not feel distant or cut off from other people, and did not feel as if his future would be cut short. The examiner diagnosed the Veteran with generalized anxiety disorder with PTSD features and assigned a GAF score of 49. At a June 2012 VA examination, the Veteran reported that his life was good and stated that he did not want it to change. He maintained that he wanted to live to be 100 years old. He denied frequent anxiety or depression but indicated that he became anxious during emotionally moving experiences that might typically elicit happiness. He explained that when a grandchild graduated, he became anxious and cried. He stated that because this anxiety only occurred on special occasions, the last time it had occurred was two months ago on Memorial Day. He reported that he had not had any PTSD-related symptoms in a long time, but indicated that he still could not look at the American flag because it made him anxious. He stated that he had not used his medication in months. The examiner noted that this psychiatric condition was obviously not one that caused much distress or impairment, and the Veteran confirmed this by saying that he had no worries. The Veteran reported that he went shopping for about 3 hours several times a week, went to a fitness center about three times a week, saw his daughter or granddaughter several times a week, and ate dinner with his daughter and granddaughter every Sunday. Examination revealed that the Veteran had anxiety and mild memory loss, such as forgetting names, directions, or recent events. The examiner found that since the Veteran had been diagnosed with generalized anxiety disorder previously, it appeared that the anxiety disorder was currently in partial remission. He described the Veteran's level of severity as being occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The examiner diagnosed the Veteran with generalized anxiety disorder and assigned a GAF score of 61 to 70. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that for the period since June 14, 2011, the Veteran's anxiety disorder is appropriately evaluated as 50 percent disabling. The Board acknowledges that the June 2011 VA examiner assigned a GAF score of 49, which is indicative of serious symptoms or serious impairment in social functioning. However, VA regulations do not dictate that disability percentages are assigned based solely on GAF scores, see 38 C.F.R. § 4.130, and in this case, the overall evidence does not show that the Veteran is entitled to a higher 70 percent rating for the period under consideration. As outlined above, the Veteran continued to maintain good social interactions with family members and had interests. During the June 2011 VA examination, although the Veteran reported periods of depression and loneliness as well as experiencing panic attacks, there is no evidence that these periods of panic or depression were near-continuous and affected his ability to function. Indeed, the June 2011 examiner found that the Veteran was able to perform his daily activities of living, drive a car, and function within normal limits for his current age of 81. There was also no evidence of depression or suicidal ideation found on either June 2011 or June 2012 examination. In fact, the Veteran reported at his June 2012 VA examination that his life was good and that he did not want to change it. Although the Veteran experienced sleep impairment, periods of irritability, anxiety that was at times severe, impaired parallel processing, and mild memory impairment, there was no evidence of obsessional rituals, incoherent speech, impaired impulse control, spatial disorientation, neglect of personal appearance or hygiene, or difficulty in adapting to stressful circumstances. Finally, the June 2012 VA examiner assigned a GAF score of 61 to 70, which is indicative of some mild symptomatology or difficulty in social functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. The Board finds that the symptomatology during this time period does not more nearly approximate the criteria for a higher rating. The Veteran is retired and has been able to maintain effective social relationships. The June 2012 VA examiner also found that the Veteran's anxiety disorder appeared to currently be in partial remission and described his disability as being mild in severity. Accordingly, the 50 percent rating assigned for the period since June 14, 2011 adequately addresses the Veteran's psychiatric symptoms. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Other Considerations The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of his disabilities. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluations assigned and do not more nearly approximate the criteria for higher evaluations at any time during the relevant periods on appeal. See 38 C.F.R. §§ 4.104, Diagnostic Code 7017, 4.130, Diagnostic Code 9413 (2012); see also Fenderson, supra. The Board has also considered whether the Veteran's coronary artery disease and anxiety disorder present exceptional or unusual disability pictures as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. The Veteran's 30 percent rating prior to July 11, 2012 for coronary artery disease contemplates his subjective complaints of pain and functional impairment. Although the Veteran complained of dyspnea, angina, and fatigue, these symptoms were brought on by, at worst, a workload of 6 METs. He had an ejection fraction of 60 percent, and there was no evidence of any episodes of acute congestive heart failure. Additionally, the Veteran's coronary artery disease was noted to be stable, and he was observed to be active with great vigor and able to engage in light exercise. Therefore, the Veteran's subjective complaints were included in the 30 percent rating. Additionally, the Veteran's 30 percent rating prior to June 14, 2011 for anxiety disorder contemplates his subjective complaints of anxiety and functional impairment. Although the Veteran exhibited anxiety, nightmares, sleep difficulty, occasional intrusive thoughts, and panic attacks, these symptoms amounted to no more than mild impairment. The Veteran had no other psychiatric symptoms and was able to maintain close relationships with family and friends. He did not even meet the criteria for generalized anxiety disorder because his medication had significantly improved his symptoms. Therefore, the Veteran's subjective complaints were included in the 30 percent rating. Similarly, the Veteran's 50 percent rating since June 14, 2011 for anxiety disorder contemplates his subjective complaints of anxiety and depression and functional impairment. Although the Veteran experienced depression, panic attacks, sleep impairment, periods of irritability, anxiety that was at times severe, impaired parallel processing, and mild memory impairment, these symptoms were not found to impair him so severely as to prevent him from functioning. Indeed, he continued to maintain effective social relationships and was found to be able to perform his activities of daily living and functioning. Additionally, he stopped taking any psychiatric medication, and his anxiety disorder appeared to be in partial remission. Therefore, the Veteran's subjective complaints were included in the 50 percent rating. Thus, the Veteran's disability pictures are contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. (CONTINUED ON NEXT PAGE) ORDER A rating in excess of 30 percent for coronary artery disease prior to July 11, 2012 is denied. A rating in excess of 30 percent for anxiety disorder prior to June 14, 2011 is denied. A rating in excess of 50 percent for anxiety disorder since June 14, 2011 is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs