Citation Nr: 1313199 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 99-22 252 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hypertensive vascular disease secondary to organic heart disease with paroxysmal atrial fibrillation and mitral valve prolapse. 2. What rating is warranted for paroxysmal supraventricular tachycardia (previously characterized as paroxysmal atrial fibrillation) from January 22, 1998 to April 16, 2010? 3. What rating is warranted for paroxysmal supraventricular tachycardia (previously characterized as paroxysmal atrial fibrillation) beginning April 17, 2010? 4. What rating is warranted for organic heart disease with mitral valve prolapse? 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Stephanie L. Caucutt, Counsel INTRODUCTION The Veteran served on active duty from January 1981 to January 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The case was certified to the Board by the RO in Atlanta, Georgia. This matter was previously before the Board in December 2000, March 2005, April 2006, July 2007, March 2008, April 2010, and February 2012. In December 2000, the Board remanded the claims for additional development. In March 2005, the Board denied entitlement to service connection for hypertension and remanded the other claims for further development. In April 2006, the Board denied entitlement to an increased rating for paroxysmal supraventricular tachycardia and entitlement to a total disability evaluation based on individual unemployability due to service connected disorders. The Veteran appealed the Board's April 2006 decision to the United States Court of Appeals for Veterans Claims (Court). In March 2007, the Court granted a joint motion for remand. The Board remanded the appeal for additional development in July 2007, in part, because the Veterans Law Judge who conducted a September 2000 hearing had retired. The Veteran was afforded the opportunity to attend a hearing before another Veterans Law Judge, which he did in November 2007. Transcripts of both hearings are associated with the claims file. In March 2008 and April 2010, the Board remanded the claims for further development. In February 2012, the Board restored the Veteran's award of service connection for organic heart disease with mitral valve prolapse. It remanded the remaining claims on appeal for further development. The case has been returned to the Board for further appellate review. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claim. This Virtual VA file has been reviewed. The Board's decision regarding the matters of what ratings are warranted for paroxysmal supraventricular tachycardia prior to April 17, 2010, and for organic heart disease; as well as the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities, is set forth below. For reasons discussed further below, the question what rating is warranted for paroxysmal supraventricular tachycardia since April 17, 2010, and entitlement to service connection for hypertensive vascular disease are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. In February 2012, the Board referred the issue of entitlement to reimbursement for unauthorized medical expenses to the Agency of Original Jurisdiction (AOJ) for appropriate action. Review of the claims file fails to reveal that any action was taken on this matter. Thus, it is once again referred to the AOJ for appropriate and immediate action. In November 2012, the appellant raised the issue of entitlement to vocational rehabilitation benefits. This issue, however, also is not currently developed or certified for appellate review. Accordingly, this matter is referred to the RO for appropriate consideration. FINDINGS OF FACT 1. For the period from January 22, 1998 to April 16, 2009, evidence indicates paroxysmal atrial fibrillation (or supraventricular tachycardia) was manifested by less than four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by electrocardiogram or Holter monitor. 2. For the period from April 17, 2009 to April 16, 2010, evidence indicates paroxysmal atrial fibrillation (or supraventricular tachycardia) was manifested by more than four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by electrocardiogram or Holter monitor. 3. Although the grant of service connection is protected, the Veteran is not currently diagnosed with an organic heart disease with mitral valve prolapse; thus, there are no signs or symptoms upon which to rate this disability. 4. In December 2012, prior to the promulgation of a decision in this appeal, the Board received notification from the Veteran that he wished to withdraw his appeal as to the matter of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. CONCLUSIONS OF LAW 1. From January 22, 1998 to April 16, 2009, the criteria for an evaluation greater than 10 percent for paroxysmal supraventricular tachycardia were not met. 38 U.S.C.A. §§ 1155, 5013, 5103A, 5107, 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7010 (2012). 2. From April 17, 2009 to April 16, 2010, the criteria for a 30 percent evaluation, and no more, for paroxysmal supraventricular tachycardia were met. 38 U.S.C.A. §§ 1155, 5013, 5103A, 5107, 5110; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7010. 3. The criteria for a compensable evaluation for organic heart disease with mitral valve prolapse are not met. 38 U.S.C.A. §§ 1155, 5013, 5103A, 5107, 5110; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7000. 4. The criteria for withdrawal of an appeal by the Veteran as to the matter of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The Board notes the enactment of the Veterans Claims Assistance Act of 2000. See 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran has withdrawn his appeal to the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. Thus, the Board need not address VA's compliance with the Veterans Claims Assistance Act of 2000 in that claim. With respect to the Veteran's increased rating claims herein decided, the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in October 2003, May 2008, and April 2010 correspondence of the information and evidence needed to substantiate and complete an increased rating claim, to include notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. The May 2008 and April 2010 letters also notified the appellant of how VA determines the disability rating and effective date. Consistent with the Board's multiple remands, letters were also sent to the appellant in April 2010 and February 2012, requesting relevant information pertaining to his claims on appeal. The appellant was provided notice of the specific rating criteria used to evaluate his disabilities in the January 1998 statement of the case and May 2000 supplemental statement of the case. These claims were most recently readjudicated in a December 2012 supplemental statement of the case. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, including obtaining VA and non-VA treatment records dated through January 2012 and contacting the Veteran in April 2010 to request information regarding any further outstanding treatment. VA has afforded the Veteran multiple VA examinations that resulted in reports containing sufficient evidence by which to evaluate his service-connected cardiovascular conditions. The appellant was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. See Washington v. Nicholson, 21 Vet. App. 191 (2007). Merits of the Increased Rating Claims Historically, in August 1984, VA granted entitlement to service connection for organic heart disease with paroxysmal atrial fibrillation and mitral valve prolapse and assigned a 30 percent evaluation, effective January 24, 1984. Thereafter, in February 1986, VA reduced the evaluation to 10 percent, effective on May 1, 1986. The Veteran perfected an appeal as to this rating action, but the reduction was upheld by the Board in July 1987. On January 22, 1998, the RO received a claim of entitlement to an increased evaluation for the Veteran's service-connected heart disorder. In July 1998, the RO denied his claim for an increased evaluation. The Veteran appealed this decision and, in a November 1998 rating decision, the RO restyled the Veteran's disability as paroxysmal supraventricular tachycardia only. No reference was made to the fact that in 1984 service connection had been granted for organic heart disease. As discussed in the Board's February 2012 decision, there is no evidence between 1984 and 1998 that VA ever attempted to sever service connection for organic heart disease. Hence, by 1998, the Veteran had been service connected for organic heart disease for more than 10 years. Given that there is no evidence that service connection was granted based on fraud, and given that the Veteran had the requisite service or character of discharge, the grant of service connection for his organic heart disease is protected. 38 U.S.C.A. § 1159 (West 2002 & Supp. 2012). See also Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Thus, the Veteran's January 1998 claim of entitlement to an increased evaluation encompassed a claim for higher ratings for both organic heart disease with mitral valve prolapsed, and atrial fibrillation. The Board notes that these diseases each have their own diagnostic criteria upon which to assign disability ratings. See 38 C.F.R. § 4.104. Pertinent to the current determination, the Veteran was previously assigned 30 percent and 10 percent under Diagnostic Code 7000, which pertains to rheumatic/valvular heart disease (i.e., organic heart disease and mitral valve prolapse). Review of the record, however, reflects that his initial 30 percent evaluation and subsequent 10 percent evaluation were assigned on the basis of symptoms attributable to his service-connected atrial fibrillation (now characterized as paroxysmal supraventricular tachycardia). No rating decision discusses evidence showing the presence of valvular lesions, an enlarged heart, diastolic murmur, or recurrence of rheumatic heart disease. Instead, the August 1984 and February 1986 RO rating decisions, as well as the July 1987 Board decision, focus on the frequency of the Veteran's episodes of tachycardia. As cited by the Board in its 1987 decision, these signs and symptoms were rated pursuant to Diagnostic Code 7013. See 38 C.F.R. § 4.104 (1977). In November 1998, the RO updated the Veteran's Diagnostic Code to reflect that the 10 percent evaluation assigned pertained to signs and symptoms associated with atrial fibrillation (also characterized as paroxysmal supraventricular tachycardia). This disability is now rated pursuant to Diagnostic Code 7010 (which replaced Diagnostic Code 7013 effective January 12, 1998). See 38 C.F.R. § 4.104. In light of the RO's actions, and because the Veteran's service-connected atrial fibrillation is most appropriately rated under Diagnostic Code 7010, the increased rating claim on appeal includes the question what evaluation is warranted for atrial fibrillation since the Veteran's January 1998 increased rating claim was filed. Further, in view of the Board's February 2012 decision which restored service connection for organic heart disease with mitral valve prolapse, the January 1998 increased rating claim also encompasses the question of what evaluation is warranted for atrial fibrillation. As explained above, the Veteran's evaluation for a cardiovascular disability has never included a compensable evaluation for signs and symptoms of organic heart disease or mitral valve prolapse. Thus, that question is separately characterized as whether a compensable rating is warranted for this disability. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Evaluation of a service-connected disorder requires a review of the Veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). If there is a question as to which evaluation to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When 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. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, in Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that staged ratings are appropriate for an increased rating claim that is not on appeal from the assignment of an initial rating when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. Paroxysmal Atrial Fibrillation Paroxysmal atrial fibrillation (or paroxysmal supraventricular tachycardia) is rated pursuant to Diagnostic Code 7010. 38 C.F.R. § 4.104. Under this diagnostic code, a 10 percent evaluation is warranted for permanent atrial fibrillation (lone atrial fibrillation), or; when there are one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by electrocardiogram or Holter monitor. A maximum 30 percent evaluation is warranted for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by electrocardiogram or Holter monitor. Id. at Diagnostic Code 7010. At this September 1998 VA examination, the Veteran reported a history of atrial fibrillation, panic attacks, and mitral valve prolapse. The examiner's review of the claims file revealed a known history of palpitations, dizziness, and pre-syncope. While the Veteran was not receiving any on-going cardiac care, he reported taking a beta blocker to assist with his atrial fibrillation. Clinical examination of the Veteran was normal. A treadmill stress test showed the Veteran attained a maximum workload of 13 METS and an electrocardiogram performed in conjunction with the examination was normal. Holter monitor testing on October 12, 1998, showed one episode of supraventricular tachycardia (SVT). The assessment was palpitations, paroxysmal SVT, and panic attacks. Following the September 1998 VA examination, the Veteran underwent further cardiac event monitoring through Northside Hospital in October and November 1998. Review of the electrocardiogram reports show an episode of SVT on October 28, 1998 as well as what "appears to be SVT" on November 5, 1998. On July 25, 1999, the Veteran was admitted to North Fulton Regional Hospital for evaluation of irregular, pounding, and a skipping heart rate at work. He complained of shortness of breath, chest pain, and lightheadedness. Electrocardiogram testing showed an episode of atrial fibrillation; the chest x-ray was within normal limits. The assessment was recurrent atrial fibrillation. Additional Holter monitor testing was completed in September 1999. Although premature atrial contraction (a form of ventricular ectopy) was observed, there were no episodes of atrial fibrillation or SVT recorded during the twelve-hour testing period. The Veteran testified at his September 2000 Board hearing that he had continuous chest pain and shortness of breath. He also reported that his pulse occasionally increased during exercise, but that it usually subsides. According to the Veteran, these "episodes" occurred as frequently as once or twice a week between 1996 and 1998. At a VA examination in February 2001, the Veteran complained of dyspnea on exertion and an occasional skipping heartbeat; he specifically denied any chest pain, shortness of breath, dyspnea, or orthopnea. Current medications included a water pill, aspirin, and a beta blocker, but no prescription-strength anti-coagulant. The examiner noted that electrocardiogram testing showed normal sinus rhythm with nonspecific ST-T changes; these findings were noted to be similar to prior electrocardiograms. The assessment included history of paroxysmal atrial fibrillation, not adequately controlled on proper therapy. Thereafter, the Veteran was admitted to the emergency department at South Fulton Hospital in May 2003 for complaints of palpitations lasting twenty minutes. Electrocardiogram testing was normal other than nonspecific T-wave abnormality. Assessment was palpitations and chest pain; no SVT, atrial fibrillation, congestive heart failure, or valvular disease was noted. Similarly, emergency department treatment records from Wellstar Cobb dated in June 2003 show complaints of chest pressure/pain with normal electrocardiogram testing; the assessment was palpitations. In July 2003, the Veteran was seen at VA for follow up evaluation of his two emergency room visits for palpitations. At such time, he reported episodes of shortness of breath and palpitations that lasted approximately twenty minutes and frequently resolved spontaneously. The assessment was palpitations, probably secondary to a panic disorder, and hypertension suboptimally controlled. The Veteran was subsequently seen at Baptist Memorial Hospital in August 2003 for evaluation of a rapid heartbeat. Electrocardiogram testing showed normal sinus rhythm with occasional premature ectopic complexities. There was no evidence of an enlarged heart. The assessment was palpitations. The Veteran was again seen at VA for follow up to his emergency room visit. The assessment noted that the etiology of his palpitations was unclear; specifically, the examiner questioned whether the etiology of the Veteran's symptoms was cardiovascular or psychiatric (i.e., panic disorder). A number of tests were scheduled, including an October 2003 exercise treadmill test at which the Veteran achieved 13.8 METS before stopping due to fatigue. Holter monitor testing was also accomplished in September and November 2004 without evidence of atrial fibrillation or SVT. In December 2004, the Veteran was seen at VA's cardiology clinic; the cardiologist noted that he brought approximately 200 pages of treatment records with him for review by the physician. According to the Veteran, he had no documented episodes of atrial fibrillation since 1999, but reported that he still experienced symptomatic palpitations. Following a review of the records and an examination of the Veteran, the physician assessed the Veteran has having palpitations, which were "very likely" due to ventricular ectopy (i.e., premature atrial contraction and premature ventricular contraction). The report reflected that a 1999 ECHO report showed a structurally normal heart. It was the physician's assessment that the Veteran's premature beats were benign. In addition to palpitations, the Veteran was diagnosed as having hypertension, treated with metoprolol. As for his history of atrial fibrillation, the cardiologist indicated that this may have been lone atrial fibrillation that is no longer active given the absence of an episode in five years. The Veteran underwent further testing at VA following his December 2004 cardiology consultation. Such testing included a February 2005 ECHO which showed an ejection fraction of 60 to 65 percent and no evidence of mitral valve prolapse. Holter event monitors were performed in February and April 2007; there was frequent atrial premature complexes, but no episodes of SVT were observed. An April 2009 VA examination report reflects that the Veteran reported continued treatment for cardiovascular problems, including hypertension, with beta blockers. He also described intermittent attacks of chest discomfort, palpitations, dyspnea, and dizziness. According to the Veteran, he experienced "major" attacks every two to three weeks; "minor attacks" occurred more frequently and were abated by remaining quiet and/or by squatting with muscle tensing. He noted that his last hospitalization for cardiac problems was in May 2008. Following a review of the claims file, examination of the Veteran, and additional testing, the examiner diagnosed the Veteran with a systolic murmur, paroxysmal atrial fibrillation, hypertension, and ventricular ectopy. Pertinent to this determination, Holter monitor testing completed between April 17 and 18, 2009 demonstrated twenty runs (or episodes) of SVT lasting up to six beats. Following the April 2009 VA examination, the Veteran was seen for cardiac follow up in May 2009. A history of paroxysmal atrial fibrillation was diagnosed. The physician noted multiple event recorders and Holter monitors with ventricular ectopy and "rare" short runs of SVT. Regarding the Veteran's functioning, the physician indicated that it appeared that the appellant could go about his daily activities without limitation. Approximately one year later, in March 2010, the Veteran was seen in the emergency department for complaints of irregular heart beat. Electrocardiogram testing revealed irregular rhythm with atrial fibrillation. Given the foregoing evidence, the Board finds that a 30 percent evaluation is warranted from April 17, 2009 to April 16, 2010. In that regard, evidence of record reflects more than four episodes of paroxysmal atrial fibrillation or other SVT documented by electrocardiogram or Holter monitor during this one-year period. Specifically, as discussed above, Holter monitor testing performed between April 17 and 18, 2009 showed twenty separate runs of SVT within a two day period alone. There was also an episode of atrial fibrillation documented by electrocardiogram in March 2010. Hence, a 30 percent rating for this term is granted. See 38 C.F.R. §§ 4.3, 4.7. For the period prior to April 17, 2009, the criteria for an evaluation greater than 10 percent were not met, however, as there was no evidence of more than four documented episodes of paroxysmal atrial fibrillation or other SVT for this period. As outlined in a May 2010 addendum to the April 2009 VA examination report, records show no more than four episodes of SVT in any one-year period between January 1998 and April 17, 2009. Specifically, the evidence demonstrates the Veteran had documented episodes of SVT on September 29, 1998, October 29, 1998, November 5, 1998, and July 25, 1999. As this evidence clearly does not demonstrate entitlement to a 30 percent evaluation, the Board has assigned a staged rating pursuant to Hart. The Board has considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. Schafrath, 1 Vet. App. at 589. 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Shinseki, 573 F.3d 1366 (Fed. Cir. 2009). As discussed above, applicable rating criteria reasonably describe the Veteran's disability level and symptomatology. The rating criteria for supraventricular arrhythmia focus on compensating a veteran based upon the frequency of episodes of atrial fibrillation or other SVT. Although not explicitly discussed, this rating criteria clearly contemplates the symptoms which accompany those episodes of atrial fibrillation or other SVT, including the shortness of breath, irregular pulse, chest discomfort, and light headedness as reported by the Veteran throughout this appeal. The Board further acknowledges that the rating criteria do not specifically address "lesser" episodes of arrhythmia, such as the Veteran's ventricular ectopy. However, as noted by a cardiologist, such findings are "benign." Accordingly, it is reasonable to conclude that Diagnostic Code 7010 contemplates these findings/episodes, but only compensates for documented SVT. Hence, the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral for extraschedular evaluation is in order. Id. As for higher ratings due to unemployability, the Veteran filed for a total disability rating based on individual unemployability and was previously denied. Although he appealed this decision, as discussed below, he has withdrawn that appeal. Thus, there is no basis for inferring a claim for entitlement to a total disability evaluation based on unemployability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In reaching these conclusions, the Board notes it considered the benefit of the doubt doctrine. As the preponderance of the evidence was against the claim, however, this doctrine is not for application. 38 U.S.C.A. § 5107. Organic Heart Disease with Mitral Valve Prolapse Turning to the Veteran's service-connected organic heart disease with mitral valve prolapse, this disability was historically assigned a noncompensable evaluation pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7000. Under this diagnostic code, a 10 percent evaluation is warranted for when there is valvular heart disease with a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted when there is valvular heart disease with a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or x-ray. 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 metabolic equivalents at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of metabolic equivalent by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in metabolic equivalents 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 Veteran was diagnosed with organic heart disease and mitral valve prolapse based upon a March 1984 VA examination which included electrocardiogram and ECHO testing. The examination report reflects that the Veteran was discharged from service after having had several episodes of rapid, irregular heart action accompanied by dyspnea, dizziness, and near syncope. At that time the appellant denied any history of high blood pressure, chest pains, or rheumatic fever. Clinical examination of the heart revealed normal rate and rhythm, and a normal heart size. There was a grade I/VI systolic murmur at the base. Electrocardiogram and chest x-ray studies were within normal limits. Initial assessment was organic heart disease, manifested by prolapse of the mitral valve and paroxysmal atrial fibrillation. A March 1984 ECHO was interpreted as showing mild to moderate mitral valve prolapse. An April 1984 addendum report notes a final assessment of mitral valve prolapse. Pertinent to the current determination, other than the March 1984 VA examination report and April 1984 addendum, none of the competent medical evidence of record supports a finding that the Veteran has currently diagnosed organic heart disease, including mitral valve prolapse. Cardiac testing conducted since 1984, including electrocardiograms and ECHO studies, have demonstrated no abnormality of the mitral valve. Furthermore, multiple VA examiners have questioned the 1984 diagnosis of organic heart disease with mitral valve prolapse. A February 2001 VA examiner acknowledged the 1984 diagnosis of mitral valve prolapse, but noted that a repeat ECHO in 1998 was normal. He also indicated that personal examination of the Veteran failed to reveal any murmur. Accordingly, it was the February 2001 VA examiner's opinion that the 1984 ECHO was "overread." Similarly, a cardiologist who examined the Veteran and reviewed the claims file in April 2012 opined that the appellant does not have organic heart disease with mitral valve prolapse. The cardiologist explained that electrocardiograms dated in March 1998, October 1998, February 2005, April 2009, and March 2012 showed no evidence of mitral valve prolapse. In other words, the only clinical evidence of mitral valve prolapse is the March 1984 ECHO. Citing medical literature, the April 2012 examiner noted that mitral valve prolapse was over diagnosed in the 1970s and 1980s because of an absence of rigorous criteria for reviewing ECHOs. In light of this information, and given the numerous "normal" findings since the 1990s, the cardiologist concluded that the Veteran did not have organic heart disease and mitral valve prolapse. The Veteran's award of service connection for this disability is protected by law. In the absence of any evidence of valvular heart disease, however, a compensable rating for this disease cannot be assigned. In that regard, there are no signs or symptoms upon which to rate the Veteran for this disability because, as discussed above, the Veteran does not have the disability. As such, this appeal must be denied. The Board notes that it considered the benefit of the doubt doctrine in reaching this conclusion. As the preponderance of the evidence was against the claim, however, this doctrine is not for application. 38 U.S.C.A. § 5107. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204(a). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing and include the name of the veteran, the applicable Department of Veterans Affairs file number, and a statement that the appeal is withdrawn. 38 C.F.R. § 20.204(b). The Veteran was denied entitlement to individual unemployability in July 1998 rating decision and he perfected an appeal as to this issue. The matter remained pending before the Board until December 2012, at which time the Veteran submitted written correspondence indicating that he wished to withdraw his appeal as to this issue only. This statement met the requirements of 38 C.F.R. § 20.204. As a result, no allegation of error of fact or law remains before the Board for consideration with regard to this issue. 38 C.F.R. § 20.204(c). Accordingly, the Board does not have jurisdiction to review this issue and it must be dismissed. ORDER For the period from January 22, 1998 to April 16, 2009, entitlement to a rating in excess of 10 percent for paroxysmal supraventricular tachycardia (previously characterized as paroxysmal atrial fibrillation) is denied. For the period from April 17, 2009 to April 16, 2010, entitlement to a 30 percent rating for paroxysmal supraventricular tachycardia (previously characterized as paroxysmal atrial fibrillation) is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a compensable rating for organic heart disease with mitral valve prolapse is denied. The appeal as to the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is dismissed. REMAND The Board sincerely regrets further delay to the matters remaining on appeal. Review of the claims file, however, reveals that additional development is needed with respect to the issues of entitlement to service connection for hypertensive vascular disease, and entitlement to a rating in excess of 10 percent for paroxysmal supraventricular tachycardia for the period since April 17, 2010. As noted above, the issue of entitlement to service connection for hypertensive vascular disease (a.k.a. hypertension) secondary to organic heart disease with mitral valve prolapse and atrial fibrillation is on appeal before the Board. Review of the file reveals that this issue was last adjudicated by the RO/AMC in a November 2011 supplemental statement of the case. Since then, additional evidence has been associated with the claims file, including the Virtual VA file, to include additional VA treatment reports and an April 2012 VA examination report that addresses whether hypertension is related to any of the appellant's service-connected cardiovascular conditions. When evidence is received by the agency of original jurisdiction prior to transfer of the records to the Board after an appeal has been initiated, such evidence may not be reviewed by the Board in the first instance. See 38 C.F.R. §§ 19.31 and 19.37 (2012). Accordingly, a remand is necessary to afford the RO/AMC the opportunity to review the additional evidence received since the November 2011 supplemental statement of the case as regards the matter of service connection for hypertensive vascular disease. Id. As regards the issue of entitlement to an evaluation greater than 10 percent for paroxysmal supraventricular tachycardia (previously characterized as paroxysmal atrial fibrillation) for the period beginning April 17, 2010, a remand is necessary to obtain additional outstanding medical evidence pertinent to this period of the appeal. Specifically, a January 2012 VA telephone note reflects that the Veteran reported that he recently underwent Holter monitor testing which was abnormal. Additionally, he requested, and was scheduled for, a consultation with VA's cardiology clinic. It is not clear from the current record whether the Veteran's Holter monitor testing was completed at a VA or non-VA facility. Thus, the RO/AMC should contact the Veteran to request information and/or evidence pertaining to his service-connected paroxysmal supraventricular tachycardia, to include any Holter monitor testing, dated since April 17, 2010. 38 C.F.R. § 3.159. The RO/AMC should also obtain any outstanding, relevant VA treatment records dated since January 20, 2012, to include any cardiology reports and/or test and laboratory results. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Thereafter, the RO/AMC should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran to request the names and addresses of all medical care providers who have treated him for paroxysmal supraventricular tachycardia/atrial fibrillation since April 17, 2010, to include the names and addresses of any private and or VA facilities that conducted any cardiac testing such as Holter monitor testing. After the Veteran has signed the appropriate releases, those records should be obtained and those records not already associated with the claims file should be associated with the claims file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit records for VA review. All attempts to procure records should be documented in the file. If records identified by the Veteran cannot be obtained, a notation to that effect should be inserted in the file. 2. Request all outstanding, relevant treatment records from the VA Medical Center in Atlanta, Georgia since January 20, 2012, to include any cardiac consultation reports as well as laboratory and/or cardiac testing results. All records obtained should be associated with the claims file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit records for VA review. All attempts to procure records should be documented in the file. If the RO/AMC cannot locate such records, the RO/AMC must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 3. Upon completion of the above requested development and any additional development deemed appropriate (to include additional examination), the RO/AMC is to readjudicate the issues of entitlement to service connection for hypertensive vascular disease; and whether an evaluation in excess of 10 percent is warranted for paroxysmal supraventricular tachycardia beginning April 17, 2010. All applicable laws, regulations, and theories of entitlement should be considered. With regard to the issue of service connection for hypertensive vascular disease, the RO/AMC's readjudication should reflect consideration of additional evidence received since the November 2011 supplemental statement of the case, along with any evidence obtained in conjunction with this remand. If any benefit sought on appeal remains denied, the appellant should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs