Citation Nr: 1318286 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 06-09 378 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. From May 25, 2005 to September 7, 2006, entitlement to an initial compensable rating for service-connected coronary artery disease (CAD). 2. On and after September 7, 2006 to November 14, 2006, entitlement to a rating in excess of 10 percent for service-connected CAD. 3. On and after March 1, 2007 to May 3, 2010, entitlement to a rating in excess of 10 percent for service-connected CAD status-post coronary artery bypass graft (CABG). REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. Millikan, Counsel INTRODUCTION The Veteran served on active military duty from June 1967 to January 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Waco, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2009, the Veteran testified at a Board hearing before a Veterans Law Judge (VLJ). A transcript of this hearing is associated with the claims file. This VLJ has since retired from the Board. VLJs who conduct hearings must participate in making the final determination of the claim on appeal. 38 U.S.C.A. § 7107(c) (West 2002); 38 C.F.R. § 20.707 (2012). In a December 2012 letter, the Board notified the Veteran that the VLJ was no longer employed by the Board and that he had the right to another hearing. See 38 C.F.R. § 20.717 (2012). He was notified that if he did not respond within 30 days, the Board would assume that another hearing was not desired and would proceed to adjudicate the claim on appeal. No response was received. Accordingly, the Board may proceed. In a December 2011 decision, the Board denied the claim on appeal; the Board also denied an evaluation in excess of 30 percent for the service-connected CAD on and after May 3, 2010 and denied service connection for peripheral neuropathy. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). Based on a July 2012 Joint Motion for Court Remand (Joint Motion), the Court remanded the Board's decision for development in compliance with the Joint Motion. Of note, the JMR directed that the service connection claim and the increased rating claim on and after May 3, 2010 were not on appeal and should not be disturbed. A letter was sent to the Veteran and his representative in December 2012 in which he was given 90 days from the date of the letter to submit additional argument or evidence in support of his appeal prior to the Board's readjudication. No response was received. Certain records from the claims file have been stored electronically as part of the Virtual VA paperless claims processing system. This system uses, instead of paper, a highly secured electronic repository to store and review documents involved in the claims process. Although the majority of records from this claims file are associated with the physical, or paper, claims file, because some of the documents were added to the electronic version of this file as part of the virtual claims file, any consideration of this appeal must consider both the paper and virtual claims files. The Board has reviewed all electronic and paper records associated with this file. There are no medical records in the electronic claims file. FINDINGS OF FACT 1. From May 25, 2005 to September 7, 2006, the Veteran's service-connected CAD is manifested by presumed coronary artery disease with continuous medication, but not cardiac hypertrophy or metabolic equivalents (METs) greater than 5 but not greater than 7. 2. From September 7, 2006 to November 14, 2006, the Veteran's service-connected CAD is manifested by cardiac hypertrophy without acute congestive heart failure (CHF), a workload of greater than 3 but not greater than 5 METs, or left ventricular dysfunction with ejection fraction in between 30 and 50 percent. 3. From March 1, 2007 to May 3, 2010, the Veteran's service-connected CAD status-post CABG is manifested by cardiac hypertrophy without acute CHF, a workload of greater than 3 but not greater than 5 METs, or left ventricular dysfunction with ejection fraction in between 30 and 50 percent. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, from May 25, 2005, to September 7, 2006, the criteria for a 10 percent evaluation, but no more, for service-connected CAD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). 2. From September 7, 2006 to November 14, 2006, the criteria for a 30 percent evaluation, but no more, for service-connected CAD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). 3. From March 1, 2007 to May 3, 2010, the criteria for a 30 percent evaluation, but no more, for service-connected CAD status-post CABG have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7017 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 369 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). But "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled." Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, section 5103(a) notice is no longer required). Additionally, where service connection has been granted, the claimant bears the burden of demonstrating prejudice from defective notice with respect to downstream elements such as effective dates or disability ratings. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Here, the Veteran appealed the initial evaluation assigned and has made no assertions of prejudice herein. Accordingly, regarding the initial evaluation and subsequent evaluations, VA's duty to notify has been satisfied. VA's duty to assist the Veteran has also been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records, VA medical records, and identified private medical records have been obtained. VA provided the Veteran adequate medical examinations in September 2006, June 2007, September 2008, and May 2010. The examinations are adequate because each is predicated on a review of the claims file, contains a history obtained from the Veteran, and contains a thorough cardiac examination relevant to the applicable rating criteria. Additionally, the Veteran provided testimony at a December 2011 Board hearing. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486. This appeal was remanded by the Board in November 2009. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). That remand directed the RO to request that the Veteran submit the results of a stress test and electrocardiogram (ECG) conducted in December 2008 or January 2009 or authorize VA to obtain the records, and to provide the Veteran with an examination to assess the current severity of his service-connected CAD status-post CABG. A letter with the proper request was sent in April 2010; no response was received. The Board finds that there has been substantial compliance with that request as "the duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Additionally, an adequate VA cardiac examination was provided in May 2010. Accordingly, the Board finds that there has been substantial compliance with its previous remand and it may proceed to adjudication of this appeal. Increased schedular evaluations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). 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. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes, however, that this rule does not apply here, because the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection for this disability. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Instead, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson, 12 Vet. App. at 126. If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126. The relevant time period for consideration in a claim for an increased initial disability rating is the period beginning on the date that the claim for service connection was filed. Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). By a December 2006 rating decision, the RO granted service connection for CAD and assigned a noncompensable evaluation under 38 C.F.R. § 4.104, Diagnostic Code 7005, effective May 25, 2005. The RO also assigned a 10 percent evaluation on and after September 7, 2006. The Veteran appealed. In a January 2009 rating decision, the RO assigned a 100 percent evaluation effective November 14, 2006, and a 10 percent evaluation on and after March 1, 2007. Those evaluations were assigned under a different diagnostic code, 38 C.F.R. § 4.104, Diagnostic Code 7017. In a May 2011 rating decision, the RO assigned a 30 percent evaluation on and after May 3, 2010, also under Diagnostic Code 7017. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2012). However, separate evaluations for separate and distinct symptomatology may be assigned where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Furthermore, if two evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). Preliminarily, the Board notes that although changes were made to portions of 38 C.F.R. §§ 4.104 and 4.100, during the time period on appeal, the applicable diagnostic codes remained essentially the same throughout the time period. See Schedule for Rating Disabilities, Guidelines for Application of Evaluation Criteria for Certain Respiratory and Cardiovascular Conditions; Evaluation of Hypertension With Heart Disease, 71 Fed. Reg. 52460 (Sept. 6, 2006). The changes, effective October 6, 2006, included a directive that whether cardiac hypertrophy or dilatation (documented by electrocardiogram (ECG), echocardiogram (EKG), or X-ray) is present and whether there is a need for continuous medication must be ascertained in all cases. 38 C.F.R. § 4.100(a). Additionally, it was noted that METs testing was required except where there was a medical contraindication, when the left ventricular ejection fraction has been measured and is 50% or less, when chronic CHF is present or there has been more than one episode of CHF within the past year, or when a 100% evaluation can be assigned on another basis. 38 C.F.R. § 4.100(b). Finally, it was noted that if left ventricular ejection fraction testing is not of record, evaluate based on the alternative criteria unless the examiner states that the LVEF test is needed because the available medical information does not sufficiently reflect the severity of the veteran's cardiovascular disability. 38 CFR § 4.100(c). Finally, a note was added to Diagnostic Code 7101 directing that hypertension be evaluated separately from heart disease. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (3) (2012). Additionally, the Board is not considering the period from November 14, 2006 to February 28, 2007 because the Veteran is rated as 100 percent disabled during that time period and no higher evaluation can be awarded. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that the veteran is presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum benefit is awarded). The Board is also not considering the time period beginning on May 3, 2010; the JMR directed that that time period was not to be disturbed. Evaluation from May 25, 2005 to September 7, 2006 The Veteran is assigned a noncompensable evaluation for this time period, which reflects that the requirements for a compensable evaluation are not met. See 38 CFR § 4.31 (2012). For CAD, a 10 percent evaluation is assigned for a workload of greater than 7 METs but not greater than 10 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent evaluation is assigned for a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on ECG, EKG, or X-ray. 38 C.F.R. § 4.104, Diagnostic Code 7005 (2005); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). In a November 15, 2004 exercise test summary, METs testing was 10.40. An ECG was noted as abnormal. In a November 15, 2004 treatment letter, a private physician, Dr. JM, noted that the Veteran had multiple risk factors for ischemic heart disease. An examination was remarkable for normal S1 and S2 with no gallop or murmur. The exercise test was discontinued secondary to dyspnea and chest pain. The stress EKG changes did not achieve diagnostic criteria. The resting EKG demonstrated left ventricular hypertrophy of moderate severity, with no wall motion abnormalities. The impressions included EKG suspicious, but non-diagnostic for ischemia, resting changes of left ventricular hypertrophy with no exercise induced wall motion abnormalities, and no exercise induced dysrhythmia. Dr. JM found the study "discordant" and stated that the findings suggested the need for more reliable testing, such as an exercise nuclear study. Dr. JM stated that coronary disease should be presumed and advanced the Veteran's Altace to 10 mg per day in order to reach the threshold for its reported benefit in terms of decreased cerebrovascular accident and myocardial infarction. He also suggested the addition of Aspirin to the Veteran's daily regimen and further recommended, but did not prescribe, a statin, given the Veteran's multiple risk factors and the implied presence of coronary heart disease. One day later, on November 16, 2004, the Veteran underwent stress testing again. The EKG was again suspicious, but nondiagnostic for ischemia, with no exercise induced dysrhythmia. Nuclear images were pending. That same day, the Veteran underwent dual radionuclear stress photon emission computerized tomography (SPECT) imaging. The stress SPECT perfusion scan demonstrated essentially normal tracer uptake, but the area did reperfuse on the resting study. The impressions were as follows: 1) minimally abnormal stress SPECT perfusion scan reflecting a small area of inferolateral ischemia that essentially completely reverses on the resting study, suggesting a smaller branch and not suggesting high grade proximal coronary heart disease; 2) ejection fraction of 80 percent; and 3) normal wall motion. In a November 22nd letter, Dr. JM noted chest pain on the Veteran's initial stress test. Dr. JM noted that the study was only minimally abnormal and did not justify pursuit invasively, but the study did, based on his risk factors, justify the usual constellation of agents in patients with known coronary heart disease including a statin, ace inhibitor, and aspirin. Dr. JM stated that with no significant angina symptoms and a diagnosis of diabetes, he chose not to initiate the use of beta blockers. In November and December 2004 private medical records, the Veteran's medications included Altace and aspirin. In a January 2005 letter, a private physician noted that a cardiovascular exam was unremarkable. The impression was multiple risk factors for coronary heart disease. It was recommended that the Veteran switch from Altace to Lotrel and continue the statin (Lipitor). In a March 2005 private record, the medications included Lotrel, Lipitor, and aspirin. In a May 2005 letter, Dr. JM noted that the Veteran was being followed for a history of hypertension, diabetes, and an abnormal stress test. His medications at that time include Lotrel, Lipitor, and aspirin. On September 2005 VA diabetes examination, it was noted that the Veteran had been found to have hypertension and a heart murmur, for which he was referred to a private cardiologist. The examiner cited the May 2005 letter indicating an abnormal stress lest. The Veteran believed that the reason for the stress test was that a private physician had discovered a heart murmur. The examiner noted no history of rheumatic fever or other cause for heart murmur. The examiner stated that the list of current medications included two medications for hypertension but none for CAD. On physical examination, the heart was normal in size with a regular rhythm. There was a Grade 3 systolic murmur. A chest X-ray showed normal cardiomediastinal silhouette and no hilar masses. An EKG showed a T-wave abnormality, but was otherwise normal. The diagnoses included a loud systolic heart murmur of unknown etiology, and possible valvular disease. In a September 2005 VA treatment record, the Veteran denied any chest pain, shortness of breath, or dyspnea on exertion. On physical examination, his heart was regular in rate and rhythm. In a February 2006 VA record, the Veteran reported occasional fatigue but no chest pain, shortness of breath, or dyspnea on exertion. On physical examination, his heart was regular in rate and rhythm. In a June 2006 VA record, the Veteran reported that he would feel his heart flutter for eight seconds, which occurred once a week, was not related to any activities, and was possibly secondary to his caffeine intake. He denied any chest pain or tightness. On physical examination, a loud systolic murmur was noted, radiating to the left mid axilla, with no carotid bruits or jugular venous distention (JVD). It was noted that his exercise tolerance was unlimited, and he walked 1 to 2 miles per day without shortness of breath or chest pain. He denied any myocardial infarction, angina, CHF, pacemaker, ischemic cardiac disease, or valvular heart disease. EKG results were noted to be unchanged from previous testing in September 2005. It was noted that the Veteran's significant heart murmur was most likely mitral regurgitation. For this time period, the JMR found that the prior Board decision did not fully address records suggesting continuous medication, including records dated in November 2004, January 2005, May 2005, September 2005, June 2006, and September 2006. This deficiency is addressed below. The Board finds that, resolving all reasonable doubt in favor of the Veteran, a 10 percent evaluation is warranted for this time period. METs testing did not indicate a workload of greater than 7 METs but less than 10 METs; rather, METs testing indicated a workload of 10.4. An increased evaluation on this basis is not warranted. The Board finds, however, that the Veteran was taking continuous medication. It is not entirely clear whether this medication was required or merely recommended, but resolving all doubt in favor of the Veteran, a 10 percent evaluation is warranted on this basis. November and December 2004 private treatment records demonstrate that the Veteran's medications included aspirin, Altace, and a statin. In another November 2004 private record, Dr. JM noted that the Veteran's studies and risk factors justified the prescription of a statin, ace inhibitor, and aspirin. A September 2005 VA examiner noted that the Veteran's list of medications included medications for hypertension, but none for CAD. However, the Dr. JM clearly recommended the use of the above-noted medications for the Veteran's CAD. Accordingly, a 10 percent evaluation is assigned for this time period. A 30 percent evaluation, however, is not warranted. Although left ventricular hypertrophy was noted in a November 2004 resting EKG, Dr. JM found the studies completed that day "discordant" and recommended a further nuclear study. Upon the subsequent nuclear study, no hypertrophy was noted. Additionally, a chest x-ray and an EKG at the September 2005 VA examination did not indicate hypertrophy. A June 2006 VA medical record noted that EKG testing was unchanged from the September 2005 EKG results. Additionally, a September 2006 VA examiner noted that the 2004 EKG indicated "borderline" hypertrophy. Further, METs testing did not result in a workload of greater than 5 but not greater than 7, as indicated by METs testing results of 10.4. Accordingly, this diagnostic code does not provide for an evaluation in excess of 10 percent. The Board has considered other potentially applicable diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). But there was no rheumatic heart disease, valvular heart disease, endocarditis, pericarditis, pericardial adhesions, syphilitic heart disease, myocardial infarction, hyperthyroid heart disease, supraventricular arrhythmias, ventricular arrhythmias, atrioventricular block, heart valve replacement, coronary bypass surgery, implantable cardiac pacemakers, cardiac transplantation, or cardiomyopathy. 38 C.F.R. § 4.104, Diagnostic Codes 7000, 7001, 7002, 7003, 7004, 7006, 7008, 7010, 7011, 7015, 7020 (2012). Additionally, hypertensive heart disease is evaluated under criteria identical to CAD. 38 C.F.R. § 4.104, Diagnostic Code 7007 (2012). Accordingly, an increased evaluation under alternate diagnostic codes is not warranted. Evaluation from September 7, 2006 to November 14, 2006 The Veteran is assigned a 10 percent evaluation for this time period, which contemplates a workload of greater than 7 METs but not greater than 10 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent evaluation is assigned for a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on ECG, EKG, or X-ray. A 60 percent evaluation is assigned for 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 that 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 7005. On September 2006 VA heart examination, the Veteran denied any chest pain or shortness of breath. He reported that if he walked more than four flights of stairs, he would get a little short of breath; otherwise he could manage most of his activities. He reported that for the last few years he had occasions of palpitations which lasted for about 10 seconds. He denied any leg swelling, orthopnea, or paroxysmal nocturnal dyspnea (PND). It was noted that he was found to have a murmur on examination 3 years earlier and was referred for an EKG, which showed borderline left ventricular hypertrophy with normal systolic left ventricular function and an ejection fraction of 70 percent. It was otherwise a normal EKG. The examiner noted that previous EKG testing showed normal sinus rhythm, stress testing showed good exercise tolerance for his condition, and a nuclear study showed a minimally abnormal stress perfusion scan with a reversible defect; the extent of the area of ischemia suggested a small branch but did not suggest high-grade proximal CAD. Ejection fraction at that time was 80 percent. On physical examination, a loud systolic murmur was heard in the tricuspid area radiating to the axilla. An exercise test day showed 7.7 METs. The impression was CAD. The Veteran denied any symptoms of heart disease, yet he had a murmur on examination which was followed up with an EKG that showed no abnormalities. The examiner noted the 2004 stress test which showed CAD with reversible defect, which was more likely than not secondary to ischemia in the smaller branch. A November 2006 VA record contained an exercise test with results of METS of 11.10. On November 2006 private treatment, it was noted that he had recently been evaluated at VA with stress testing after developing chest pain anginal in nature. On stress testing, the Veteran's maximum workload was 10.4 METs; his discomfort was exertional and mid retrosternal and radiated to the right shoulder. An ECG showed normal sinus rhythm, left atrial enlargement, left ventricular hypertrophy, and T-wave abnormality. Chest X-ray showed the heart size to be normal. For this time period, the JMR found that although the Board cited to an August 2007 EKG that suggested entitlement to a 30 percent evaluation, the Board required medical evidence linking the results to the Veteran's service-connected CAD. The JMR found that this was not explicitly required by the applicable diagnostic code. This deficiency is addressed below. The Board finds that a 30 percent evaluation is warranted for this time period. METs testing did not indicate a workload of greater than 5 but not greater than 7 METs; rather METs testing indicated a workload of 7.7, 10.4, and 11.1. The Board finds, however, that cardiac hypertrophy has been shown by EKG or ECG. The September 2006 VA heart examination noted that a prior EKG showed borderline left ventricular hypertrophy. A November 2006 private record noted left ventricular hypertrophy as indicated by an ECG. Accordingly, a 30 percent evaluation is assigned for this time period. A 60 percent evaluation, however, is not warranted. The evidence of record for this time period indicates there has been no acute CHF. Additionally, testing was not greater than 3 METs but less than 5 METs; rather the workload was 7.7, 10.4, 11.1 METs. And although left ventricular hypertrophy was noted, left ventricular dysfunction was not demonstrated. The September 2006 VA examination noted a prior EKG showed normal left ventricular function. Even in June 2007, the left ventricular function was well-preserved. Accordingly, an evaluation in excess of 30 percent is not warranted for this time period. The Board has considered the application of other diagnostic codes. See Schafrath, 1 Vet. App. 589. But there was no rheumatic heart disease, valvular heart disease, endocarditis, pericarditis, pericardial adhesions, syphilitic heart disease, myocardial infarction, hyperthyroid heart disease, supraventricular arrhythmias, ventricular arrhythmias, atrioventricular block, heart valve replacement, coronary bypass surgery, implantable cardiac pacemakers, cardiac transplantation, or cardiomyopathy. 38 C.F.R. § 4.104, Diagnostic Codes 7000-04, 7006, 7008, 7010, 7011, 7015, 7020. Additionally, hypertensive heart disease is evaluated under criteria identical to CAD. 38 C.F.R. § 4.104, Diagnostic Code 7007. Accordingly, an increased evaluation under alternate diagnostic codes is not warranted. Evaluation from March 1, 2007 to May 3, 2010 Following his November 2006 surgery, the Veteran's CAD was assigned a 10 percent evaluation under the diagnostic code for coronary bypass surgery and changed to CAD status-post CABG, which contemplates a workload greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication is required. 38 C.F.R. § 4.104, Diagnostic Code 7017. A 30 percent evaluation is assigned if the evidence demonstrates workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on EKG, ECG, or X-ray. A 60 percent evaluation is assigned for more than one episode of acute CHF in the past year, or workload of greater than 3 METs but not greater than 5 METs that 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. The evidence indicates that the Veteran underwent CABG on November 14, 2006. A December 2006 letter from the private surgeon noted that the Veteran underwent double CABG. His postoperative course was relatively smooth and he was doing well on a routine follow-up visit with no new complaints. On physical examination, heart sounds were regular without murmurs or rubs. All wounds were healed and his sternum was stable. A chest X-ray showed postoperative changes, including some residual density in the left posterior costophrenic sulcus. A December 2006 private medical record noted that it had been one month since the Veteran's double bypass surgery, and he had done well. He did not complain of any chest pain or other anginal equivalent. He was on the appropriate regimen of an Ace inhibitor, a statin, aspirin, and a beta blocker. His cardiovascular exam was unremarkable. The impression was coronary heart disease status post coronary bypass surgery, doing well. On January 2007 stress testing, the Veteran's maximum workload was 11.1 METs. The private physician noted that exercise was terminated secondary to leg pain. The Veteran experienced no significant dysrhythmia and there were no significant ST segment changes. The impressions were good exercise tolerance for the Veteran's age and condition, EKG negative for ischemia, and no exercise-induced dysrhythmia. Following a nuclear study, the impressions included an essentially normal SPECT perfusion scan with no evidence of significant reversible ischemia, an ejection fraction measuring 67 percent, and normal wall motion. On June 2007 VA heart examination, an outpatient exercise stress test was abnormal, and the Veteran had progressively worsening shortness of breath. The examiner noted that the Veteran underwent a cardiac cath in November 2006 which showed well preserved left ventricular function with mildly dilated left ventricular diastolic pressure; there was 50 percent narrowing of the distal left atrial dimension (LAD). The examiner noted the history of CABG in November 2006. On examination, the Veteran denied chest pain, shortness of breath, generalized fatigue, palpitations, orthopnea, PND, or lower extremity edema. On physical examination, the heart was regular in rate and rhythm. The examiner estimated the METS to be between 5 and 6, but the results of stress testing showed that the Veteran's maximum workload was 8.7 METs; he exercised to 84 percent of his maximum predicted heart rate, and testing was discontinued due to peripheral muscle fatigue. On stress testing, the Veteran did not complain of chest pain. The Veteran was noted to have multiple risk factors including diabetes, hypertension, hypercholesterolemia, and smoking history. He had significant left main and proximal left anterior descending artery lesions on cardiac catheterization and underwent CABG surgery in November 2006. The examiner noted that the Veteran was doing well and denied shortness of breath and chest pain but endorsed generalized fatigue. In September 2007 VA treatment records, the assessment was no evidence of endocarditis on transthoracic EKG. The assessment was also CAD status-post CABG and asymptomatic hypertrophic obstructive cardiomyopathy (HOCM) found on transthoracic EKG. On September 2008 VA heart examination, the examiner noted that the Veteran had a cardiology workup in November 2007 which included review of an August 2007 transtracheal EKG, which showed normal left ventricular and right ventricular systolic function, concentric left ventricular hypertrophy with HOCM physiology, and a dilated left atrium. The findings were considered as asymptomatic HOCM found on transthoracic EKG. The Veteran's prescription of Metoprolol was increased. On current examination, the Veteran reported angina once to twice per month. He had been given Nitrolingual spray by his private cardiologist but had not used it, because his infrequent angina pain subsided upon sitting down. He reported that he usually noticed angina when climbing stairs, rushing, or under stress; he tried to control the climbing pain by going slowly and resting on flights, or avoiding stairs if possible. He denied any dyspnea, but reported being tired and fatigued frequently, often taking short (10 minute) naps while at work. He denied any history of dizziness or syncopal attacks. The Veteran had no history of congestive heart failure, myocardial infarction, or rheumatic heart disease. A recent EKG revealed evidence of some valvular changes with thickening of the aortic valve without vegetation, moderate mitral regurgitation posteriorly directed due to systolic anterior motion of the anterior mitral leaflet clarified on testing. Left and right ventricular systolic function appeared preserved on August 2007 evaluations. Stress testing performed the day before the September 2008 VA examination showed a workload of 7.9 METs. On physical examination, the heart was regular in rate and rhythm with no rubs or gallop noted. A murmur was heard that was classified as a crescendo-decrescendo murmur heard over the entire precordium but did not appear to radiate. Chest X-ray results showed a normal cardiomediastinal silhouette with normal pulmonary vasculature. The diagnoses included CAD with stable angina associated with cardiomyopathy. The level of disability was stable, with METs of 7.9. In a November 2008 VA medical record, the Veteran denied chest pain, shortness of breath, and orthopnea. He reported dyspnea on exertion with minimal activity, relieved by rest. Prior to the CABG, he had chest tightness with activity but was not currently experiencing that. Upon examination, there was 3/6 systolic murmur radiating to carotids. In a February 2009 VA record, the Veteran reported he was seen by outside physicians and takes aspirin and fenofibrate. He reported one episode of severe dyspnea on exertion after climbing 1 flight of stairs. He reported getting a stress test done in January, and he was told his HOCM had worsened. He did not have chest pain or orthopnea. May 2009 VA record noted CAD status-post CABG. The Veteran was seen for follow-up. He stated he was last seen by his cardiologist last week with repeat transthoracic EKG which showed no gradient, and his murmur was not heard. He was still with dyspnea on exertion with 1 flight of stairs, intermittently, but was trying to be physically active and watch his diet. He denied chest pain and orthopnea. Examination indicated regular rate and rhythm, 4/6 systolic murmur, increased with valsalva. All of these records indicate the Veteran remained on the following medications: Lisinopril, loratadine, Metoprolol, nitroglycerin, Verapamil, aspirin, fenofibrate, and ferrous sulfate. At the September 2009 Travel Board hearing, the Veteran testified that he had no energy to do anything since his diagnosis with CAD. He testified that he could not work as long as he used to and he had to take an hour break in the middle of the workday, with his manager's approval, to increase his energy level. He testified that he could not climb stairs anymore because it caused him shortness of breath. He testified that he was unable to mow his lawn anymore. He testified that he could walk as long as there was no incline. He testified that he was taking Verapamil to keep his heart rate down. The Veteran submitted a September 2009 medical opinion letter from his private treating cardiologist, Dr. TA. Dr. TA noted that, upon first seeing the Veteran, he had records of a VA EKG that showed a significant left ventricular outflow tract gradient of 47 mmHg at rest, which increased to 97 mmHg with a Valsalva maneuver. The Veteran was noted to have significant exertional dyspnea, which was noted to be New York Heart Association class III. Dr. TA performed another EKG that showed similar findings, including asymmetric septal hypertrophy and a resting left ventricular outflow tract gradient of 155 mmHg due to systolic motion of the anterior mitral valve leaflet. A nuclear perfusion study showed no evidence of ischemia. A cardiac catheterization confirmed the outflow tract gradient and examined the Veteran's anatomy for suitability for an alcohol septal ablation, but his coronary anatomy would not allow for it. His medications included Verapamil and Metoprolol, which produced most improvement, although Dr. TA opined that the Veteran still had class II or III symptoms most of the time. Dr. TA noted that he had not performed a walking stress test due to the Veteran's severe symptoms although he would be very surprised if he could achieve 5 METs of work. Dr. TA opined that the Veteran met every criterion for cardiac hypertrophy and had, in addition to coronary disease, hypertrophic cardiomyopathy. He supported a higher level of disability based on his findings. Dr. TA noted that the Veteran's condition was long-standing and his only option was a surgical option, that itself had a significant mortality/morbidity issue. In a December 2009 VA treatment record, the Veteran was seen for follow-up. The assessment was CAD, status-post CABG. He reported feeling more rundown lately. There was no chest pain, but since the last visit, he had noted some orthopnea. He could climb a max of 2 flights of stairs and becomes dispneic with minimal activity. The impression was CAD, continue ace inhibitor, beta blocker, aspirin, and statin. In a March 2010 VA treatment record, the Veteran was seen for follow-up. It was noted that previously, the Veteran was on certain medications for his diabetes and had increased shortness of breath. Since then, he'd been switched to Metformin and Glyburide, but still had shortness of breath with exertion. His exercise tolerance remained the same, max 2 flights of stairs. Upon examination, there was easy fatigue, but a denial of chest pain, shortness of breath, PND, and orthopnea. The heart was regular in rate and rhythm, with a 3/6 systolic murmur, increased with valsalva. The impression was CAD, continue ace inhibitor, beta blocker, aspirin, and statin. The Veteran was afforded a VA heart examination in May 2010. The examiner noted the history of November 2006 CABG surgery. The examiner also noted an August 2007 EKG that showed concentric left ventricular hypertrophy with hypertrophic cardiomyopathy physiology and dilated left atrium, with an ejection fraction of greater than 50 percent. The examiner noted the September 2008 exercise stress test was negative at moderate functional capacity, with a workload of 7.9 METs, and the September 2008 EKG showed sinus brachycardia and lateral T-wave abnormalities. The Veteran reported dyspnea with exertion; walking two blocks or climbing two flights of stairs caused him shortness of breath and discomfort in his anterior chest. He reported fatigue and occasional mild dizziness, but denied any syncope, orthopnea, or peripheral edema. The Veteran reported that his symptoms occurred daily. He reported that he was able to mow his yard using a push mower but it took him half a day to do so. He reported that he was able to vacuum slowly but not shovel. The examiner estimated the Veteran's maximum METs to be in the 5 to 7 range. On physical examination, the heart was regular in rate and rhythm. A Grade III/VI systolic harsh murmur at the apex upper right sternal border and upper left sternal border was noted. The murmur became more pronounced with a Valsalva maneuver but was without change from squatting to a standing position. The examiner diagnosed ischemic heart disease, status-post CABG, and hypertrophic cardiomyopathy. The JMR noted that although the Board cited to an August 2007 EKG that suggested entitlement to a 30 percent evaluation, the Board required medical evidence linking the results to the Veteran's service-connected CAD. The JMR also found that the diagnostic code did not appear to require such evidence. Regarding this time period, the JMR noted that the Board did not fully address a September 2009 letter from a private physician indicating an estimated METS of 5. These deficiencies are addressed below. The Board finds that a 30 percent evaluation, but no more, is warranted for the time period from March 1, 2007 to May 3, 2010 (following the Veteran's CABG surgery and temporary total evaluation period for convalescence). The Veteran's CAD does not cause a workload of greater than 5 but not greater than 7 METs; the actual recorded METs were 7.9 and 8.7. Although Dr. TA stated he would be surprised if the Veteran could achieve 5 METs and the 2010 VA examiner estimated in between 5 and 7 METs, the actual results of METs testing indicated a workload of 7.9 and 8.7. An increased evaluation on this basis is thus not warranted. However, the evidence of record demonstrates the Veteran's CAD is manifested by cardiac hypertrophy. In a September 2009 letter, Dr. TA stated that the criteria for cardiac hypertrophy were met. Left ventricular hypertrophy was shown on an August 2007 EKG. A 30 percent evaluation is thus warranted. A 60 percent evaluation, however, is not for assignment. The evidence shows there is no acute CHF, the METs testing resulted in a workload of 7.9, 8.7, and 11.1, which does not show METs greater than 3 but not greater than 5. Additionally, the evidence demonstrates that there is no left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A November 2006 cardiac cath showed well-preserved left ventricular function. The June 2007 VA examination noted well preserved left ventricular function. An August 2007 EKG showed normal left ventricular systolic function. A 60 percent evaluation is thus not for assignment. An increased evaluation under other potentially applicable diagnostic codes has been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). But there was no rheumatic heart disease, valvular heart disease, endocarditis, pericarditis, pericardial adhesions, syphilitic heart disease, myocardial infarction, hyperthyroid heart disease, supraventricular arrhythmias, ventricular arrhythmias, atrioventricular block, heart valve replacement, coronary bypass surgery, implantable cardiac pacemakers, or cardiac transplantation. 38 C.F.R. § 4.104, Diagnostic Codes 7000, 7001, 7002, 7003, 7004, 7006, 7008, 7010, 7011, 7015. Additionally, hypertensive heart disease, CAD, and cardiomyopathy are rated identically to CABG. 38 C.F.R. § 4.104, Diagnostic Codes 7005, 7007, 7020 (2012). Accordingly, alternative diagnostic codes do not provide for an increased evaluation. Finally, the Board notes that the May 2010 VA examiner stated that the Veteran's symptoms are due to a combination of his service-connected ischemic heart disease and his non-service-connected hypertrophic cardiomyopathy. The examiner explained that hypertrophic cardiomyopathy is a genetic disease, and is not secondary to ischemic heart disease (to include CAD). Based on the results of a nuclear perfusion test, showing no evidence of ischemia, versus the results of an EKG, showing a significant gradient from the hypertrophic cardiomyopathy, the VA examiner opined that the major disease causing the symptomatology and functional loss is the Veteran's non-ervice-connected cardiomyopathy. The VA examiner noted that the service-connected ischemic heart disease was a factor, but has less of an effect on his functionality. Where it is not possible to distinguish symptoms of the service connected disability being rated from those of a co-existing nonservice-connected disability, the reasonable doubt doctrine dictates that all symptoms should be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). In this case, although the May 2010 VA examiner clearly noted that some of the symptoms were due only to a non-service-connected hypertrophic cardiomyopathy, the examiner did not distinguish which symptoms were related to which disorder and noted that the CAD was a factor. Therefore, the Board finds that the effects of hypertrophic cardiomyopathy and the effects of CAD cannot be separated. Extraschedular evaluation Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this regard, the schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected CAD but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's CAD, as the criteria assess functional loss such as METs testing, dyspnea, fatigue, angina, dizziness, syncope, the use of medication, and other diagnostic findings such as cardiac hypertrophy. The Veteran's symptoms of fatigue, dyspnea, angina, decreased METS, and cardiac hypertrophy, are reflected in these criteria. Moreover, the evidence does not demonstrate other related factors. For the time periods on appeal, and excluding the Veteran's heart surgery, the Veteran has not required hospitalization due to service-connected CAD. Furthermore, the Veteran has not alleged, and the record does not indicate, marked interference of employment due to CAD. At the 2007 and 2010 VA examinations, the Veteran reported he worked in computer operations in a sedentary position. At the 2010 examination, he stated that although the symptoms were distracting, the symptoms did not prevent him from working or cause functional loss at work. Accordingly, this issue need not be referred for consideration of an extraschedular rating. ORDER From May 25, 2005, to September 7, 2006, a 10 percent evaluation, but no more, is assigned for the Veteran's service-connected CAD, subject to the laws and regulations governing the payment of monetary benefits. From September 7, 2006 to November 14, 2006, a 30 percent evaluation, but no more, is assigned for the Veteran's service-connected CAD, subject to the laws and regulations governing the payment of monetary benefits. From March 1, 2007 to May 3, 2010, a 30 percent evaluation, but no more, is assigned for the Veteran's service-connected CAD status-post CABG, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ CHERYL MASON Veterans Law Judge, Board of Veterans' Appeals