Citation Nr: 1320694 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 11-01 214 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a heart disorder. 2. Entitlement to a rating in excess of 30 percent for calcification of the right upper lobe of the lung (lung disorder). REPRESENTATION Veteran represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran had active military service from August 1966 to July 1970. This appeal comes to the Board of Veterans' Appeals (Board) from December 2009 and February 2010 rating decisions. The Veteran testified at a January 2012 Board hearing before the undersigned, which was held at the Roanoke RO. A transcript of the hearing has been associated with the claims file. In the October 2012 remand, the Board concluded that the Veteran's statement in his substantive appeal gave the Board jurisdiction over his claim for an increased rating for his service-connected lung disorder. See 38 C.F.R. §§ 20.101(d), 20.200 (2012). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran's heart disability either began during or was otherwise caused by his military service; or that it was caused or aggravated by his service connected lung disability. 2. The weight of the evidence does not establish that a rating in excess of 30 percent is warranted for his service connected lung disability. CONCLUSIONS OF LAW 1. Criteria for service connection for a heart disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. Criteria for a rating in excess of 30 percent for a lung disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.96, 4.97, Diagnostic Codes (DCs) 6820, 6828 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection may also be granted for a chronic disease shown in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection. Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In this case, the Veteran is seeking service connection for a heart condition. At a VA examination in November 2012, the Veteran was diagnosed with cardiomyopathy, which is a form of myocarditis, and is considered to be a "chronic disease" listed under 38 C.F.R. § 3.309(a), therefore 38 C.F.R. § 3.303(b) does apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, as will be discussed, the Veteran's cardiomyopathy is not shown to have become chronic in service, was not continuous from service, and did not manifest to 10 percent within a year of separation from service. Instead, the Veteran's heart condition was not diagnosed for more than 20 years after he separated from service. As such, service connection is not warranted under 38 C.F.R. § 3.303(b). In his notice of disagreement, the Veteran asserted that he had served in Vietnam and was exposed to Agent Orange, he also asserted that he was taking two medications for hypertension. Certain chronic diseases, including hypertension, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Here, however, hypertension was not diagnosed for multiple decades after service and thus this presumptive service connection is not available. The Veteran did serve in Vietnam, and he is therefore presumed to have been exposed to herbicides. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6). However, neither cardiomyopathy, nor hypertension, has been presumptively linked to herbicide exposure. Service connection is presumptively warranted for ischemic heart disease and coronary artery disease based on herbicide exposure, however, the Veteran has specifically been found not to have either ischemic heart disease or coronary artery disease by recent VA examinations. The Board no turns to the Veteran's contentions on a direct basis. The Veteran contends that service connection is warranted for a heart condition. He points to the fact that he was noted to have a heart murmur on his separation physical and he believes that if more sophisticated testing was available at that time that it would have shown the presence of a heart condition. At his hearing before the Board in 2012, the Veteran testified that it was his belief that his high blood pressure, weakness, and shortness of breath were secondary to a heart condition that developed in service. He did however deny receiving any heart treatment between 1972 and 1995. The Veteran recalled finding out about the murmur at his separation physical and then being sent to Salem for an evaluation to determine if anything was wrong. He remembered jogging in place while the doctor listened to his heart, and then having the doctor tell him to go home and get a job (which essentially implies that no heart disability was found, a conclusion which is supported by the medical evidence of record from the time of separation and shortly thereafter that did not show the presence of a heart disability). The Veteran also denied experiencing any of his current symptoms such as shortness of breath and weakness while in service. The Veteran's June 1970 separation physical did note a "Grade III/VI murmur heard best at [the] aortic area with radiation into [the] neck and back"; and a June 1970 consultation report stated that the Veteran had a systolic ejection murmur in the aortic area with radiation into the neck. The Veteran was referred for testing, but there was no diastolic murmur found; there were no symptoms of cardiovascular disease ("CV disease") or congestive heart failure; and an ECG was within normal limits. Shortly after separation, in October 1970, the Veteran filed claims for service connection for heart and lung conditions. He was provided with a VA examination in November 1970 at which a chest x-ray was essentially normal, an EKG was interpreted as normal. The examiner found no evidence of heart disease, noting that the heart was not enlarged, the rhythm was regular, and no murmurs were noted in standing, supine, or left lateral decubitus positions, and no murmurs were heard after exercise. In November 1971, the Veteran asserted that he had been diagnosed with a slight heart ailment while stationed in Vietnam, and he contended that the examination shortly after service had found that he had a heart condition but that it was simply not serious enough to warrant disability compensation. However, he asserted that he had begun to experience more frequent and severe pains in the heart region. Yet, the medical evidence of record, including testing, did not lead to any heart disability being diagnosed at that time, and as noted, the VA examination in 1970 specifically found no heart disease. The Board does not dispute that the Veteran was noted to have a murmur at his separation physical, as such is plainly established by the evidence of record, but such a finding does not in and of itself establish a chronic heart disorder. As the VA examiner explained in November 2012, the presence of a systolic murmur in an otherwise healthy, young, asymptomatic person is called a functional murmur and has no medical meaning; it is neither a disease nor a disorder. Rather, it is simply an incidental finding. The Veteran wrote another statement in April 1995 asserting that he was having shortness of breath and asked for his heart condition to be considered again. At an October 1998 VA examination, the Veteran reported getting shortness of breath with exertion. The cardiac examination showed regular rate and rhythm and there was a grade two midsystolic murmur. There were no bruits, irregular beats, or rubs or gallups. An EKG was normal, and no other abnormalities were noted. There was no other evidence at the time showing the presence of a heart disorder. In September 2009, a VA echocardiogram report showed a diagnosis of mildly increased left atrial dimensions, moderately impaired left ventricular systolic function with wall motion abnormalities, and mild mitral regurgitation. A September 2010 VA angiogram report reflects a diagnosis of mild (less than 30 percent) stenosis of the proximal left circumflex artery. A December 2011 VA treatment record also shows a diagnosis of non-ischemic cardiomyopathy (NICM) and pulmonary hypertension. In October 2009 the Veteran reported getting shortness of breath and tired with moderate activity. He was assessed with severe COPD and moderate left ventricular dysfunction. The Veteran was provided with a VA examination in August 2010. The examination found no evidence of congestive heart failure, or pulmonary hypertension. A murmur was noted, but regular rhythm and no abnormal breath sounds. An echocardiogram showed that the Veteran's heart was normal in size; the Veteran had an ejection fraction of 45 percent. The left atrium was normal in size, the left ventricle was mildly dilated, and the left ventricular systolic function was moderately reduced. The impression of the examiner was that the Veteran had mildly increased left atrial dimensions, moderately impaired left ventricular systolic function with wall motion abnormalities and mild mitral regurgitation. It was also specifically found that ischemic heart disease was not present. In September 2010, a CT angiogram did not show any significant coronary artery stenosis. In his substantive appeal, the Veteran again asserted that he was diagnosed with a murmur in service, and he theorized that the medical technology did not exist at that time to diagnose any actual heart problem. He also asserted that the murmur led to his developing high blood pressure, weakness, and shortness of breath. However, while he, as a lay person, is competent to report what comes to him through his senses (such as reporting a symptom like shortness of breath), he lacks the medical training and expertise to provide a complex medical opinion such as diagnosing a heart disability or determining its etiology. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, his opinion is insufficiently competent to provide the requisite nexus between a current heart disorder and his military service. Nevertheless, given the fact that a systolic heart murmur was detected during active service and again in October 1998, the Board concluded that a medical opinion of record should be obtained to address whether the Veteran had a current heart disability as a result of his military service. The Board also sought clarification as to whether the murmur that was detected was considered a clinically significant (i.e. disabling) condition. In this regard, the Board noted that a physiologic murmur, also known as a functional or innocent murmur, is defined as one which is generated in the absence of organic cardiac disease. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 706 (31st ed. 2007). As such, it would not constitute a disability for VA compensation purposes. See, e.g. 38 C.F.R. § 4.104, DC 7015, NOTE (2011) (providing, in pertinent part, that with regard to atrioventricular block, simple delayed P-R conduction time, in the absence of other evidence of cardiac disease, is not a disability). The Board also sought clarification as to whether the left ventricular dysfunction diagnosed by the September 2009 VA echocardiogram or any other current heart disorder was related to, or otherwise caused by, the heart murmur detected during active service; and clarification as to whether the Veteran has a disorder secondary to (i.e. caused or aggravated by) his service-connected lung disorder, to include the possibility that pulmonary hypertension was caused by his service connected lung disorder and in turn caused a heart disorder. The Veteran underwent the VA examination in November 2012. The examiner diagnosed cardiomyopathy with onset in 2009 and hypertension diagnosed in 1995. The examiner noted the Veteran's concerns about his ongoing shortness of breath, and the past notation of a heart murmur. He also noted that an echocardiogram revealed a weakened heart and showed cardiac hypertrophy. An EKG showed complete left bundle branch block (LBBB). However, the examiner specifically found that ischemic heart disease was not present and noted that the Veteran had not experienced either a myocardial infarction or congestive heart failure. The examiner opined the diagnosed conditions were less likely than not incurred in or caused by service. He acknowledged that the Veteran had what was initially characterized as a grade 3/6 systolic murmur during his separation physical in 1970, and observed that one medical professional even entertained the possibility of aortic stenosis. However, the examiner pointed out that an internal medicine consult found no history that would suggest cardiovascular disease, and no prior history that would put the Veteran at risk for valvular heart disease. The examiner noted that a systolic murmur was seen, but an EKG was normal and no cardiac disease was diagnosed. The examiner explained that the murmur is not a disease disorder, congenital or developmental, and it was not something that could be made worse with military service. The examiner observed that following service the Veteran required no further cardiac evaluation or treatment until the 1990s at which time he was diagnosed with cardiomyopathy. Having reviewed the evidence of record and examined the Veteran, the examiner concluded that it was less likely than not that the Veteran's heart murmur itself is a disorder. The examiner also opined that it was less likely than not that the Veteran's current heart disorder (ventricular dysfunction with no evidence of ischemia) was secondary to his military service or to the heart murmur shown in service. The examiner noted that the Veteran's heart condition was secondary either to his pulmonary hypertension or to his chronic hypertension, neither of which has been shown to be related to either the Veteran's military service or to his service connected lung disability. The examiner noted that the Veteran's diastolic dysfunction on the echocardiogram was consistent with chronic systolic hypertension, noting that the Veteran was not found to have cardiovascular disease at separation, and that the heart murmur that was noted at separation was insignificant and was common in young, asymptomatic healthy people. That is the heart murmur was not a cardiac disorder, but rather a variation of normal in the population. The Veteran also did not require any additional care for approximately 25 years after his discharge. The examiner allowed that there was evidence that the Veteran had pulmonary hypertension, but noted that for a definitive diagnosis to be made, a right heart catheterization would need to be performed. The examiner also allowed that if the Veteran had pulmonary hypertension, it was possible that it could have caused or contributed to his current heart problems in the sense that pulmonary hypertension can cause heart problems. However, the examiner explained that there were many causes of pulmonary hypertension, and he noted that it was the opinion of the pulmonary consultant that the most likely cause of pulmonary hypertension in the Veteran would be untreated sleep apnea, which is a common cause for such a condition. The examiner noted that eosinophilic granuloma was a rare condition in adults which would only theoretically cause pulmonary hypertension if it was active and causing extensive lung involvement with honeycombing seen on imaging. However, the examiner explained that such a situation was found almost exclusively in smokers, which the Veteran was not. The examiner noted that the Veteran did not have honeycombing to suggest active eosinophilic granulomatous lung disease and he had never required treatment for eosinophilic granulomatous disease of the lung. As such, the examiner concluded that the Veteran's present pulmonary left ventricular dysfunction was neither related to, nor aggravated by, either his service connected lung disorder or his heart murmur. Moreover, he opined that the eosinophilic granulomatous did not cause the left ventricular dysfunction. Given this clear and unequivocal medical opinion, the Board finds no basis to conclude that any service connected pulmonary condition caused or aggravated the Veteran's current heart disability. In December 2012, the Veteran submitted private treatment records from a cardiology consultation. The treatment records showed that the Veteran was diagnosed with hypertension, murmur, LBBB and dyspnea, but no opinion was provided as to the etiology of any of the conditions. The Veteran's claims file, including the private treatment records, were returned to the VA examiner, but he indicated in an April 2013 addendum that the records did not alter his previously expressed opinions. Having reviewed the entirety of the record, the examiner's opinion was thorough and based on a complete understanding of the Veteran's medical history and his current symptoms. Moreover, the examiner appears to have conducted all testing necessary to reach a well-informed opinion. As such, the Board finds the examiner's opinion to be highly probative and entitled to great weight. Additionally, no medical opinion has been advanced which undermines the examiner's conclusions in any way. In fact, the only evidence which supports the Veteran's allegation that he has a current heart disability as a result of his military service is through his own statements, and it has already been explained that he lacks the medical training and experience to be able to establish such a connection. In conclusion, while the Veteran was noted to have a heart murmur during service, this has not been shown to either constitute a current heart disability or to have caused a current heart disability. Additionally, the Veteran's service connected lung disability has not been shown to have caused or aggravated a current heart disability. Finally, a chronic heart disability was not shown to have either begun in service or manifested to 10 percent within a year of service, it has not been shown to have existed continuously since service, and it has not been shown to be presumptively linked to the Veteran's military service, to include as secondary to any herbicide exposure therein. As such, the criteria for service connection for a current heart disability is denied. II. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In September 2009, the Veteran filed a claim seeking an increased rating for his service connected pulmonary condition, calcification of the right upper lobe of the lung, which is rated at 30 percent under 38 C.F.R. § 4.118, Diagnostic Code 6820-6828. Diagnostic Code 6820 provides that benign neoplasms in any specified part of respiratory system should be evaluated using an appropriate respiratory analogy; and Diagnostic Code 6828 for eosinophilic granuloma of lung has been determined to be the appropriate respiratory analogy. The regulations provide that ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 will not be combined with each other or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Pursuant to 38 C.F.R. § 4.96(d): (1) pulmonary function tests (PFTs) are required to evaluate these conditions except: (i) When the results of a maximum exercise capacity test are of record and are 20 ml/kg/min or less; if a maximum exercise capacity test is not of record, evaluate based on alternative criteria; (ii) when pulmonary hypertension (documented by an echocardiogram or cardiac catheterization), cor pulmonale, or right ventricular hypertrophy has been diagnosed; (iii) when there have been one or more episodes of acute respiratory failure; or (iv) when outpatient oxygen therapy is required. (2) If the DLCO (SB) (Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method) test is not of record, evaluate based on alternative criteria as long as the examiner states why the test would not be useful or valid in a particular case. (3) When the PFTs are not consistent with clinical findings, evaluate based on the PFTs unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. (4) Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. (5) When evaluating based on PFTs, use post-bronchodilator results in applying the evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, use the pre-bronchodilator values for rating purposes. (6) When there is a disparity between the results of different PFTs (FEV-1 (Forced Expiratory Volume in one second), FVC (Forced Vital Capacity), etc.), so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. (7) If the FEV-1 and the FVC are both greater than 100 percent, do not assign a compensable evaluation based on a decreased FEV-1/FVC ratio. Under the General Rating Formula for Interstitial Lung Disease (diagnostic codes 6825 through 6833): A 10 percent rating is assigned when Forced Vital Capacity (FVC) is between 75 and 80 percent of what was predicted; or when Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is between 66-80 percent of what was predicted. A 30 percent rating is assigned when FVC is between 65 and 74 percent of what was predicted; or when DLCO (SB) is between 56 and 65 percent of what was predicted. A 60 percent rating is assigned when FVC is between 40 and 55 percent of what was predicted; when DLCO (SB) is between 40 and 55 percent of what was predicted; or when maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardiorespiratory limitation. A 100 percent rating is assigned when FVC is less than 50 percent of what was predicted; when DLCO (SB) is less than 40-percent of what was predicted; when maximum exercise capacity is less than 15 ml/kg/min oxygen consumption with cardiorespiratory limitation; when there is either cor pulmonale or pulmonary hypertension; or when outpatient oxygen therapy is required. As noted, the Veteran filed a claim for an increased rating in September 2009. He called VA in September 2009 to report that his pulmonary numbers were really low. A medical professional from VA contacted the Veteran and discussed his lung disease with him and the Veteran explained that he was afraid to take Albuterol because his mother had been allegedly overtreated with it, leading to her death. The medical professional reported convincing the Veteran of the need to repeat the PFT with the use of a bronchodilator; but a review of the subsequent treatment records and examination reports does not show that a PFT was ever conducted post bronchodilator. At a VA examination in October 2009, the Veteran stated that he started getting shortness of breath with exertion that had continued to worsen over the years. The Veteran stated that his lung function had been poor but he acknowledged having been told that it was due to his poor participation. Chest x-rays from February 2009 were reviewed but no uncalcified nodule was identified and no heart enlargement, congestive failure pneumonia, or other pathology was seen. The impression was old granulomatous change. The results of a PFT from August 2009 showed pre-bronchodilator percent of predicted of: FVC 39, FEV1, 36, FEV1/FVC 94. However, no post-bronchodilator testing was conducted. In January 2010, the Veteran presented at VA, inquiring why he did not qualify for a higher rating. The doctor noted that in reviewing the Veteran's August 2009 test results, both his forced vital capacity and FEV1 were less than 40% of predicted, which the medical professional explained were incredulous and likely due to low expired volumes/submaximal effort. The medical professional noted that the Veteran had undergone approximately 10 PFTs in the previous decade and a half and had the drill down. The medical professional also noted that the chest x-ray did not show the severe restriction suggested by the spirometry. Thus, he did not concur with the interpretation of severe obstruction, but did concur with the possibility of poor effort. The Veteran was then scheduled for additional testing. In March 2010, the Veteran was seen in the VA pulmonary clinic. The Veteran stated that his exercise tolerance had improved somewhat from the fall, but he remained significantly dyspneic with exertion. Pulmonary function testing showed FVC 2.41 (51% predicted); FEV1 1.78 (50% predicted); FEV1 ration of 74 percent; and DLCO 19.14 (59% predicted). However, the testing still appears not to have included the use of a bronchodilator. The medical professional stated that the pulmonary function testing demonstrated a moderate restrictive ventilator impairment based on spirometry and TLC (effort dependent variables); whereas his FRC was at the low range of normal (more effort independent). The Veteran was provided with an additional VA examination in November 2012. It was noted that his respiratory condition did not require the use of inhaled medications, oral bronchodilators, antibiotics or oxygen therapy. Pulmonary function testing was conducted, and the examiner stated that the test results accurately reflected the Veteran's pulmonary functioning at that time. However, the Veteran refused to take the test post-bronchodilator. Pre-bronchodilator testing showed FVC was 39 percent of predicted, FEV-1 was 38 percent of predicted, and FEV-1/FVC was 96 percent of predicted. The examiner stated that the FEV-1/FVC was the test result that most accurately reflected the Veteran's level of disability. Post-bronchodilator testing was not conducted as the Veteran refused. DLCO was not reported due to invalid effort. The Board has reviewed the entirety of the Veteran's medical treatment records from the course of his appeal. The fact remains that the Veteran has repeatedly refused to consent to the use of bronchodilators. This has rendered the pulmonary function tests which have been conducted effectively unusable for VA rating purposes. See 38 C.F.R. § 4.96 (d)(4). In this case, the examiner did not state that post-bronchodilator studies should not be done. As a result, only pre-bronchodilator results are of record, and even then there is some question of whether they are consistent with the other findings of record due to repeated poor efforts on the Veteran's part. The regulations do provide that a pulmonary function test is not require in the case of pulmonary hypertension, documented by an echocardiogram or cardiac catheterization; and in this case, pulmonary hypertension was in fact documented. See 38 C.F.R. § 4.96 (d)(1). However, the pulmonary hypertension has not found to be related to the Veteran's service connected lung disability as explained by the VA examiner in 2012, and discussed in the service connection portion of this decision. Yet, even if pulmonary function testing is not used, the evidence does not show that a higher rating would be warranted for the Veteran's service connected lung disability. The medical professional in March 2010 stated that while the Veteran's pulmonary function testing (without the use of a bronchodilator) demonstrated a moderate restrictive ventilator impairment based on spirometry and TLC (effort dependent variables); his FRC was at the low range of normal (more effort independent). As such, absent pulmonary function testing, the Veteran's clinical testing does not appear to show impairment that would warrant a rating in excess of the 30 percent that was assigned, as FRC was near normal. The Veteran has reported shortness of breath throughout the course of his appeal, but there is no showing that this is of such severity to warrant a rating in excess of 30 percent. In fact, the granuloma of the lung for which the Veteran is service connected is barely noticeable on imaging. In March 2010, the VA medical professional noted that on the dyspnea index, the Veteran was only at Stage II of V stages, with Stage I being no shortness of breath except with strenuous exertion. The Board's intention here is not to minimize the impairment caused by the Veteran's service connected lung disability or to imply that it does not impact the Veteran. However, the Veteran is currently assigned a 30 percent in recognition of this fact. As noted in the supplemental statement of the case in 2013, the Veteran's examination findings did not support a rating in excess of 30 percent, but they also did not show improvement in the Veteran's condition. Therefore, the currently assigned schedular rating is most appropriate and the Veteran's claim is denied. The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's lung disability that would render the schedular criteria inadequate. The Veteran's main symptom is shortness of breath, which is contemplated in the rating assigned, in the sense that because the Veteran refused to submit to bronchodilator testing, the regulations directed the Board to consider other factors, which required the Board to contemplate the Veteran's reported symptomatology. Moreover, even if it were found that the assigned schedular rating did not reasonably described the Veteran's symptomatology, there is no showing that his service connected lung disability caused any of the "governing norms" of an extraschedular rating. For example, he has not required any, much less frequent, hospitalization for his service connected lung disability, and the lung disability has not been shown to cause marked interference with employment, as noted by the VA examiner who stated that it caused no interference with employment. Accordingly, referral for consideration of an extraschedular rating is not warranted. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. The Board acknowledges that the Veteran is no longer employed. He has not, however, alleged that he is unemployable on account of his service connected lung disability; and the examiner in 2012 specifically found that the Veteran's service connected lung disability did not impact his ability to work. Thus, the Board finds that Rice is inapplicable to this claim since there is no evidence of unemployability due to the Veteran's service connected lung disability. III. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by letters dated in September and November 2009, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. The letters also informed the Veteran how disability ratings and effective dates were established. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Private and VA treatment records have been obtained, as have service treatment records. Additionally, the Veteran testified at a hearing before the Board in January 2012. As noted, the Board previously remanded the Veteran's claim for several VA examinations to be provided. These examinations were provided in November 2012, and the report from the examinations detailed the requisite testing that was provided, and included detailed rationales for the examiner's conclusions. In May 2013, the Veteran submitted a statement asserting that his VA examination was inadequate because the examiner did not have the appropriate background in cardiovascular and pulmonary disorders per the Board's remand instructions. The Veteran reported having asked the examiner whether he had the qualification noted in the Board remand, to which the examiner allegedly replied that if the Veteran wanted to wait for someone with the proper background, he would have to wait a long time. The Veteran believes that if the examiner had "proper qualifications" it would give him a fair chance at winning his case. The Board disagrees. The Board may assume the competency of any VA medical examiner, including nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Cox v. Nicholson, 20 Vet. App. 563 (2007). Here, the record is void of evidence suggesting that the examiner was not actually qualified through education, training, or experience to offer the medical diagnoses and opinions that he did. While he might have better, or more artfully, answered the Veteran's question as to his qualifications at the examination, the examiner was selected to provide the examination because he had the requisite qualifications. Moreover, a plain reading of the examination report shows that the requested opinions were provided following appropriate testing and the opinions were supported by a complete rationale. Given the well-reasoned opinion which was tailored to the specific facts of the Veteran's medical history, the examination is found to be fully adequate. It is noted that the Veteran's claims file was returned to the examiner following the addition of more medical records in order to determine if there was any change in his opinion, but he explained that there was not. It is also noted that no contrary medical opinion has been advanced that points out any inadequacy in the testing, conclusions, or rationales that were provided by the VA examiner. As such, the VA examination report is found to be at the very least substantially compliant with the Board's remand instructions, and because the Board's remand instructions were complied with, there is no prejudice for the Board to proceed. See Stegall v. West, 11 Vet. App. 268 (1998). As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for a heart disorder is denied. A rating in excess of 30 percent for calcification of the right upper lobe of the lung (lung disorder) is denied. ____________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs