Citation Nr: 1328359 Decision Date: 09/05/13 Archive Date: 09/16/13 DOCKET NO. 09-03 321A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for coronary artery disease, to include as secondary to service-connected hypertension. 2. Entitlement to a compensable initial rating for a thoracic aortic aneurysm. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from July 1981 to September 1992. This case comes before the Board of Veterans' Appeals (Board) on appeal of a May 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Wilmington, Delaware. Jurisdiction of the Veteran's claims file was subsequently transferred to the Baltimore, Maryland RO. The May 2007 rating decision denied service connection for coronary artery disease, but awarded service connection for a thoracic aortic aneurysm and assigned a noncompensable rating. FINDINGS OF FACT 1. Coronary artery disease was not shown to be causally or etiologically related to any disease, injury, or incident during active service, and was not caused or aggravated by a service-connected disability. 2. Prior to October 13, 2010, the Veteran's aortic aneurysm measured less than 5 centimeters in diameter, was asymptomatic, had not been surgically corrected, and did not preclude exertion. 3. Since October 13, 2010, the Veteran's aortic aneurysm has measured 5 centimeters in diameter. CONCLUSIONS OF LAW 1. Coronary artery disease was not incurred in or aggravated by the Veteran's active service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 2. Prior to October 13, 2010, criteria for a compensable rating for an aortic aneurysm have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.104, Diagnostic Code 7110 (2012). 3. Since October 13, 2010, criteria for a 100 percent rating for an aortic aneurysm have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.104, Diagnostic Code 7110 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable RO decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, with regard to the claim for service connection for coronary artery disease, a November 2006 letter, sent prior to the initial May 2007 rating decision, advised the Veteran of the evidence and information necessary to substantiate his service connection claim, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the letter advised the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. With regard to the claim for increased rating for an aortic aneurysm, the Veteran has appealed with respect to the propriety of the initially assigned rating from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for his aortic aneurysm was granted and an initial rating was assigned in the May 2007 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records and VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records necessary to decide his pending appeal. The Board has also reviewed his Virtual VA claims file. Additionally, he was afforded a VA examination in November 2011 in order to adjudicate both claims. The Board finds that the opinions and findings by the VA examiners are sufficient to decide the Veteran's claims. The Board notes that the Veteran's claims were remanded in November 2011 in order to afford him with VA examinations with opinions and current findings. As explained above, as the remand directives have been substantially complied with, no further action is necessary in this regard. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Service Connection The Veteran contends that his coronary artery disease was caused or aggravated by his service-connected hypertension with left ventricular dysfunction. He contends that his longstanding hypertension, beginning in service, has contributed to the development of his coronary artery disease. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a) . Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or evidence of continuity of symptomatology. If the disability claimed is not considered to be a chronic disease under 38 C.F.R. § 3.307, credible lay evidence of continuous symptoms may establish service connection. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic heart disease, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. A disability which is proximately due to or the result of a service-connected disease or injury shall be service- connected. 38 C.F.R. § 3.310 (2012). Secondary service connection is permitted based on aggravation. Compensation is payable for the degree of aggravation of a non-service- connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Establishing service connection on a secondary basis essentially requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.303, 3.310 (2012). Service treatment records reflect that in September 1989, the Veteran reported severe headaches related to his hypertension, as well as chest pains. An EKG was borderline for left ventricular hypertrophy. In November 1989, the Veteran presented with atypical chest pain and palpitations. His hypertension was stable on medication. He had had two episodes of atypical chest pain starting three weeks previously. A chest x-ray had shown a cardiac silhouette that was borderline enlarged, otherwise within normal limits. On February 1992 physical examination, the Veteran was noted to suffer from chest pain secondary to hypertension. On April 1994 VA examination, the Veteran reported having been diagnosed with hypertension in 1986. He had had a stress test in 1989 which was normal. He at times had a little minor chest pressure with exercise, but no definite signs of angina. On April 1998 VA examination, the Veteran reported that two weeks previously, he had been hospitalized for nausea, chest pain, and lightheadedness. However, EKG had been normal. On July 1999 VA examination, the Veteran reported occasional episodes of shortness of breath, but denied orthopnea, chest pain, or paroxysmal nocturnal dyspnea. Physical examination resulted in the assessment of no evidence of congestive heart failure. EKG showed left ventricular dysfunction, but was otherwise an unremarkable study. VA treatment records reflect that in October 1999, his blood pressure was uncontrolled, though when he took his medication, it was controlled. In March 2000, it was controlled. VA treatment records reflect that in August 2002, the Veteran had chest pain with nausea, shortness of breath, and lightheadedness. In July 2003, the Veteran reported dizziness, nausea, and vomiting following eating at a restaurant. He had had occasional episodes of chest pain over the past year which had changed in character from being more sharp to being dull in nature. He reported that a March 2001 exercise stress test had been normal. EKG was within normal limits. Chest x-ray showed slight cardiomegaly. A chest CT scan suggested the presence of coronary artery disease. However, from a prognostic standpoint, it was a low risk perfusion study suggesting minimally increased and/or risk for subsequent cardiovascular events. VA treatment records reflect that in September 2006, the Veteran presented with headaches, shortness of breath, and on and off chest pain. EKG has not changed. A chest x-ray showed cadiomegaly. On February 2007 VA examination, it was noted that the Veteran had coronary artery disease that was asymptomatic with no treatment. Because of the development of coronary artery disease, there had been some change in his hypertension. On November 2011 VA examination, it was noted that the Veteran was diagnosed with nonclinical coronary artery disease in 2003 and had no further evaluation since then. After reviewing the claims file, the examiner opined that it was less likely than not that the Veteran's coronary artery disease was caused or aggravated by his service-connected hypertension. The examiner explained that the Veteran had had documented hypertension since 1986 and was diagnosed with noncritical coronary artery disease in 2003. Hypertension was not a known cause of coronary artery disease. In terms of aggravation, there was no documentation of any worsening of his ischemic status. First, the Board finds that presumptive service connection is not warranted in this case as there is no indication that the Veteran suffered from, or was diagnosed with, coronary artery disease within one year following separation from service in 1992. 38 C.F.R. § 3.307, 3.309. Next, the Board finds that the preponderance of the evidence is against a finding that the Veteran's coronary artery disease was caused or aggravated by his service or his service-connected hypertension. On a direct basis, there is no indication of a chronic disease in service, continuity of symptoms since service, or a medical nexus to relate the current coronary artery disease to service. Specifically, the service treatment records, while showing complaints of chest pain, consistently link that chest pain with the Veteran's already service-connected hypertension with left ventricular dysfunction. At no time was the Veteran diagnosed with any other heart condition. The records are clear in categorizing the heart symptoms with his ongoing hypertension and left ventricular dysfunction, as stated on separation examination. Moreover, the post-service VA examinations conducted in 1994, 1998, and 1999 demonstrated normal stress testing and EKG findings. The Veteran reported such and the examiner's found such to be the case. Coronary artery disease was not diagnosed until 2003, more than a decade following service separation. Thus, there is no indication of coronary artery disease, or other heart disease that is not already service-connected, in service or for many years following service. Finally, there is no medical opinion or medical record to suggest that the Veteran's coronary artery disease began in service or was otherwise caused by service. The records show date of onset as 2003. Moreover, the Veteran contends that his coronary artery disease was caused by his hypertension, rather than his service. Accordingly, the Board finds that the credible and competent evidence of record weighs against the claim for service connection for coronary artery disease on a direct basis and thus the claim must be denied. The Board also finds that service connection for coronary artery disease on a secondary basis is also not warranted. In so finding, the Board places great weight on the November 2011 VA examiner's opinion because the opinion contains clear conclusions and well-explained rationale. The examiner explained that medical knowledge did not show a link between hypertension and the development of coronary artery disease. The record does not otherwise contain any medical opinion or literature to the contrary. Thus, the Board finds the examiner's reasoning to be probative. Accordingly, the Board finds that the weight of the credible and competent evidence establishes that the Veteran's hypertension did not cause his coronary artery disease. With regard to the theory of aggravation, the examiner reviewed the treatment records and found no indication of aggravation. The examiner explained that ever since the diagnosis of coronary artery disease in 2003, there was no record of any further complaints or treatment for coronary artery disease. Therefore, there was no indication that the Veteran's coronary artery disease had been aggravated by the Veteran's hypertension. In fact, a review of the record comports with the examiner's findings, as the Veteran's ongoing diagnoses are silent for coronary artery disease and the Veteran has not sought further treatment for that condition. Also, the records do not demonstrate any correlation between the onset or worsening of coronary artery disease and the longstanding hypertension. Instead, one VA medical record states the opposite, that his coronary artery disease could impact his hypertension. Accordingly, the Board finds the November 2011 VA examiner's opinion, and the medical evidence or record, probative on the matter. Therefore, the weight of the evidence establishes that coronary artery disease was not caused or aggravated by his hypertension. Lastly, the Board points out that the Veteran has not contended that his aortic aneurysm has caused or aggravated his coronary artery disease, and the evidence does not in any way support such a finding. The Board notes that the Veteran has contended on his own behalf that his coronary artery disease is related to his military service or his service-connected hypertension. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's coronary artery disease and any instance of his military service, or as related to a service-connected disability, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010). While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992). Here, while the Veteran is competent to describe his in- service and post-service symptoms, such as chest pain and shortness of breath, the Board accords his statements regarding the etiology of his coronary artery disease little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). The Veteran has offered only conclusory statements regarding the relationship between his in-service symptoms, and his hypertension, with his coronary artery disease. However, the competent, probative opinion in this case took into consideration all the relevant facts in providing the opinion reached, as explained above. Therefore, the Board accords greater probative weight to the examiner's opinion finding against his claim. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for coronary artery disease. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Increased Rating Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012); 38 U.S.C.A. § 1155 (West 2002). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The Veteran's heart disorder, aortic aneurysm, has been assigned a noncompensable evaluation pursuant to Diagnostic Code 7110, which pertains to aortic aneurysms. 38 C.F.R. § 4.104, DC 7110 (2012). Under DC 7110, the next highest 60 percent rating is warranted if the aortic aneurysm precludes exertion. A 100 percent rating is warranted if the aortic aneurysm is five centimeters or larger in diameter, or is symptomatic, or for an indefinite period from the date of hospital admission for surgical correction. Turning to the evidence of record, VA treatment records reflect that a CT scan in July 2003 reflects that the Veteran's aneurysm measured 4.7 cm. Another scan done in August 2004 also reflected a size of 4.7 cm. In November 2006, a CT scan of the thorax showed mild ectasis of the thoracic aorta without interval change, currently measuring 4.7 centimeters by 5 centimeters, unchanged since August 2004. The descending thoracic aorta also remained stable measuring 3.7 centimeters by 3.9 centimeters in size. In December 2007, the Veteran reported dyspnea on exertion that had progressed over the last several months. He denied chest pain. The diagnosis was ascending aortic aneurysm. It was recommended that his hypertension be closely managed. When his aneurysm reached 5.5 centimeters, elective repair would be indicated. A March 2009 scan reportedly showed that it was mild and unchanged. An October 13, 2010, CT scan showed that the ascending aortic aneurysm measured 5 centimeters, which was slightly larger than on previous scan completed in 2009. The October 2010 report shows that the prior 2009 CT scan had measured the ascending aorta at 4.8 centimeters. On November 2011 VA examination, the Veteran's history was noted. He was seen in the emergency room in 2003 and found to have an ascending thoracic aortic aneurysm which has since been followed. His blood pressure had been aggressively treated. The examiner noted that the aneurysm had slightly increased through the years and was presently 5 centimeters. The descending aorta slightly increased to 4.20 centimeters. The aneurysm was not symptomatic and did not preclude exertion. The examiner stated that the Veteran's aneurysm did not preclude his ability to work. In this case, the Board finds that prior to October 13, 2010, a compensable rating was not warranted under the rating criteria. The Veteran's aortic aneurysm did not measure 5 centimeters in diameter, but rather measured at the most 4.8 centimeters in diameter. Although the November 2006 CT report contained two measurements (one of 4.7 and one of 5.0), the report also indicated that size was unchanged since the prior report of August 2004 which the Board notes showed a diameter of only 4.7. Thus, it appears that the November 2006 report was indicating that the diameter was 4.7 while the length was 5.0. This interpretation is confirmed by the fact that a diameter of under 5.0 was found on a subsequent examination in 2009. The Board also notes that after physical examination and review of the records spanning the appeal period, his aortic aneurysm was determined on 2011 examination be asymptomatic, to not preclude exertion, and the Veteran has not had surgical correction of the aneurysm. The Board notes that the Veteran reported dyspnea on exertion in December 2007. However, such is not the same as precluding exertion. Nor do such complaints equate to a symptomatic aneurysm because his symptoms at the time were not tied to his aortic aneurysm but rather to his hypertension or other unknown cardiac origin. Thus, a review of the VA treatment records comport with the November 2011 VA examiner's finding that his aortic aneurysm had not been symptomatic. Accordingly, in light of the specific diagnostic criteria, the Board finds that a compensable rating for the Veteran's aortic aneurysm is not warranted prior to October 13, 2010. Since October 13, 2010, a 100 percent rating is warranted. Specifically, a CTscan clearly demonstrated a finding of a 5 centimeter aortic aneurysm. His aneurysm had grown slightly from the previous scan, from 4.8 centimeters. The regulation is clear that a 5 centimeter in diameter aortic aneurysm warrants a 100 percent rating. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, during the appeal period, the Veteran has not stated that his aortic aneurysm precludes employment, and the November 2011 VA examiner stated that it did not preclude employment. Therefore, the Board finds that a claim for a TDIU has not been raised by the record. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra- schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra- schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected aortic aneurysm with the established criteria found in the rating schedule. As discussed in detail previously, the Veteran's symptomatology is fully addressed by the rating criteria under which such disabilities are rated. There are no additional symptoms that are not addressed by the rating schedule. Therefore, the Board finds that rating criteria reasonably describes the Veteran's disability level and symptomatology for his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Moreover, to the extent that the Veteran's aortic aneurysm may interfere with his employability, such interference is addressed by the schedular rating criteria. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Therefore, the Board finds that there are no attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra- schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Board has considered whether a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). However, prior to October 13, 2010, the criteria for a compensable rating for an aortic aneurysm has been shown. Since October 13, 2010, a 100 percent rating has been warranted. The benefit of the doubt rule has been applied in this case. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for coronary artery disease is denied. Prior to October 13, 2010, a compensable rating for an aortic aneurysm is denied. Since October 13, 2010, a 100 percent rating for an aortic aneurysm is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs