Citation Nr: 1329252 Decision Date: 09/12/13 Archive Date: 09/20/13 DOCKET NO. 12-22 039 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for arteriosclerotic heart disease (coronary artery disease) from June 30, 2011. 2. Entitlement to an initial rating in excess of 30 percent for arteriosclerotic heart disease (coronary artery disease) from April 2, 2013. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Castillo, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1970 to April 1972. This matter is before the Board of Veterans' Appeals (Board) on appeal of a November 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a September 2011 rating decision, the RO granted service connection for coronary artery disease with an evaluation of 10 percent effective March 11, 2008. In the November 2011 rating decision, the RO re-evaluated their initial rating as follows: 30 percent disabling from October 2006; 60 percent disabling from December 2007; and 10 percent disabling from June 2011. While the Board does not understand the basis for the October 2006 rating, it will not disturb it. The Veteran seeks an increased rating for coronary artery disease in excess of 10 percent from June 30, 2011. The issues have been recharacterized to comport with the evidence of record. FINDINGS OF FACT 1. Giving the Veteran the benefit of all doubt, since June 30, 2011, the Veteran's coronary artery disease was manifested by a METs score no greater than 7. 2. Since April 2, 2013, the Veteran's coronary artery disease was manifested by left ventricular dysfunction with an ejection fraction of 48 percent. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating for coronary artery disease from June 30, 2011, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005 (2013). 2. The criteria for a 60 percent rating for coronary artery disease from April 2, 2013, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005 (2013). Notice and Assistance Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. The appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial and will not be discussed . Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained; he did not identify any outstanding medical treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran's Social Security Administration disability determination, and the records considered in that determination, were obtained in June 2008. 38 C.F.R. § 3.159 (c)(2). A VA examination was conducted in June 2011. The Veteran contends that this examination was inadequate for rating purposes. 38 C.F.R. § 3.159(c)(4); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Specifically, the Veteran alleges the examination was inadequate because it did not include MET testing. The June 2011 VA examination did include MET testing and a MET score. The June 2011 examination report, an August 2011 addendum opinion, and an April 2013 VA examination are adequate to evaluate the Veteran's coronary artery disease. These medical opinions provided clear conclusions with supporting data, and a reasoned medical explanation connecting the two. Thus, the record contains sound medical opinions upon which a decision may be based. Id. at 124-25; Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no indication in the record that any additional evidence, relevant to the issue decided, is available and not part of the claim file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Sanders, 129 S. Ct. 1696; see also Dingess/Hartman, 19 Vet. App. at 486. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks an increased rating for coronary artery disease in excess of 10 percent from June 30, 2011. 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 veteran working or seeking work. § 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. § 4.7. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, consideration of the appropriateness of "staged rating" must be given. Id. Diagnostic Code 7005 provides the rating criteria for coronary artery disease. A 30 percent rating is warranted for coronary artery disease resulting in workload 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 dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for coronary artery disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction (LVEF) of 30 to 50 percent. A 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. The Veteran underwent a VA heart examination in June 2011. The examination showed METs greater than 3 but less than 5, which resulted in dyspnea, fatigue, and angina. LVEF was 60 percent, which is normal. The examiner noted that the LVEF would be more accurate in assessing the Veteran's cardiac function than the estimated METs. The examiner reported no evidence of congestive heart failure, hypertrophy, or dilation. The examiner opined that the Veteran's heart condition does not impair his ability to perform sedentary labor. The examiner issued an addendum opinion in August 2011. He opined that the Veteran's back pain medication, Hydrocodone, would limit his activity and confuse the estimation of METs. Thus, it would be more accurate to consider the 60 percent LVEF in assessing his cardiac function rather than the estimated METs. The Veteran's treating VA physician conducted a heart examination in April 2013. The examination report showed METs greater than 3 but less than 5 which resulted in fatigue and angina. LVEF was 48 percent. The examiner reported no evidence of congestive heart failure, hypertrophy, or dilation. The examiner reported that the Veteran was unable to do any strenuous or sustained work. The Veteran's coronary artery disease is currently rated at 10 percent from June 30, 2011, pursuant to § 4.104, DC 7005. To merit a disability rating of 60 percent requires evidence of 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 resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction (LVEF) of 30 to 50 percent. The June 2011 VA examination report reflects that the examiner disregarded the METs score because the Veteran's non-service connected back condition medication "confuses the issue about exertion." He considered the 60 percent LVEF to be a more accurate reflection of the Veteran's condition. Based upon this report, the RO assigned a 10 percent rating from the date of the examination. In fact, the rating criteria do not address an LVEF for any rating less than 60 percent. The June 2011 examiner did not provide an approximation as to what an adjusted METs score would be. Five to seven METs would warrant a 30 percent rating and greater than seven to ten METs would warrant a 10 percent rating. As there is not a preponderance of the evidence demonstrating greater than seven METs, we must give the Veteran the benefit of the doubt and conclude that no more than sever METs was demonstrated. Accordingly, a 30 percent rating is warranted from June 2011. The April 2013 report submitted by the Veteran's VA treating physician documents an LVEF of 48 percent, entitling him to a 60 percent rating from that date, the earliest such an LVEF is shown. To merit a disability rating of 100 percent, the next highest rating, requires evidence of chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. These requirements have not been shown at any time during the appeal. This case does not present indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The coronary artery disease is primarily productive of congestive heart failure, decreased METs, and decreased LVEF. The respective manifestations are contemplated in DC 7005 and are adequate to evaluate the Veteran's disability. Therefore, referral for consideration of an extraschedular rating is not warranted. The Board also considered whether a claim of total disability based on individual unemployability was inferred in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). As the Veteran has not asserted, and the record does not raise the issue of total disability based on individual unemployability, Rice is inapplicable. ORDER 1. An initial rating of 30 percent for arteriosclerotic heart disease (coronary artery disease) from June 30, 2011, is granted. 2. An initial rating of 60 percent for arteriosclerotic heart disease (coronary artery disease) from April 2, 2013, is granted. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs