Citation Nr: 1329772 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 99-11 829A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington THE ISSUE Entitlement to a rating in excess of 30 percent for valvular regurgitation with premature ventricular contractions (PVCs) from October 16, 2000. REPRESENTATION Appellant represented by: African American PTSD Association WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The Veteran served on active duty from June 1965 to October 1992. This appeal to the Board of Veterans' Appeals (Board) arose from a February 2002 rating decision (issued in March 2002) in which the RO, inter alia, reopened the Veteran's claim for service connection for heart disease, as well as granted service connection and assigned an initial, zero percent (noncompensable) rating for valvular regurgitation with PVCs, effective April 15, 1997. The Veteran filed a notice of disagreement (NOD) with the initial rating assigned in June 2002; and the RO issued a statement of the case (SOC) in August 2003. The Veteran filed a substantive appeal (via a VA Form 9, Appeal to Board of Veterans' Appeals) in September 2003. In a November 2003 rating decision, the RO assigned a 30 percent rating for valvular regurgitation with PVCs, effective October 16, 2000. In April 2004, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO; a transcript of that hearing is of record. In June 2005, the Board remanded the matters on appeal to the RO, via the Appeals Management Center (AMC), in Washington, DC, for additional development. After attempting to accomplish the requested action, the AMC continued to deny each claim (as reflected in a May 2007 supplemental SOC (SSOC)), and returned the matter to the Board for further appellate consideration. In September 2008, the Board again remanded the matters on appeal to the RO, via the AMC, for additional development. After accomplishing further action, the AMC continued to deny each claim (as reflected in a June 2010 SSOC), and returned these matters to the Board for further appellate consideration. In November 2011, the Board awarded an initial 10 percent rating for valvular regurgitation with PVCs for the period from April 15, 1997 through January 11, 2008; as well as awarded a 30 percent rating for the disability for the period from January 12, 1998 through October 15, 2000. The Board also remanded the claim for a rating in excess of 30 percent for valvular regurgitation with PVCs, from October 16, 2000 forward, for additional evidentiary development. After accomplishing further action, the AMC continued to deny the remaining claim (as reflected in a June 2012 SSOC), and returned the remaining matter to the Board for further appellate consideration. In August 2012m the Board again denied remanded the claim for a rating in excess of 30 percent from October 16, 2008 to the RO, via the AMC, for further action. After accomplishing the requested action, the AMC continued to deny the claim (as reflected in a January 2013 SSOC), and returned the matter to the Board. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matter herein decided have been accomplished. 2. Historically, the Veteran's valvular regurgitation with PVCs has been manifested by left ventricular hypertrophy, valvular dysfunction, and arrhythmias and dysrhythmias (resolved since December 2009); trace mitral valve regurgitation and aortic valve sclerosis (but no significant valvular abnormality); and intermittent episodes of arrhythmias and PVCs.. 3. More recently, the Veteran has complained of chronic fatigue, chest pain, and shortness of breath on walking; reports of increased symptoms of substernal pain with continued shortness of breath and fatigue; complaints of palpitations with associated lightheadedness; and one episode of syncope (in December 2003). 4. For the period from October 16, 2000 to November 18, 2009, the Veteran's valvular regurgitation with PVCs was manifested by a workload of between 5 and 6 METs, with dyspnea, fatigue, and angina. There is no evidence of cardiac hypertrophy or dilation on electrocardiogram (ECG or EKG), echocardiogram (echo), or X-ray. 5. For the period beginning on November 19, 2009, the Veteran's valvular regurgitation with PVCs has been manifested by an estimated workload of 3 METs or less resulting in dyspnea, fatigue, angina, and dizziness. VA physicians have been unable to determine how much of the Veteran's dyspnea, fatigue, angina, and dizziness are related to his service-connected valvular regurgitation with PVCs versus metabolic deregulation associated with his diabetes, neuropathy, hypertension, and labyrinthitis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for valvular regurgitation with PVCs, for the period from October 16, 2000 to November 18, 2009, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.104, DC 7099-7015 (2012). 2. Resolving all reasonable doubt in the Veteran's favor, as of November 19, 2009, the criteria for a 100 percent rating for valvular regurgitation with PVCs are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§3.102, 3.321, 4.1, 4.3, 4.7, 4.104, DC 7099-7015 (2012 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claims, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claims, in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 -23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a March 2001 letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate what was then a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The February 2002 RO rating decision reflects the initial adjudication of the claim after issuance of the March 2001 letter. After the award of service connection, and the Veteran's disagreement with the initial, noncompensable rating assigned, the SOC set forth the criteria for higher ratings (the timing and form of which suffices, in part, for Dingess/Hartman). Moreover, a December 2008 letter provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After issuance of the December 2008 letter, and opportunity for the Veteran to respond, the June 2010 supplemental SOC (SSOC) reflects readjudication of the claims. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of the reports of VA examinations conducted throughout the pendency of the claim on appeal, in November 2000, September 2003. November 2006, November 2009, March 2011, and November 2012. The evidentiary record also includes VA treatment records dated from 1999 to 2012, including records that appear in the paperless, electronic (Virtual VA) file associated with the Veteran's paper claims file (which have also been considered by the RO). Also of record and considered in connection with the appeal is the April 2004 Board hearing transcript, along with various written statements provided by the Veteran on his behalf. The Board also finds that no additional RO action to further develop the record in connection with either claim, prior to appellate consideration, is required. As for the April 2004 Board hearing, the Board points out that the Veteran appeared and provided testimony on the matter herein decided. The transcript from that hearing reflects that the Veteran was afforded the opportunity to present hearing testimony, argument and evidence. The transcript also reflects appropriate exchanges between the Veteran and the undersigned Veterans Law Judge, in accordance with Stuckey v. West, 13 Vet. App. 163 (1999) and Constantino v. West, 12 Vet. App. 517 (1999). The transcript further reflects that the Veterans Law Judge (VLJ) identified the material issue herein decided, while the VLJ and the Veteran discussed evidence of record that supports the increased rating claim on appeal. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board hearing is, thus, deemed legally sufficient. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices, the Veteran has been notified and made aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). . Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes that VA revised the criteria for evaluating cardiovascular disorders, effective January 12, 1998. See Schedule for Rating Disabilities: Cardiovascular System, 62 Fed. Reg. 65,207 (Dec. 1997). In the 2011 decision, the evaluating the disability under consideration from the 1997 effective of the award of service connection through October 15, 2000, However, because the matter is appeal only involves consideration of the service-connected heart disability from October 16, 2000, this claim will only be evaluated under the criteria made effective in January 1998. As noted, the Veteran's service-connected heart disability is rated as 30 percent disabling under DC 7099-7015, effective October 16, 2000. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and 99. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that an unlisted organic disease of the cardiovascular system, under Diagnostic Code 7099, was the service-connected disorder, while the residual condition (to which the Veteran's service-connected heart disability is rated by analogy) is atrioventricular block, which is evaluated under DC 7015. Under DC 7015, a 100 percent rating is to be assigned for chronic congestive heart failure; if a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or with left ventricular dysfunction with an ejection fraction of less than 30 percent. With more than one episode of acute congestive heart failure in the past year; if a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or with left ventricular dysfunction with an ejection fraction of 30 to 50 percent, a 60 percent evaluation is warranted. A 30 percent rating is appropriate when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. When a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when continuous medication or a pacemaker required, a 10 percent rating is to be assigned. The pertinent evidence of record includes VA examination reports dated in November 2000, January 2001, September 2003, November 2006, November 2009, March 2011, and November 2012, as well as VA and private treatment records dated from 2000 to 2012. VA treatment records dated from 2000 to 2012 document the Veteran's varying complaints of dizziness, malaise, and chest pressure, but consistently show his heart size and rhythm are normal. VA treatment records also show the Veteran variously reported experiencing dizziness, chest pressure, and elevated blood pressure readings in April 2001 and December 2003; however, the evidence shows that the Veteran's symptoms were attributed to his hypertension and hypertension medication. See September 2004 private treatment record; November 2006 VA examination report. In this regard, private treatment records document the treatment the Veteran received after his syncopal episode in December 2003 and show that this episode of severe dizziness was due to his beta blockers. The VA and private treatment records contain various imagining studies, including chest X-rays and echoes conducted from 2000 to 2012. An October 16, 2000 echo revealed trace regurgitation, normal left ventricle sixe and systolic function, with an estimated ejection fraction of more than 50 percent. See also September 2003 echo. A November 2003 ECG revealed normal sinus rhythm with occasional premature supraventricular complexes. See also ECGs dated July 2001, August 2001, December 2003; see also November 2009 ECG. ECGs have also variously shown sinus bradycardia and normal sinus rhythm with sinus arrhythmia. See ECGs dated December 2003, January 2004, and December 2005. The evidentiary record contains a May 2002 myocardial scan which showed mildly decreased exercise tolerance but normal left ventricular chamber size. The record also contains a portion of an October 2003 Graded Exercise Summary that is in graphical form, which will be discussed in detail below. During a November 2000 VA examination, the Veteran's history of hypertension, cardiomegaly, and recurrent preventricular contractions was noted, as was his history of ventricular hypertrophy and aortic valve thickening. Physical examination revealed normal heart rate and cardiomegaly was not discernible. The relevant impression was mild cardiomegaly with aortic valve thickening without clear etiology but likely associated with hypertension. On January 2001 VA examination, the examiner noted the Veteran has had numerous EKGs conducted over the years which have been essentially normal but have also shown PVCs. The examiner noted, however, that the Veteran is not taking any medications for any arrhythmias. The examiner also noted the most recent echo showed no abnormalities of significance, with normal left ventricular ejection fraction, normal ventricular size, and trace regurgitation of the mitral valve. The examiner noted there was historical evidence suggestive of left ventricular prominence, but he stated there was normal left ventricular ejection fraction, with no EKG or echo evidence of left ventricular hypertrophy. In this regard, the examiner also noted that most of the rhythm strips associated with the record do not show PVCs, although the Veteran was diagnosed with them in the past. A January 2001 chest x-ray revealed an unremarkable heart and aorta, with no acute cardiopulmonary disease, while an ECG revealed sinus bradycardia. The examination report reflects that an exercise tolerance test was scheduled but cancelled because the Veteran failed to show for the evaluation. In sum, the January 2001 VA examiner stated that the Veteran's cardiac manifestations do not include evidence of coronary artery disease, left ventricular dysfunction, and only mild trace mitral regurgitation. The examiner also stated there is no abnormality of aortic valve function, although the valve is sclerotic. During the September 2003 VA examination, the examiner noted the Veteran's history of hypertensive heart disease, with occasional PVCs. He also noted that the Veteran did not have chest pains and that he walked 2.8 miles daily. The Veteran was afforded an echo which revealed an estimated ejection fraction of more than 50 percent. The September 2003 examiner estimated the Veteran's MET level as 6 to 7, but he did not provide an explanation of such or give specific examples, other than the Veteran's ability to walk 2.8 miles a day. On November 2006 VA examination, the Veteran reported receiving treatment from Madigan Hospital, and the examiner noted the Veteran's various hypertension medications. The examiner noted the Veteran was hospitalized for an episode of severe dizziness which resulted in a motor vehicle accident in 2002 and was suspected to be due to a beta blocker causing dizziness and syncope. The examiner also noted the Veteran's history of PVCs and sinus bradycardia, which were documented a few times. As for the Veteran's current symptoms, the November 2006 VA examiner reported the Veteran had chronic fatigue, chest pain which subsides on itself, and shortness of breath on walking. The examiner noted the Veteran used to walk 2.8 miles but that he cannot walk now and feels shortness of breath even at rest. The Veteran was noted to get dizzy spells and a history of syncope in the past but none in the previous 12 months. There was no acute cardiac illness of congestive heart failure. The examiner noted that an exercise test for METs was proposed but the Veteran reported he could not get on the treadmill because of right hip pain. However, the examiner noted that, based on the Veteran's report, he cannot go up stairs and experiences shortness of breath while walking over 15 minutes and at level ground. Based on these findings, the November 2006 VA examiner estimated the Veteran's METs to be 5 to 6. An echo revealed an estimated ejection fraction of more than 55 percent, with no gross valvular regurgitation or stenosis. A chest x-ray showed mild cardiomegaly and no chamber enlargements or congestive heart failure, while the ECG was normal without any block or PVCs. In November 2009, a VA physician reviewed the Veteran's claims file and noted that the November 2006 VA examination was a thorough summary of his cardiac condition. The November 2009 VA examiner noted the Veteran's condition had worsened since 2006, as the Veteran reported experiencing random and frequent flare-ups of substernal pain, with shortness of breath and generalized fatigue. The Veteran was only taking medication for his blood pressure. The examiner noted the Veteran has had no syncopal episodes in the past three years, although he frequently feels fait and weak. The examiner noted the Veteran is unable to walk because of a combination of factors, including diabetic neuropathy, back, and knee pain. The examiner also noted the Veteran has chronic labyrinthitis causing frequent dizziness and that he cannot walk faster than approximately one mile per hour, quickly climb a flight of stairs or do heavy work. The examiner noted the previous estimated METs of 5 to 6 and noted the Veteran remained unable to do an exercise tolerance test. Examination revealed that, if the Veteran tried to move quickly, he feels substernal pain, shortness of breath, and general fatigue. An ECG revealed sinus rhythm with marked sinus arrhythmia, and a chest x-ray revealed normal heart size, mild uncoiling of the thoracic aorta, and no acute cardiopulmonary disease. An echo revealed an estimated ejection fraction of more than 60 percent, with no significant valvular regurgitation, normal left ventricular systolic function, and smaller left ventricular diastolic size. The examiner noted the Veteran is not a candidate for exercise tolerance testing because of his neuropathy, labyrinthitis, and fatigue, but estimated his METs to be between 2 and 3 based on the limitations described above. During a March 2011 VA examination, the November 2009 VA examiner examined the Veteran a second time, noting that the Veteran reported his condition is unchanged. The examiner again noted the Veteran is taking medications for his blood pressure but is not taking any medication for his heart. The examiner again noted the Veteran is not a candidate for an exercise tolerance test due to his fatigue, diabetic neuropathy, and labyrinthitis causing dizziness, and shortness of breath. In this regard, the Veteran reported becoming short of breath if he walks up give steps or walking more block or less. He also reported random flare-ups of substernal chest pain with minimal exercise and at rest. He did not have syncope and there was no evidence of cardiac hypertrophy or congestive heart failure. Physical examination was identical to the examination conducted in November 2009. A Holter monitor revealed no arrhythmias, while an echo revealed an estimated ejection fraction of more than 60 percent, and an ECG revealed sinus bradycardia with sinus arrhythmia. The March 2011 VA examiner stated the Veteran does not exhibit signs of congestive heart failure and estimated his METs between 2 and 3. The examiner stated it is impossible to determine how much of the Veteran's dyspnea, fatigue, angina, and dizziness are related to his heart versus metabolic deregulation associated with his diabetes, neuropathy, hypertension, and labyrinthitis. He stated there was no longer evidence of valvular regulation, irregular heartbeat was not noticed on a 2009 ECG, and no arrhythmia on Holter monitor testing. In November 2012, a VA physician reviewed the claims file and examined the Veteran before continuing his diagnosis of valvular regurgitation. As for current symptoms, the examiner noted the Veteran experienced daily palpitations associated with lightheadedness, but the Veteran denied shortness of breath or chest pains associated with the palpitations at that time. The Veteran reported having chest pains about twice a week, which occur with and without activity. The examiner noted the Veteran has had only had one syncopal episode in December 2003 for which he was hospitalized. The examiner stated there is evidence that the Veteran's dysrhythmias have become more of a problem since October 2000 and she noted that the Veteran's one syncopal episode in December 2003 was presumably related to his dysrhythmias. The examiner noted the Veteran has extensive documentation of ventricular dysrhythmias, including PVCs, which have been documented on EKG and Holter monitor. The examiner also noted a history of mild left ventricular hypertrophy seen on echoes conducted in December 2003; however, the examiner noted this has resolved (or that the 2003 findings were erroneous), as the two most recent echoes do not show left ventricular hypertrophy and the ejection fraction was normal at more than 60 percent. The examiner noted that there is a history of mitral and tricuspid valve regurgitation seen by echo on September 2003. There is also documentation of aortic valve sclerosis from December 2009, but the examiner noted that no mitral regurgitation was seen and the study stated there was no evidence of significant valvular abnormalities. With respect to MET levels, the examiner conducted an interview- based METs test, at which time the Veteran reported experiencing dyspnea, dizziness, fatigue, and angina. The examiner estimated 1 to 3 METs, which was consistent with activities such as eating, dressing, taking a shower, and slow walking for 1 to 2 blocks. The examiner stated the limitation in METs is due to multiple factors, including the Veteran's diabetic neuropathy, vertigo, and back issues which limit his METs level. The examiner stated that she was unable to differentiate the symptomatology associated with the service-connected heart disability from the Veteran's other medical issues because he is not able to walk more than a few blocks due to severe peripheral neuropathy from diabetes and he also has back issues and vertigo. With all of the medical issues combined, the examiner stated the Veteran's activity level is consistent with 2 to 3 METs, but he is not able to do stair climbing. The examiner stated that she was able to locate the October 23, 2003 Graded Exercise Summary, but she stated it only consisted on one page with an EKG, without a summary or information regarding METs. As such, the October 2003 Graded Exercise Study is not considered competent medical evidence of the Veteran's estimated METs. As noted, an EKG conducted in November 2012 revealed sinus bradycardia with sinus arrhythmia, while a March 2011 chest x-ray was normal. A March 2011 echo revealed an estimated left ventricular ejection fraction of more than 60 percent, with normal wall motion and thickness. Given the above-noted facts, the Board finds that ,resolving all reasonable doubt in favor of the Veteran, the Board finds the that the collective evidence supports the assignment of a schedular 100 percent rating under DC 7015, effective November 18, 2009, but that the evidence weighs against assignment of a rating higher than 30 percent prior to that date. As discussed in detail above, the Veteran's service-connected heart disability has been historically manifested by left ventricular hypertrophy, valvular dysfunction, and arrhythmias and dysrhythmias, as documented on various echoes and ECGs conducted since October 2000. It appears, however, that the Veteran's left ventricular hypertrophy has resolved, as the two most recent echoes (conducted in December 2009 and March 2011) do not show left ventricular hypertrophy and revealed normal left ventricular ejection fraction. Likewise, while there is evidence showing mitral valve regurgitation and aortic valve sclerosis, the valvular regurgitation has been no more than trace and physicians have determined there is no significant valvular abnormality, despite the evidence of valvular sclerosis. With respect to the Veteran's heart beat, the evidence shows the Veteran has experienced sinus bradycardia, which is a slowed heart beat, in 2001, 2003, and 2011. See VA treatment records dated January and November 2001, November and December 2003, and March 2011. The evidence also shows he has experienced intermittent episodes of arrhythmias and PVCs, as there is evidence of such on objective examination in November 2008 and on ECG in November 2009 and March 2011. In this regard, the evidence shows that some of the Veteran's arrhythmias have been attributed to increased dosage of hypertension medication as opposed to a cardiac cause. Regardless, the preponderance of the evidence shows that the Veteran's service-connected heart disability is manifested by intermittent arrhythmias, although he is on no medications for such. See January 2001 ___ The evidence also shows that. more recently, the Veteran's service-connected heart disability is currently manifested by complaints of chronic fatigue, chest pain, and shortness of breath on walking. See VA examination reports dated November 2006 and November 2009. The Veteran reported increased symptoms of substernal pain with continued shortness of breath and fatigue in 2006 and, in November 2012, he reported experiencing daily palpitations with associated lightheadedness. As noted, the Veteran has only had one episode of syncope in December 2003, which was attributed to his beta blockers, although the November 2012 VA examiner noted that the syncopal episode was presumably due to the Veteran's dysrhythmias. With respect to left ventricular ejection fraction, the preponderance of the evidence shows that, since October 2000, the Veteran's left ventricular ejection fraction has been estimated to no less than 50 percent. See VA examination reports dated January 2001, November 2006, November 2009, and March 2011. With respect to the Veteran's activity level, a May 2002 myocardial scan shows mildly decreased exercise tolerance. The first physician to estimate the Veteran's METs was the September 2003 VA examiner who estimated the Veteran's METs to be 5 to 6, noting the Veteran's report of walking 2.8 miles a day but being unable to go up stairs and experiencing shortness of breath while waking more than 15 minutes and at rest. The November 2009 VA examiner estimated the Veteran's METs to be between 2 and 3, noting that the Veteran is unable to walk because of a combination of factors, including diabetic neuropathy, back, and knee pain. The examiner also noted the Veteran has chronic labyrinthitis causing frequent dizziness and that he cannot walk faster than approximately one mile per hour, quickly climb a flight of stairs or do heavy work. In March 2011, the November 2009 VA examiner again estimated the Veteran's METs to be between 2 and 3, noting that it is impossible to determine how much of the Veteran's dyspnea, fatigue, angina, and dizziness are related to his heart versus metabolic deregulation associated with his diabetes, neuropathy, hypertension, and labyrinthitis. The November 2012 VA examiner estimated 1 to 3 METs, which was consistent with activities such as eating, dressing, taking a shower, and slow walking for 1-2 blocks. The examiner stated the limitation in METs is due to multiple factors, including the Veteran's diabetic neuropathy, vertigo, and back issues which limit his METs level. The examiner further stated she is unable to differentiate the symptomatology associated with the service-connected heart disability from the Veteran's other medical issues because he is not able to walk more than a few blocks due to severe peripheral neuropathy from diabetes and he also has back issues and vertigo. With all of the medical issues combined, the examiner stated the Veteran's activity level is consistent with 2-3 METs. In applying the foregoing facts to the rating criteria of DC 7015, the Board finds that a 100 percent rating is warranted under DC 7015, effective November 18, 2009, the first date the Veteran is shown to have a workload of 3 METs or less, which results in dyspnea, fatigue, angina, and dizziness. See November 2009, March 2011, and November 2013 VA examination reports. In making this determination, the Board notes that the evidence dated from October 19, 2000 to November 18, 2009 does not contain evidence of workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. There is only evidence of mildly decreased exercise tolerance with estimated METs between 5 and 6, and the Veteran is shown to be able to walk 2.8 miles a day. See May 2002 myocardial scan and September 2003 VA examination report. There is also no evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray prior to November 18, 2009. Hence, there is simply no evidence dated from October 19, 2000 to November 18, 2009, which contains evidence of symptoms which warrant a disability rating higher than 30 percent under DC 7015. Nevertheless, the VA examination reports dated November 18, 2009 and thereafter show the Veteran's estimated METs between 2 and 3, with complaints of dyspnea, fatigue, angina, and dizziness. In this regard, the physicians who conducted the November 2009 and November 2012 VA examinations have stated it is impossible to determine how much of the Veteran's dyspnea, fatigue, angina, and dizziness are related to his heart versus his non-service-connected diabetes, neuropathy, hypertension, and labyrinthitis. However, the physicians have explained that the service-connected heart disability and the non-service connection disabilities affect the Veteran's activity level and result in limited ability to work and other symptoms, including shortness of breath, angina and dizziness. See VA examination reports dated November 2009, March 2011, and November 2012. When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected condition, reasonable doubt should be resolved in the appellant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102 (2012). In light of the above, the Board shall attribute the Veteran's limited activity level due to limited ability to work and other symptoms, as reflected in the METs, to his service-connected heart disability. Id, As such, the Board finds that, as of November 18, 2009, the Veteran's service-connected heart disability is manifested by a workload of 3 METs or less, with resulting dyspnea, fatigue, angina, and dizziness, which warrants a 100 percent rating under DC 7015. As discussed above, the Board finds that a rating higher than 30 percent is not warranted prior to November 18, 2009 under DC 7015, as the evidence does not show a workload of between 3 and 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope and there is no radiographic evidence of cardiac hypertrophy or dilation. The Board has also considered whether any other potentially applicable diagnostic code provides a basis for a rating higher than 30 percent prior to November 18, 2009. It is noted that the clinical records show that the Veteran has hypertension; however, service connection has been established for hypertension and that issue is not currently on appeal. As such, analysis of the claim under DC 7007 is not warranted. The Board acknowledges the Veteran's assertions that his service-connected disability is manifested by ventricular dysfunction, valvular regurgitation, and left ventricular hypertrophy and, as such, should be rated based upon those conditions. In this regard, the Board has considered the applicability of all other potentially applicable diagnostic codes, including those for evaluation of valvular heart disease, endocarditis, pericarditis, pericardial adhesions, arteriosclerotic heart disease, myocardial infarction, heart valve replacement, coronary bypass, and cardiomyopathy, which are rated under DCs 7000, 7001, 7002, 7003, 7004, 7005, 7006, 7016, 7017 and 7020, respectively. However, the Board notes that the criteria for the next higher, 50 percent rating are the same as under DC 7015, i.e., a workload of between 3 and 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. As discussed above, the evidence of record does not show the level of symptomatology needed to warrant a rating higher than 30 50 percent under the applicable rating criteria. Therefore, DCs 7000, 7001, 7002, 7003, 7004, 7005, 7006, 7016, 7017 or 7020 likewise provide no basis for assignment of a rating higher than 30 percent prior to November 18, 2009. Likewise, the Board finds that DC 2010, for evaluation of supraventricular arrhythmias, does not assist the Veteran in obtaining a higher rating prior to November 18, 2009, as the highest rating available under that code is 30 percent. Further, absent evidence of syphilitic heart disease, hyperthyroid heart disease, cardiac pacemaker or transplant, evaluation of this disability under any other diagnostic code pertaining to diseases of the heart is not appropriate. See 38 C.F.R. 4.104, DCs 7000-7017. In evaluating this claim, the Veteran's own assertions, and those of his representative, have been considered. However, the Board finds that the lay assertions made in support of his claim for higher rating are not entitled to more weight than the objective findings rendered by trained medical professionals in evaluating the Veteran's service-connected heart disability. See 38 C.F.R. § 3.159 (a)(1); see also Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997). As indicated above, the persuasive evidence indicates that the Veteran's service-connected heart disability more nearly approximates the level of disability contemplated by the 30 percent rating for the period her, from October 16, 2000 to November 17, 2009, while a 100 percent rating is warranted for the period beginning on November 18, 2009. The above determinations are based upon application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that, at no pertinent point prior to November 18, 2009 did the disability under consideration reflect so exceptional or so unusual a picture as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (2012). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalizations). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. at 116. In this case, the Board finds that the schedular criteria are adequate to rate the Veteran's service-connected heart disability at all times pertinent to this appeal-to include the relevant period . Indeed, the rating schedule fully contemplates the described symptomatology, including the Veteran's activity level as a result of dyspnea, fatigue, angina, dizziness, and syncope, whether those symptoms are attributable to a valvular or left ventricular problem. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board concludes that, while the evidence supports award of a 100 percent rating heart for valvular regurgitation with PVCs, for the period beginning November 18, 2009, no more than a 30 percent rating for the disability is warranted prior to that date. The Board had favorably applied the benefit-of-the doubt doctrine in reaching the decision to award the maximum, 100 rating from November 18, 2009, but finds that the preponderance of the evidence is against assignment of any rating higher prior to that date.. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER For the period from October 16, 2000 to November 17, 2009, a rating in excess of 30 percent for valvular regurgitation with PVCs is denied. For the period from November 19, 2009, a 100 percent rating for valvular regurgitation with PVCs is granted, subject to the legal authority governing the payment of compensation. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs