Citation Nr: 1330489 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 09-22 685 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 60 percent for arteriosclerotic heart disease prior to March 29, 2013. 2. Entitlement to an evaluation in excess of 10 percent for carotid artery stenosis and hypoplastic left vertebral artery. 3. Entitlement to an effective date prior to April 19, 2007, for the award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from August 1950 to April 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an August 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The claims on appeal previously included a claim for restoration of a 60 percent disability rating for arteriosclerotic heart disease. That claim was granted in a February 2013 Board decision. Also in February 2013, the Board remanded the Veteran's remaining claims for additional development and adjudicative action. While the case was in remand status, the issue of entitlement to a TDIU was resolved by a June 2013 Decision Review Officer decision granting the claim. In the June 2013 decision, the Veteran was also granted a 100 percent disability rating for arteriosclerotic heart disease, effective March 29, 2013. Since this grant was effective long after the date of receipt of claim, the issue of entitlement to a higher rating for the disability during the period prior to March 29, 2013, remains at issue. In an August 2013 brief, the Veteran's representative raised the issues of entitlement to service connection for pes planus and increased or separate ratings for complications associated with the Veteran's service-connected diabetes mellitus. These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). The issue of entitlement to an earlier effective date for the award of a TDIU is addressed in the REMAND that follows the ORDER section of this decision. FINDINGS OF FACT 1. Prior to March 29, 2013, the Veteran's arteriosclerotic heart disease was not manifested by chronic congestive heart failure, an exercise tolerance of 3 METS or less, or a left ventricular ejection fraction of less than 30 percent. 2. The Veteran's corrected visual acuity for distance has been no worse than 20/40 for the right eye and 20/80 for the left eye; the carotid artery stenosis and hypoplastic left vertebral artery have not been productive of any significant neurological impairments or multi-infarct dementia. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 60 for arteriosclerotic heart disease prior to March 29, 2013, are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2013). 2. The criteria for a disability rating higher than 10 for carotid artery stenosis and hypoplastic left vertebral artery are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.84, Diagnostic Code 6079; § 4.124a, Diagnostic Code 8045 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in a letter mailed in May 2012. Although the Veteran was not provided complete notice until after the initial adjudication of the claims, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The Board also finds that the duty to assist has also been met. The Veteran's service treatment records and post-service VA records have been obtained. There is no indication, nor has the Veteran alleged, that additional records relevant to his claims have not been obtained. He was also provided with VA examinations with respect to his claims in June 2007, January 2009, March 2013, and April 2013. The Board finds that the reports of these examinations are adequate for rating purposes. There is no indication that the carotid artery and left vertebral artery disability has increased in severity since the most recent VA examinations. The Board concludes that no further examinations are required. As noted above, the Board remanded the Veteran's claims in February 2013 for additional development and adjudicative action. Specifically, the Board directed that the originating agency obtain all outstanding VA treatment records pertinent to the Veteran's claims and to provide him with VA examinations. His outstanding VA treatment records have been obtained, and he was provided with VA examinations in March and April of 2013. As determined above, the Board finds the VA examination reports, to include the March and April 2013 examination reports, to be adequate for rating purposes. Therefore, the Board finds that the agency of original jurisdiction has substantially complied with the prior remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West,13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Accordingly, the Board will address the merits of the claims. General Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during active service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to these disabilities. In this regard the Board notes that where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Arteriosclerotic Heart Disease The Veteran claims that a disability rating higher than 60 percent is warranted for his service-connected arteriosclerotic heart disease prior to March 29, 2013. The claims file reflects that he filed the claim for an increased rating currently on appeal in April 2007. Arteriosclerotic heart disease (coronary artery disease) is rated under 38 C.F.R. § 4.104, Diagnostic Code 7005. A 30 percent rating is assigned for coronary artery disease if a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; of if there is evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A rating of 60 percent is assigned when there is more than one episode of congestive heart failure within the past year; where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction (EF) of 30 to 50 percent. A rating of 100 percent is assigned for chronic congestive heart failure; or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. Regulations for diseases of the heart were amended effective October 6, 2006. However, a review of the regulations both prior to and after October 6, 2006 reveals that the relevant provisions in Diagnostic Codes 7005-7007 remain unchanged. See 71 Fed. Reg. 52,460 (Sept. 6, 2006). It is noted that one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Turning to the merits of the claim, a June 2007 VA examination report shows the Veteran's report of occasional chest discomfort that he did not treat with medication and palpations occurring "now and then." The Veteran relayed that he underwent an electrocardiogram a month earlier, which he stated was normal. He denied having congestive heart failure or passing out, but the Veteran reported experiencing dizziness and lightheadedness, especially when he stood up after sitting. The Veteran described a history of syncopal attacks approximately ten years prior that occurred after excise and exertion. He had no further syncopal attacks or passing out episodes after being placed on medication in 2003. The examiner noted that the Veteran used prescription medications for his cardiac disability. An associated echocardiogram performed in July 2007 revealed visually estimated ejection fraction of 55 to 60 percent for the left ventricle. A chest X-ray showed mild cardiomegaly. The examiner noted that the Veteran had additional medical problems, but that he was independent with his activities of daily living and ambulation. The Veteran underwent an exercise electrocardiogram (ECG) stress test in July 2007. The Veteran performed the excise stress test for four minutes, but was unable to continue with testing due to pain in his thigh and legs. During this testing, he achieved 82 percent of his maximal predicted heart rate for his age and 2.8 METS of workload with exercise. He demonstrated a normal blood pressure response with exercise. The examiner highlighted that the stress test was terminated due to hip and knee pain and estimated that the Veteran's workload was greater than 3 but not greater than 5. The Veteran underwent an additional VA examination in January 2009 to assess the severity of his service-connected arteriosclerotic heart disease. He reported that his condition had worsened. His symptoms included: occasional chest pain at rest, for which he used nitroglycerin as needed; a history of syncope occurring at least once a month; constant fatigue; monthly angina; dizziness once a month; and dyspnea with moderate exertion. The examiner noted that the Veteran required the use of continuous medication to treat his condition. There was no history of myocardial infarction or congestive heart disease. The cardiac examination revealed S1 and S2 heart sounds and a regular rhythm, with no evidence of a heart murmur, click, or pericardial rub. An X-ray examination revealed that the heart size was mildly larger than normal. The examiner noted that the Veteran attempted a stress test on a previous occasion but was unable to complete the test due to a knee condition. Testing for left ventricular dysfunction revealed an ejection fraction greater than 50 percent. METs were estimated at greater than 3 but not greater than 5. The examination revealed a relevant diagnosis of coronary artery disease. The examiner determined that the Veteran's collective disabilities (which also included carotid artery stenosis and hypoplastic left vertebral artery) had severe effects on the Veteran's ability to perform chores, shopping, exercise and recreation, and prevented his participation in sports. His disabilities had moderate affect on his ability to travel, and mild effects on bathing, toileting, dressing, and grooming. VA treatment records show treatment of the Veteran's cardiac symptomatology. A July 2009 record shows that he sought emergency treatment for chest pains; testing at that time did not reveal an acute myocardial infarction. A November 2009 discharge summary shows that the Veteran continued to experience recurrent chest pain and that he underwent a left heart catheterization and percutaneous coronary angioplasty with stent placement. He was noted to have posterolateral artery (PLA) disease. The discharge summary notes that a September 2009 echocardiogram revealed a left ventricular ejection fraction of 65 percent with diastolic dysfunction. A follow up treatment record dated in December 2009 includes the Veteran's report of angina occurring approximately once a month, fatigue, and shortness of breath on exertion, which the examiner determined could be due to deconditioning and obesity. There were no episodes of dizziness, syncope, or palpitations reported. A January 2010 VA cardiology outpatient record reflect the Veteran's history of coronary artery disease, status post elective cardiac catherization in November 2009. The Veteran reported that he did not exercise but that he used a recently purchased stationary bike a few times with toleration. He was noted to have chest pains that occurred "on and off," which lasted very briefly. The Veteran denied experiencing shortness of breath, paroxysmal nocturnal dyspnoea (PND), orthopnea, palpations, dizziness, or syncope. The examiner determined that there were no signs and symptoms suggestive of congestive heart failure. A March 2010 VA examination report documents the Veteran's report of chest pain on his left side that occurred once a month. His chest pain was relieved with nitroglycerin. The Veteran reported having palpations, but he denied having congestive heart failure, passing out episodes, stroke, transient ischemic attacks (TIAs), or any further myocardial infarction after November 2009. Additional symptoms included light headedness and dizziness "now and again," especially when he stood up quickly after prolonged sitting. He also indicated that he experienced dyspnea on exertion after walking one quarter of a mile. The physical examination revealed audible first and second heart sounds that were regular and without murmur, gallop, or pericardial rub. The point of maximal impulse (PMI) was not displaced and the pericardium was not hyperactive. The associated chest X-ray study revealed cardiomegaly. The Veteran advanced his contentions in numerous statements submitted in support of his claim. In a September 2007 statement, he reported that he experienced passing out spells that occurred four to five times a month. The Veteran reported in January 2010 that he had suffered two heart attacks in November and December of 2009, for which he underwent placement of two stents in his heart. In a May 2010 statement, he reported some improvement with exercise, as tolerated. Given the foregoing, a disability rating in excess of 60 percent is not warranted for the Veteran's arteriosclerotic heart disease at any time prior to March 29, 2013. The preponderance of the evidence shows that the Veteran had an exercise tolerance greater than 3 METs and left ventricle ejection fraction greater than 50 percent for this time period. Although the July 2007 ECG revealed a workload of 2.8 METs, the Board highlights that this testing was not completed due to the Veteran's physical limitations. However, based on the clinical examination and assessment of the incomplete ECG, the July 2007 examiner estimated that the Veteran's workload was greater than 3 but not greater than 5 METs. The January 2009 examiner also reached this conclusion following the clinical examination of the Veteran. Additionally, there is no evidence whatsoever of chronic congestive heart failure. Accordingly, the criteria for the next-higher 100 percent rating are not met at any time prior to March 29, 2013. In reaching this determination, the Board is mindful of the Veteran's reports of shortness of breath, dizziness, lightheadedness, syncopal episodes, and angina, which occurred at varied frequencies; however, these symptoms are contemplated by the currently assigned disability rating. Carotid Artery Stenosis and Hypoplastic Left Vertebral Artery The Veteran claims that his carotid artery stenosis and hypoplastic left vertebral artery disabilities are more severe than what is reflected by the currently assigned 10 percent disability rating. The RO granted service connection for carotid artery stenosis and hypoplastic left vertebral artery, as secondary to service-connected diabetes mellitus, in an October 2004 rating decision based on evidence of transient visual blurring attributed to his carotid artery stenosis. His disability has been rated by analogy under Diagnostic Codes 8045-6079. Diagnostic Code 6079 provides the relevant rating criteria for impairment of central visual acuity. Effective October 23, 2008, VA amended the criteria for rating residuals of traumatic brain injuries (TBIs), or more specifically, neurological and convulsive disorders, including under Diagnostic Code 8045. 73 Fed. Reg. 54,693, 54,708 (Sept. 23, 2008). This amendment applies to applications received by VA on and after October 23, 2008. The former criteria apply to applications received by VA before that date. A veteran whose residuals of TBI VA rated under Diagnostic Code 8045 prior to the amendment, however, is permitted to request review under the amended criteria regardless of whether his disability has worsened since the last review or VA receives additional evidence. The effective date of any increase in disability compensation based solely on the amended criteria can be no earlier than October 23, 2008, the effective date of the amended criteria. In this case, even though the Veteran did not make a specific request to this effect, the RO reviewed the Veteran's claim under the amended criteria in a Statement of the Case dated in April 2009. The rating criteria in effect prior to October 23, 2008, state that, for brain disease due to trauma, purely neurological disabilities, such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., following trauma to the brain, will be rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045-8207). Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under Diagnostic Code 9304. This 10 percent rating will not be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Code 9304 are not assignable in the absence of multi-infarct dementia association with brain trauma. The Board notes that the portion of the rating schedule that addresses disabilities of the eyes was revised effective December 10, 2008. Only claims received on or after December 10, 2008, will be evaluated under the new criteria. 73 Fed. Reg. 66543-54 (Nov. 10, 2008). As the Veteran's claim for an increased rating was received prior to December 10, 2008, the revised criteria are not for application. Evaluations for impairment of central visual acuity range from noncompensable to 100 percent. 38 C.F.R. § 4.84a, Diagnostic Codes 6061 to 6079. Under Diagnostic Code 6079, a noncompensable evaluation is warranted where vision is 20/40 in both eyes. A 10 percent evaluation is warranted where vision is 20/50, 20/70 or 20/100 in one eye and 20/40 in the other eye. A 10 percent evaluation is also warranted where vision is 20/50 in both eyes. A 10 percent evaluation is the highest rating assignable under this diagnostic code. A next-higher 20 percent disability rating is warranted for impairment of central visual acuity under multiple diagnostic codes in the following situations: (1) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/50; (2) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/50; (3) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a , Diagnostic Codes 6077, 6078 (2008). The evaluations continued to increase for additional impairment of central visual acuity, which was to be measured based on the best distant vision obtainable after the best correction by glasses. 38 C.F.R. §§ 4.75, 4.83a, and 4.84a, Table V. The Board notes that the medical evidence reflects that multiple eye disorders have been diagnosed during the pendency of the claim, to include diabetic retinopathy and bilateral cataract. As service connection has not been awarded for diabetic retinopathy or cataracts, these disorders are not considered in the present claim. The claims files include a June 2007 VA examination report that shows the assessment of the Veteran's carotid artery stenosis and hypoplastic left vertebral artery disability. At the time of the examination, the Veteran reported experiencing dizziness and lightheadedness, especially when he stood up after sitting. The Veteran also reported a history of syncope attack approximately ten years prior, after which he was placed on medication and had no further syncopal attacks or passing out. The examiner noted that a magnetic resonance imaging study of the Veteran's neck performed in 2003 revealed non-visual left vertebral artery secondary to hypoplasty or stenosis and mild stenosis of the right external carotid artery. On the physical examination, no complications or manifestations were attributed to the Veteran's carotid artery stenosis and left hypoplastic vertebral artery. The examination revealed carotid artery stenosis and hypoplastic left vertebral artery. VA treatment records reflect the Veteran's report of eye problems and assessments of his visual acuity. Collectively, these records show that the Veteran has multiple eye diagnoses, to include bilateral cataract, and reflect his reports of vision impairment. An April 2007 record documents his report of blurry vision and shows a diagnosis of bilateral cataract, visually significant. In February 2008, the Veteran complained of blurred vision and his visual acuity with correction was reported as 20/30 for the right eye and 20/60 for the left eye. Eye assessments performed in April 2008 revealed corrected visual acuity for distance of 20/40 for the right eye and 20/80 for the left eye. At that time, the Veteran reported having blurred vision. The Veteran underwent a VA eye examination in July 2008, and the examiner noted that the Veteran underwent cataract removal surgery for his left eye in October 2007. The physical examination revealed that corrected visual acuity was 20/30 for the right eye and 20/50 for the left eye. The external examination was normal. A January 2009 VA examination report reflects the Veteran's history of carotid artery stenosis and hypoplastic left vertebral artery. He reported that he passed out approximately once a month due to his carotid artery condition. The Veteran described a syncope episode that occurred the previous summer when he was driving his lawn mower and the mower turned over on top of him. His symptoms were also reported to include constant fatigue and dizziness once a month. The examiner confirmed the diagnoses of carotid artery stenosis and hypoplastic left vertebral artery (along with the arteriosclerotic heart disease). Collectively, the effect of the Veteran's diagnoses on his usual daily activities ranged from mild to severe, and his disabilities prevented his participation in sports. However, the examiner did not specifically identify any effect on his usual daily activities that was solely due to his carotid artery stenosis and left hypoplastic vertebral artery diagnoses. A February 2009 VA treatment record shows that an assessment of the Veteran's visual acuity with correction was 20/20 for the right eye and 20/25 for the left eye. He was noted to have undergone cataract surgery, with subsequent symptoms of a floater and a roving light in the left eye. A March 2013 VA examination report reflects diagnoses of bilateral carotid artery stenosis and hypoplastic left vertebral artery. The Veteran denied having a stroke, TIAs, loss of vision, left hand weakness, speech difficulties, hemiplegia/hemiparesis, difficulty with bladder and bowel control, or other neurological manifestations. The physical examination did not reveal any signs or symptoms associated with the Veteran's diagnoses. Findings on the carotid ultrasound were suggestive of significant stenosis. Following the clinical assessment, the examiner determined that the Veteran's carotid artery stenosis and left hypoplastic vertebral artery were stable. The examiner concluded that the Veteran had no complications, including stroke or TIAs, and he noted that the Veteran had not undergone a carotid endarterectomy. An April 2013 VA eye examination report shows the assessment of the Veteran's visual acuity. The examination revealed best corrected visual acuity for distance of 20/40 or better for both eyes. There was no evidence of a neurologic eye condition or visual field defects. The examination revealed the presence of floaters and rare dot-type hemorrhages in the posterior poles of the eyes, which the examiner attributed to diabetes mellitus. The examiner also noted the presence of a foreign body, identified as a portion of crystalline lens, in the Veteran's left eye due to cataract surgery in 2007, and chronic blepharoconjunctivitis following the surgery. A chorioretinal scar was observed in the left eye, and the examiner was unable to determine whether the scar was the result of the cataract surgery. The examiner noted the presence of a cataract in the right eye, which he stated limited the Veteran's best corrected vision in the right eye to 20/40. Based on the examination results, the examiner identified bilateral diabetic retinopathy and right eye cataract as the Veteran's ocular diagnoses that were relevant to vision or have the potential to reduce vision. The examiner explained that the Veteran's cataract in his right eye decreased his vision to a best corrected level of 20/40 and stated that the Veteran would perceive blurring in the right eye due to the cataract. There were no vision problems attributed to the Veteran's carotid artery and left hypoplastic vertebral artery diagnoses. In light of the evidence of record, a rating higher 10 percent is not warranted for the Veteran's service-connected carotid artery and hypoplastic left vertebral artery disabilities under Diagnostic Code 6079. Here, the Board notes that the objective medical evidence during the appeal period does not show any current visual impairment due to the Veteran's carotid artery and left hypoplastic vertebral artery diagnoses. In any event, the Board further finds that the next-higher, 20 percent rating is not warranted under any other diagnostic code pertaining impairment of visual acuity. The Veteran's best corrected visual acuity for distance was assessed on multiple occasions during the appeal. The objective evidence shows that his visual acuity was no worse than 20/40 for the right eye and 20/80 for the left eye during the appeal. These findings do not warrant a disability rating higher than 10 percent under any other relevant diagnostic code. Accordingly, a rating in excess of 10 percent due to impairment of visual acuity is not warranted. In determining that a higher disability is not warranted in this case, the Board acknowledges the Veteran's reports of experiencing dizziness, lightheadedness, and syncopal episodes that he has at times attributed to his carotid artery stenosis and left hypoplastic vertebral artery. The Board highlights, however, that the objective medical evidence does not show that these symptoms are due to his service-connected carotid artery stenosis and left hypoplastic vertebral artery. Indeed, the March 2013 VA examiner most recently determined that the Veteran's disabilities were stable and that he did not have any current complications. The Board also notes that the Veteran has reported these symptoms in regards to his service-connected arteriosclerotic heart disease. See 38 C.F.R. § 4.14 (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). Essentially, the evidence does not show that a higher rating is warranted for the Veteran's carotid artery and left hypoplastic vertebral artery disabilities under any other diagnostic code. The objective medical evidence fails to show that the Veteran's service-connected disabilities are manifested by any neurological disabilities to warrant consideration of any additional diagnostic codes as provided by Diagnostic Code 8045. To the extent the Veteran claims that a higher rating is warranted under Diagnostic Code 8045 based on his subjective complaints, his service-connected disabilities are not manifested by multi-infarct dementia, and thus, they do not meet the criteria for a disability rating higher than 10 percent. Moreover, separate ratings on the basis of impairment of visual acuity and subjective symptoms under Diagnostic Code 8045 so only a single 10 percent rating is warranted. Other Considerations Consideration has been given to assigning staged ratings; however, at no time during the period in question have the disabilities warranted higher schedular ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the doctrine of reasonable doubt in reaching the above determinations; however, as the preponderance of the evidence is against the claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether the Veteran's claims should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations of the Veteran's disabilities are contemplated by the schedular criteria. Therefore, the Board has determined that referral of the claims for extra-schedular consideration is not in order. ORDER A disability rating higher than 60 percent for arteriosclerotic heart disease prior to March 29, 2013, is denied. A disability rating higher than 10 percent for carotid artery stenosis and hypoplastic left vertebral artery is denied. REMAND The Board finds it necessary to remand for the issue of entitlement to an effective date earlier than April 19, 2007, for the award of a TDIU to the originating agency for further consideration. As previously noted, the AMC granted the claim for a TDIU in the June 2013 rating decision, effective from April 19, 2007. In an August 2013 brief, the Veteran's representative disagreed with the effective date that was assigned and asserted that TDIU benefits should be awarded as early as June 23, 1993. The Veteran's brief represents a notice of disagreement (NOD) as to the effective assigned for the TDIU benefits in the June 2013 rating decision. The Veteran has not been issued a Statement of the Case (SOC) for the issue of an earlier effective date for his TDIU benefits. Therefore, the matter must be remanded for the issuance of an SOC. See Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED to the RO for the following action: Issue a Statement of the Case to the Veteran and his representative concerning the issue of entitlement to an effective date prior to April 19, 2007, for the award of a TDIU. The Veteran must be informed of the requirements to perfect an appeal with respect to this new issue. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). As noted above, this case has been advanced on the Board's docket. It must also be handled in an expeditious manner by the RO. See 38 U.S.C.A. §§ 5109B, 7122 (West Supp. 2012). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs