Citation Nr: 1337756 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 11-12 769 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an increased initial rating for a heart disability, to include heart murmur. REPRESENTATION Appellant represented by: James G. Fausone, Attorney ATTORNEY FOR THE BOARD A. Lech, Associate Counsel INTRODUCTION The Veteran had active service from December 1963 to December 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, that granted service connection and assigned a 0 percent rating for a heart disability, effective March 10, 2005, enacting a January 2009 Board decision. The Veteran appealed the assigned rating. A February 2013 rating decision increased the rating assigned for the heart disability to 30 percent, effective May 7, 2010. However, as that grant does not represent a total grant of benefits sought on appeal, this claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Board has reviewed the physical claims file and the Virtual VA electronic claims file. The appeal is REMANDED to the RO via the Appeals Management Center in Washington, D.C. REMAND Although the Board regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim. At a February 2013 VA examination, the examiner diagnosed valvular heart disease and heart murmur. The examiner reported that an exercise stress test was performed in 2011, but was not available for review, and that an interview-based metabolic equivalent (METs) test was conducted in January 2012. The reported interview-based results included dyspnea and instantaneous "sting" to the chest or chest pain. The examiner noted that workload was greater than 5 to 7 METs, consistent with activities such as walking one flight of stairs, golfing (without cart), mowing the lawn (using a push mower), and heavy yard work (digging). The examiner stated that the METs level limitation was due solely to the Veteran's heart condition. In an April 2013 letter, the Veteran's representative specifically took issue with the fact that the February 2013 VA examination did not include a stress test to ascertain the Veteran's METs and that, instead, the examiner estimated the Veteran's METs. METs testing is required in all cases except when there is medical contraindication; when the left ventricular ejection fraction has been measured and is 50 percent or less; when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the year; or when a 100 percent rating can be assigned on another basis. 38 CRF 4.100(b) (2013). If a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation 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 CRF 4.104, Note (2) (2013). The February 2013 examiner did not state that there was a medical contraindication to the Veteran performing a stress test, and did not acknowledge any other reasons for why a stress test could not be performed. The examiner did not provide any explanation or rationale for not performing a stress test at the examination. Therefore, the Veteran must be afforded a new examination which includes a stress test, if no medical contraindications exist. A remand is required for another examination. VA's duty to assist includes providing a new medical examination when a Veteran asserts or provides evidence that a disability has worsened and the available evidence is inadequate to evaluate the Veteran's current condition. Weggenmann v. Brown, 5 Vet. App. 281 (1993); 38 C.F.R. § 3.326(a) (2013). While the February 2013 heart examination did not include a stress test, the examiner did not state that a stress test was not performed for medical reasons. The examiner and did not perform any testing to ascertain the Veteran's METs and based the conclusions on an interview-based METs test that was a year old at the time of the February 2013 examination. That does not provide the Board to an accurate picture of the Veteran's current disability. Therefore, the Veteran must be provided another medical examination. Also, current treatment records should be obtained before a decision is made by the Board. Accordingly, the case is REMANDED for the following action: 1. Obtain all pertinent VA and private medical records not yet associated with the file. 2. Then, schedule the Veteran for a VA heart examination. The examiner should review the claims file and should note that review in the examination report. The examiner should identify all symptoms and manifestations attributable to the Veteran's heart disability, in accordance with the rating criteria specified at 38 C.F.R. § 4.104, Diagnostic Code 7099-7000 (2013). The examiner should provide comprehensive information that addresses all components of the applicable rating criteria, to include an assessment of exercise capacity in terms of METs (metabolic equivalents); left ventricular ejection fraction; and commentary on the presence, or lack thereof, of chronic congestive heart failure, and its frequency. If a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation 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, but the examiner should specifically state in the report why an exercise stress test is medically contraindicated. The examination report must include a complete rationale for all opinions and conclusions reached. 3. Then readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).