Citation Nr: 1342676 Decision Date: 12/24/13 Archive Date: 12/31/13 DOCKET NO. 11-16 636 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased rating for service-connected coronary artery disease (CAD), currently rated as 30 percent disabling. WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The Veteran had active duty service from May 1967 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran's notice of disagreement was received in January 2011. A statement of the case was issued in June 2011, and a substantive appeal was received in June 2011. In March 2013, a Travel Board hearing was held before the undersigned; a transcript of the hearing is included in the claims file. At the hearing, the Veteran requested and was granted a 60 day abeyance period for the submission of additional evidence. No addional medical evidence has been submitted, and the time has lapsed. The matter of an increased rating for diabetic nephropathy with hypertension associated with diabetes mellitus has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See March 2013 hearing transcript. Therefore, the Board does not have jurisdiction over is, and it is referred to the AOJ for appropriate action. The Board notes that the January 2011 rating decision assigned a temporary 100 percent rating for convalescence under 38 C.F.R. § 4.30 following coronary artery bypass surgery from May 7, 2010 through August 31, 2010. This period of time is not for consideration herein. The 30 percent rating for the service connected CAD was continued from September 1, 2010, following the expiration of the temporary total rating. The Board has reviewed both the Veteran's physical claims file and "Virtual VA" to ensure that the complete record is considered. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND In an April 2012 letter, the Veteran stated that he has gone from a person who could walk 3 miles a day to a person who can barely walk around the house. Further, during his March 2013 Travel Board hearing, he testified that his CAD symptoms have increased. The most recent VA CAD examination was in April 2011 (with addendum in May 2011). In light of the length of the intervening period since the April 2011 examination and the allegation of worsening, a contemporaneous examination is necessary to assess the current severity of the disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (an examination was indicated where there was an allegation of increased disability, and two-years had passed since the last VA examination). The record also suggests that the medical evidence is incomplete. The most recent VA and private treatment records associated with the record (including in Virtual VA) are dated in 2011. Further, the Veteran has testified that he received VA and private cardiovascular treatment in 2012. He specifically indicated having been treated by Dr. Story at Cardiology Consultants in 2012. Updated records of any VA and/or private treatment the Veteran may have received are likely to contain pertinent information (and VA records are constructively of record) and must be secured/available for appellate review. Accordingly, the case is REMANDED for the following action: 1. The RO should specifically secure complete records of all VA treatment he has received from 2011 to the present. 2. The RO should take appropriate action to request copies of any outstanding private treatment records from all providers identified by the Veteran regarding cardiovascular treatment, to specifically include all records from Dr. Story at Cardiology Consultants. The Veteran should be notified if any records he identified are not received pursuant to the RO's request. 3. After completion of the above, schedule the Veteran for a VA examination to determine the current nature and severity of his CAD. The examiner must review the Veteran's claims files in conjunction with the examination, and any indicated studies should be completed. The examiner should report all signs and symptoms necessary for rating the Veteran's coronary artery disease under the rating criteria. In particular, the examiner should provide the following: a) The number of workload METs resulting in dyspnea, fatigue, angina, or syncope. b) An indication as to whether the Veteran has had chronic congestive heart failure or more than one episode of acute congestive heart failure in the past year. c) A statement as to whether the Veteran has left ventricular dysfunction, and if so, the percent of ejection fraction. The examiner should explain the rationale for all opinions given. 4. The RO should then re-adjudicate the claim (to include consideration of the possibility of "staged" ratings, if indicated by facts found). See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). If the claim remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative an opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ ALAN S. PEEVY 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).