Citation Nr: 1546505 Decision Date: 11/03/15 Archive Date: 11/10/15 DOCKET NO. 13-17 026 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to an initial rating in excess of 60 percent for coronary artery disease prior to June 11, 2012. 2. Entitlement to a rating in excess of 30 percent for coronary artery disease on or after June 11, 2012. REPRESENTATION Veteran is represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Banister, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1960 to April 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2012 rating decision rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. During the pendency of this appeal, the Veteran's claims file was transferred to the RO in Wichita, Kansas, and is currently under the jurisdiction of the RO in Reno, Nevada. REMAND In a July 2012 rating decision, service connection was granted for coronary artery disease, to which a 60 percent disability rating was assigned, effective March 21, 2012, and a 30 percent disability rating was assigned beginning June 11, 2012. Thereafter, the Veteran appealed the initial ratings assigned to his service-connected coronary artery disease. In May 2013, the Veteran submitted a signed authorization and consent to release information (VA Form 21-4142) for records of treatment from S. D., M.D., a private cardiologist at Good Samaritan Hospital in Kearney, Nebraska. In July 2013, the RO requested the Veteran's treatment records from Good Samaritan Hospital; however, no records of treatment or negative response was received. Moreover, the RO did not inform the Veteran that it was unable to obtain his private treatment records from Good Samaritan Hospital. Accordingly, the Board finds that a remand is necessary in order to make another attempt to obtain the Veteran's private treatment records from Good Samaritan Hospital. See 38 C.F.R. 3.159(c)(1) (2015). Additionally, in March 2015, the Veteran was provided a second VA examination to assess the severity of his service-connected coronary artery disease. However, no supplemental statement of the case was issued following the examination. As the RO has not considered this additional pertinent evidence obtained pursuant to its own development, the Board finds that a remand is necessary for issuance of a supplemental statement of the case. See 38 C.F.R. § 19.31(b)(1) (2015). Moreover, the Board finds the VA examination conducted in March 2015 is inadequate. The examiner noted that there was no medical contraindication for not performing a metabolic equivalents (METs) test, and yet an exercise stress test was not performed. An interview-based METs test is to be used only when a laboratory determination of METs by exercise testing cannot be done for medical reasons. 38 C.F.R. § 4.104 (2015). Accordingly, the case is remanded for the following action: 1. The RO must attempt to obtain the Veteran's private treatment records from Dr. D. at Good Samaritan Hospital in Kearney, Nebraska. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain the named records, the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. The Veteran must be afforded an examination to determine the current severity of his service-connected coronary artery disease. The evidence of record, in the form of electronic records, must be made available to the examiner, and the examiner must indicate that these records have been reviewed. All pertinent symptomatology and findings necessary to evaluate the Veteran's coronary artery disease must be reported in detail. The examiner must report whether there is current evidence of congestive heart failure, or evidence of congestive heart failure since 2012. The examiner also must address at what level of METs the veteran experiences dyspnea, fatigue, angina, dizziness or syncope. If an exercise test cannot be done for medical reasons, that fact must be documented on the examination report, and the examiner's estimation of the level of activity, an interview-based METs test, expressed in METs and supported by examples of specific activities, that result in cardiac symptoms, is acceptable. The examiner must state whether there is evidence of left ventricular dysfunction, and report the Veteran's current ejection fraction. Evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray must be reported. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the evidence of record that shows that notice scheduling the examination was sent to his last known address. Documentation must be also be obtained and associated with the evidence of record demonstrating any notice that was sent was returned as undeliverable. 4. After completing the above action, and any other development as may be indicated by any response received as a consequence of the action taken in the paragraph above, the RO must re-adjudicate the Veteran's claim of entitlement to a higher initial rating for coronary artery disease, to include consideration of all relevant evidence received after the March 2013 statement of the case. If any benefit sought on appeal remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2014).