Citation Nr: 1623464 Decision Date: 06/13/16 Archive Date: 06/29/16 DOCKET NO. 15-03 182 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for coronary artery disease status post myocardial infarction. 2. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Associate Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Veteran had active duty service from April 1968 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into account the existence of these electronic records. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Initially, the Board notes that subsequent to June and December 2014 statements of the case addressing PTSD and coronary artery disease, respectively, but prior to April 2015 certification to the Board, a substantial amount of evidence was associated with the claims file. Most notably, the Veteran submitted an Ischemic Heart Disease Disability Benefits Questionnaire that had been filled out by a VA physician and, in June 2014 and in April 2015, he submitted a PTSD Disability Benefits Questionnaires that had been completed by a private psychologist. In April 2015, a few days prior to certification to the Board, he was afforded a new VA Heart Conditions examination. As this new and relevant evidence has not been initially considered by the AOJ, remand is required for initial review of the evidence and for issuance of a supplemental statement of the case if the claims are not otherwise satisfied. 38 C.F.R. §§ 19.31, 19.37(a) (2015). Moreover, as noted above, in April 2015, the Veteran was provided with a VA Heart Conditions examination. There, a VA registered nurse practitioner opined that there was no objective evidence of cardiac ischemia or functional impairment related to ischemic heart disease. Further, she estimated that, based on an interview with the Veteran, he would experience dyspnea, fatigue and dizziness at 7 to 10 METs when only considering the effects of his service-connected cardiac disorder. The examiner also noted that a METs test had not been performed since October 2010 but she did not explain why a more recent one had not been scheduled despite also indicating that the Veteran's left ventricular ejection fraction was 50 percent or greater and that he has not had congestive heart failure. Further, in the January 2015 Ischemic Heart Disease Disability Benefits Questionnaire, which appears to have been filled out by a VA primary care physician associated with the VA Lee County Healthcare Center in Cape Coral, Florida, the doctor estimated that the Veteran would experience dyspnea, fatigue, angina, and dizziness at between 1 and 3 METs. Similarly, the physician also noted that a METs test had not been performed but did not explain why one had not been provided other than to note that "New METs not required for treatment plan." An EKG recently added to the file seems to suggest findings of cardiac failure and congestive heart failure. These matters need further clarification. The Veteran's coronary artery disease is rated under 38 C.F.R. § 4.104, Diagnostic Codes 7006-7005, applicable to arteriosclerotic heart disease. Generally, METs testing is required in all cases for assigning a rating under the evaluation criteria for heart disease except when there is a 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 past year, or when a 100 percent evaluation can be assigned on another basis. 38 C.F.R. § 4.100(b). In light of the above, there is a question as to whether the Veteran is capable of performing a METs test and, if not, at what level of exertion he would experience symptoms including dyspnea, fatigue, angina, dizziness and/or syncope. Given the widely varying estimates provided by the examiners above, the Board finds that these questions should be answered by a cardiologist or similar medical professional with specialized training and experience with cardiac disorders. In addition, while VA treatment records were mostly recently associated with the claims file in June 2015, to the extent there are any outstanding treatment records, those should be associated with the claims file. Finally, there is evidence that the Veteran's service-connected disabilities may have significantly impacted his employability, and in correspondence dated June 2014, the Veteran alleged that his service-connected disabilities, to include PTSD and coronary artery disease, have prevented him from working since 2004. The issue of entitlement to a TDIU has thus been raised by the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Associate with the claims file any pertinent and outstanding VA treatment records dated from June 2015 to the present. 2. Thereafter, schedule the Veteran for a VA examination with a cardiologist or similar medical professional with specialized training and experience with cardiac disorders to assess the nature and severity of his coronary artery disease. The Veteran should be scheduled for a METs test, or the examiner should provide a supplemental opinion as to why such a test is contraindicated, or that it is not warranted. See 38 C.F.R. § 4.100 (2015) (providing that a stress test is not warranted if the Veteran's left ventricular ejection fraction is measured at 50 percent or less, if the Veteran has chronic congestive heart failure, or if the Veteran has had more than one episode of congestive heart failure within the past year). The claims file must be sent to the examiner for review and the examiner should conduct an examination in accordance with the current VA disability benefits questionnaire or worksheet for evaluating coronary artery disease. The clinician should also provide specific examples of the Veteran's activity level for the estimated METs, and provide a rationale for the estimated METs level. 3. After the development requested has been completed, the AOJ should review any report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. If additional development is indicated to adjudicate the TDIU claim, such additional development should be undertaken. 4. After completing any additional development deemed necessary, readjudicate the claims. If any benefit requested on appeal is not granted to the Veteran's satisfaction, the appellant and his representative should be furnished a supplemental statement of the case, which addresses all of the evidence obtained after the issuance of the last supplemental statement of the case, and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ MICHAEL D. LYON 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) (2015).