Citation Nr: 1707496 Decision Date: 03/10/17 Archive Date: 03/17/17 DOCKET NO. 04-11 931A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a higher evaluation for hypertension with cardiomegaly, rated as 30 percent disabling from July 1, 2006, and as 60 percent disabling from March 26, 2012. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to June 1, 2014. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from February 1991 to September 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The procedural history of this case is a lengthy one and has been explained at length in prior Board decisions. Of import to the matters currently before it, the Board notes that in a January 2007 decision, the Board denied a rating in excess of 30 percent for hypertension with cardiomegaly for the period prior to July 1, 2006, and a compensable rating for hypertension with cardiomegaly from July 1, 2006. The Veteran appealed the Board's decision to the U.S. Court of Appeals for Veterans Claims (Court), and in a December 2008 memorandum decision, the Court let stand that portion of the Board's January 2007 decision denying a rating in excess of 30 percent for hypertension with cardiomegaly prior to July 1, 2006, but vacated that part of the Board's January 2007 decision denying a compensable rating for hypertension with cardiomegaly for the period from July 1, 2006. Thus, the matter of entitlement to an increased rating prior to July 1, 2006, is no longer part of the current appeal. Then, after several remand actions for further development, the Board, in an August 2012 decision, denied a disability rating in excess of 30 percent from July 1, 2006, and greater than 60 percent from March 26, 2012. The Veteran again appealed to the Court and in April 2014, the Veteran's representative and VA's General Counsel filed a Joint Motion with the Court to vacate the Board's decision and remand the case, which was granted by the Court that same month. The basis for the Joint Motion included the Board's failure to provide sufficient reasons and bases for its determination that TDIU was not warranted. In a September 2014 action, the Board remanded, for further development, the issue of entitlement to a higher evaluation for hypertension with cardiomegaly, rated as 30 percent disabling from July 1, 2006, and as 60 percent disabling from March 26, 2012, to include whether a TDIU is warranted. Upon completion of the requested development, the Appeals Management Center (AMC) issued a February 2016 rating decision wherein it, among other things, awarded a TDIU, effective from June 1, 2014. It would appear from that rating decision that the AMC had determined that the Veteran's service-connected panic disorder with agoraphobia rendered him unemployable, without regard to the occupational impact of his hypertension with cardiomegaly. The AMC also issued a supplemental statement of the case (SSOC) that same month denying a higher evaluation for hypertension with cardiomegaly, rated as 30 percent disabling from July 1, 2006, and as 60 percent disabling from March 26, 2012. In correspondence received that same month, the Veteran expressed his disagreement with the effective date assigned for his award of a TDIU. The Veteran reported that although working prior to June 2014, his earned income did not exceed the poverty threshold and requested consideration of a TDIU prior to the effective date assigned by the AMC. The Veteran also stated that "no additional appeals or information will be submitted regarding the hypertension/cariomeg[a]ly." In the instant case, because the issue of entitlement to a TDIU was previously before the Board as part of the Veteran's increased rating claim, it remains part of the current appeal, especially in light of the Veteran's request for an earlier effective date for the assignment of a TDIU. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (holding that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or as part of a claim for increased compensation). Accordingly, at this juncture, Board concludes that it must consider whether a TDIU is warranted prior to June 1, 2014, as part of the Veteran's claim for an increased rating for hypertension with cardiomegaly. Furthermore, despite the Veteran's statement that no additional appeals would be submitted regarding his service-connected hypertension with cardiomegaly, because the Veteran did not expressly withdraw the issue of entitlement to higher rating for such from appellate consideration, the Board must also again consider the issue of entitlement to a higher evaluation for hypertension with cardiomegaly, rated as 30 percent disabling from July 1, 2006, and as 60 percent disabling from March 26, 2012. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue(s) of entitlement to a TDIU prior to June 1, 2014, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period from July 1, 2006, to March 25, 2012, the Veteran's diastolic blood pressure readings were consistently below 100, his systolic blood pressure readings were consistently below 160, and his hypertension did not require medication for control. 2. For the period from March 26, 2012, the Veteran's diastolic pressure has been below 100, his systolic pressure has been below 160, and he requires a small dose of medication for control of his hypertension. 3. For the period from July 1, 2006, to March 25, 2012, repeated examination consistently showed no evidence of congestive heart failure; repeated diagnostic testing consistently showed that the Veteran exhibited normal left ventricular function, with an ejection fraction of no less than 55 to 60 percent; and the most probative evidence showed that the Veteran's estimated METs level was between 5 and 7. 4. For the period from March 26, 2012, the Veteran's cardiac disability has not been productive of chronic congestive heart failure, left ventricular dysfunction with an ejection fraction of less than 30 percent, or a workload of 3 METs or less. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and in excess of 60 percent from March 26, 2012, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.16, 4.104, Diagnostic Codes 7007, 7101 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). The Veteran has not disputed the contents of the VCAA notice in this case. Further, as previously determined by the Board in its 2012 decision that was appealed to the Court, the Veteran was adequately informed of the information and evidence necessary to substantiate the claim for a higher rating for his service-connected hypertension with cardiomegaly, as well as of VA's duty to assist and of his responsibilities in the adjudication of his claim by way of various notice letters. Notably, the parties' Joint Motions have included no reference to the Board's finding that VA had complied with its duty to notify via letters sent to the Veteran in February 2001, February 2006, and June 2006. Upon review of the record, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied and that the Veteran had a meaningful opportunity to participate in the development of his increased rating claim. Regarding the duty to assist, the Board finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claim. All available evidence pertaining to the effective date matter decided herein has been obtained. The evidence includes the Veteran's service records, VA examination reports, VA treatment records, applications for VA disability benefits, and lay statements in support of his claim. There is no suggestion that additional evidence relevant to the matter being denied exists and can be procured. There is also no indication that any additional action is needed to comply with the duty to assist, as the Veteran has been afforded multiple VA examinations in connection with his claim, which examinations were provided by a qualified medical professionals. The examination reports, along with the other lay and medical evidence of record, contains sufficient information for the Board to rely upon to evaluation the severity of the Veteran's disability is the context of the rating criteria and throughout the appeal period. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2016). II. Analysis As noted above, in its August 2012 decision, the Board denied entitlement to a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and in excess of 60 percent from March 26, 2012, which decision was appealed to the Court. Although the Court vacated the entirety of the Board's August 2012 decision, the Board points out that Veteran's then-attorney raised no assertion of error in his appellate brief to the Court with regard to the Board's determination that higher ratings were not warranted on a schedular or extraschedular basis. There is also no indication in the Joint Motion that the parties found that the Board had in any way erred in its determination regarding the schedular ratings assigned for his hypertension with cardiomegaly. Rather, the Joint Motion focused on the Board's failure to discuss evidence suggestive of unemployability and indicated that the Board should have discussed whether the Veteran was entitled to TDIU based on the fact that he met the threshold rating criteria for the assignment of such a rating. In any event, because the August 2012 decision was vacated in its entirety, the Board again must address whether a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and/or in excess of 60 percent from March 26, 2012, is warranted. The Veteran's service-connected hypertension with cardiomegaly is evaluated under 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101-7007 (2016). Diagnostic Code 7101 is used to evaluate hypertensive vascular disease (hypertension and isolated systolic hypertension) and provides for the assignment of a 10 percent rating when diastolic pressure is predominantly 100 or more; or systolic pressure is predominantly 160 or more; or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, DC 7101 (2016). A 20 percent rating is assigned when diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. Id. A 40 percent rating is assigned when diastolic pressure is predominantly 120 or more. Id. A 60 percent rating is warranted when diastolic pressure is predominantly 130 or more. Id. Diagnostic Code 7007 pertains to hypertensive heart disease and provides for a 30 percent evaluation where a workload greater than 5 METs (metabolic equivalents) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness or syncope; or when there is evidence of cardiac hypertrophy or dilatation on electrocardiogram (EKG), echocardiogram (echo) or X-ray. 38 C.F.R. § 4.104, DC 7007 (2016). A 60 percent rating is assigned when there is more than one episode of acute congestive heart failure in the past year or workload that is greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness or syncope; or when there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating is assigned where there is chronic congestive heart failure, or a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. 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). The Board notes that effective October 6, 2006, the rating criteria were revised to provide that hypertension is to be rated separately from hypertensive heart disease or other types of heart disease. See 71 Fed. Reg. 52,457-60 (Sept. 6, 2006) (codified at 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (3) (2016)). These amended rating criteria, however, apply only to applications for benefits received by VA on or after October 6, 2006. Id. ("The provisions of this final rule shall apply to all applications for benefits received by VA on or after the effective date of this final rule."). As the Veteran's claim was received prior to that date, the revised criteria are not applicable. In any event, as set forth in more detail below, the evidence of record shows that the criteria for a compensable rating under Diagnostic Code 7101 have not been met at any time since July 1, 2006. Given this evidence, a separate compensable rating would not have been warranted even with application of the amended criteria. Turning to the evidence of record bearing on the severity of the Veteran's hypertension with cardiomegaly from July 1, 2006, forward shows that during a September 2006 Board hearing, the Veteran testified that since his separation from active service, he had experienced symptoms such as a rapid heart rate with chest pain, fatigue, dizziness, and trouble sleeping. He claimed that his job options were limited because his bosses did not think he could handle stress. In support of the Veteran's claim, the RO obtained VA clinical records dated from June 2004 to November 2009. These records are entirely negative for complaints or findings pertaining to hypertension or cardiomegaly. In August 2009, a private nurse practitioner indicated that the Veteran had an abnormal EKG with a right bundle branch block and left anterior fascicular block. At his May 2010 Board hearing, the Veteran testified that he was then receiving his medical care from VA, but that he was not on any medication for his cardiac condition. He did report taking medication for his agoraphobia. At the hearing, the Veteran submitted a May 2010 document entitled "EXPERT INDEPENDENT MEDICAL EVALUATION (IME)" from Craig N. Bash, M.D. Dr. Bash indicated that he had reviewed the Veteran's "medical records/testimony/lay statements/personnel records, imaging based medical examination . . . and an in-person history/clinical interview." He described himself as being "exquisitely well trained" to interpret imaging studies "as they represent a form of patient examination akin to an in person face to face exam because objective data is obtained from both processes." Dr. Bash stated that it was his opinion that the record documented a consistent trend of progressive serious cardiac disease which began in service with chest pain, EKG changes, and hypertension and had progressed to "cardiomeglia [sic] with persistent EKG block changes with new left axis deviation which resulted in chronic intermittent chest pain with exertion." He further opined that the Veteran's cardiac function had likely declined since his last evaluation in June 2005 where he reached a level of 8.5 METS. He also stated that it was his medical opinion that the Veteran should be assigned a 30 percent rating under Diagnostic Code 7005, as it most closely described the Veteran's chronic cardiac problems. In pertinent part, additional VA clinical records show that at a physical examination in August 2010, the Veteran's blood pressure was 114/81. He reported a history of post prandial chest tightness and a right bundle branch block and indicated that he took nitroglycerin as needed. The examiner recommended cardiac work-up, including an exercise treadmill test and an echocardiogram. A chest X-ray was performed in August 2010 in connection with the Veteran's report that he had cardiomegaly. The heart was determined to be along the upper limits normal for size, possibly slightly accentuated due to shallow inspiration. The radiologist noted that there was no evidence of congestive failure, a pulmonary consolidation, or pleural effusion. In October 2010, the Veteran underwent myocardial perfusion imaging which showed normal left ventricular systolic function with an estimated ejection fraction of 55-60 percent. The Veteran was advised that he was being scheduled for a "chemical stress test" as he had been unable to satisfactorily complete an exercise stress test. In November 2010, the Veteran underwent VA medical examination at which he reported a history of cardiomegaly. The examiner noted that the Veteran was on no medication for hypertension or heart disease. The Veteran reported that he currently attended graduate school full time. At the time of that examination, the Veteran's blood pressure was recorded to be 122/79. The examiner indicated that there was no clinical evidence of congestive heart failure or pulmonary hypertension. He noted that an October 2010 echocardiogram had shown normal left ventricular systolic function with an estimated ejection fraction of 55 to 60 percent. The examiner also noted that during a Bruce stress test performed in October 2010, the Veteran had exercised for 1:38 minutes with maximum work attained of 3.50 METS, but that the test results were totally unsatisfactory due to the Veteran's claimed chest discomfort and limited exercise tolerance. Thus, a Lexiscan myocardial perfusion imaging study had been scheduled. After examining the Veteran and reviewing the available record, the examiner diagnosed the Veteran as having hypertension, stable, on no medication; and history of cardiomegaly with no current objective evidence on chest X-ray or echocardiogram. The examiner indicated that the Veteran's cardiac condition had no effect on his occupation or daily activities. In December 2010, the Veteran underwent the Lexiscan stress test without chest pain, shortness of breath, or significant arrhythmias. The impression was essentially unremarkable EKG response to Lexiscan challenge. In an April 2011 addendum, a VA examiner indicated that he had reviewed the Veteran's medical records and claims file thoroughly as well as the new Lexiscan results. He noted that the prior exercise stress test had been determined by the examining cardiologist to be unsatisfactory due to dyspnea. He noted that the follow up study had shown normal myocardial perfusion with a resting left ventricular ejection fraction of 62 percent. He indicated that based on a personal interview with Veteran in November 2010, he estimated that the Veteran's true METs score was at least between 5-7. He indicated that the Veteran had been diagnosed as having hypertension and cardiomegaly that had not required pharmacologic treatment thus far and that an echocardiogram in October 2010 had confirmed no functional or structural abnormalities of the heart. The impression was normal left ventricular systolic function with estimated ejection fraction of 55-60%. The examiner further indicated that it was likely that the Veteran was able to obtain and maintain gainful employment in the physical and sedentary sector without limitations. He explained that this was possible, given that the Veteran had exhibited a normal myocardial perfusion scan and echocardiogram. He also noted that the Veteran's cardiologist had indicated that the prior stress test was unsatisfactory and hence had no weight on his cardiac status. Finally, he noted that the Veteran was currently on no medical therapy for heart disease only for a mood disorder. Additional VA clinical records show that in January 2011, the Veteran was seen in the cardiology clinic for an evaluation for possible cardiac catheterization. He reported a history of episodes of chest tightness and dyspnea not related to activity. He indicated that nitroglycerin controlled his chest pain. The examiner noted that echocardiogram had been unremarkable and that a recent myocardial perfusion imaging study performed the month prior had shown no ischemia. The Veteran reported that he had undergone cardiac catheterization about two years prior which showed "some inflammation." The examiner noted, however, that unfortunately the Veteran did not bring the record with him. On examination, the Veteran's blood pressure was 130/74. The evaluation was deferred pending review of the Veteran's cardiac catheterization records. In a January 2011 addendum, the examiner noted that a review of the records provided by the Veteran indicated that he had undergone a left heart catheterization in February 2009 which showed no angiographic evidence of coronary artery disease, no global or regional wall motion abnormality with a 60 percent ejection fraction, and no aortic stenosis. Based on these findings and the recent negative myocardial perfusion imaging study, the Veteran's cardiologist concluded that no further catheterization was necessary. In February 2011, the Veteran underwent a blood pressure check which showed a reading of 110/64. In March 2011, the Veteran was seen in connection with his reports being very stressed from graduate school. It was noted that he had a history of atypical chest pain and that a recent myocardial perfusion imaging study had been negative, as had a cardiac catheterization two years prior. The impression was benign atypical chest pain for which he takes nitroglycerin a couple times monthly. In January 2012, the Veteran sought emergency treatment, claiming to be suffering from a reaction to medication he had been taking for his anxiety disorder and agoraphobia. He indicated that he had been under a lot of stress lately while pursuing a graduate degree in psychology. On examination, his blood pressure was 128/87. On follow-up later that month, the Veteran claimed that he had been suffering from frequent panic attacks since his discharge from service. During these episodes, he claimed to experience sweating, chest pain, palpitations, tightness, an inability to concentrate. On examination, the Veteran's blood pressure was 126/74. The impressions included panic attacks by history and atypical chest pain with negative cardiac workup. The Veteran underwent another VA medical examination in April 2012. [The RO has listed the date of the examination as March 26, 2012, although the electronic records contained in the Veteran's Virtual VA file appear to indicate that the examination and diagnostic tests were conducted on April 10, 2012]. During the examination, the Veteran reported a history of an enlarged heart and abnormal EKG. The examiner noted that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more but that his current treatment plan included taking Metoprolol and nitroglycerin. During the examination, the following blood pressure readings were recorded: 128/91, 113/82, and 116/79. The examiner indicated that the Veteran exhibited no other complications nor did his hypertension impact his ability to work. Cardiac exam revealed a regular rate and rhythm. There was no murmur, rub or gallop. In connection with the examination, the Veteran underwent a chest X-ray which showed that his cardiomediastinal silhouette was within normal limits. A note was made to the effect that the Veteran made a shallow inspiratory effort during the study. The Veteran also participated in a Bruce exercise EKG stress test in connection with the examination. He achieved a work level of maximum METS of 4.60 before the test was stopped due to his complaints of feeling dizzy. The impression was nondiagnostic exercise EKG stress test secondary to not attaining maximum target heart rate. Finally, in connection with the examination, an echocardiogram was performed which was normal, with a left ventricular ejection fraction of 55-60 percent. After examining the Veteran, reviewing the results of diagnostic testing, and considering the claims folder in detail, the examiner indicated that it was his opinion that the Veteran had mild hypertension which is controlled with a small dose of Metoprolol. She indicated that the Veteran was capable of gainful sedentary or physical employment. The Veteran underwent another VA medical examination in April 2012. [The RO has listed the date of the examination as March 26, 2012, although the electronic records contained in the Veteran's Virtual VA file appear to indicate that the examination and diagnostic tests were conducted on April 10, 2012]. During the examination, the Veteran reported a history of an enlarged heart and abnormal EKG. The examiner noted that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more but that his current treatment plan included taking Metoprolol and nitroglycerin. During the examination, the following blood pressure readings were recorded: 128/91, 113/82, and 116/79. The examiner indicated that the Veteran exhibited no other complications nor did his hypertension impact his ability to work. Cardiac exam revealed a regular rate and rhythm. There was no murmur, rub or gallop. In connection with the examination, the Veteran underwent a chest X-ray which showed that his cardiomediastinal silhouette was within normal limits. A note was made to the effect that the Veteran made a shallow inspiratory effort during the study. The Veteran also participated in a Bruce exercise EKG stress test in connection with the examination. He achieved a work level of maximum METS of 4.60 before the test was stopped due to his complaints of feeling dizzy. The impression was nondiagnostic exercise EKG stress test secondary to not attaining maximum target heart rate. Finally, in connection with the examination, an echocardiogram was performed which was normal, with a left ventricular ejection fraction of 55-60 percent. After examining the Veteran, reviewing the results of diagnostic testing, and considering the claims folder in detail, the examiner indicated that it was his opinion that the Veteran had mild hypertension which is controlled with a small dose of Metoprolol. She indicated that the Veteran was capable of gainful sedentary or physical employment. Additional private medical records were associated with the claims folder after the Board's 2014 action. A review of those records reveals blood pressure readings in line with the previously recorded blood pressure readings, to include readings of 101/73 in August 2012, 112/81 in November 2012, 120/82 in December 2012, 104/71 in May 2013, 104/72 in July 2013, and 108/74 in September 2013. In October 2014, the Veteran presented for a private medical consolation. Cardiac examination evidence no palpable heaves, extra heart sounds, murmurs, peripheral edema, or jugular vein distention. The cardiac apex was not displace and the rhythm and rate were normal. The private clinician stated that the veteran's VA and private cardiology records had been reviewed and that based on review of the records and discussion with the Veteran, it was obvious that the Veteran has a cardiac condition including cardiomegaly, chronic right bundle branch block with left anterior fascicular chest block. The Veteran was again examined by VA in January 2015. Specific to his hypertension, the Veteran reported an occasional elevation of blood pressure at home, stating that during his "'chest pain' episodes his pressure increased up to 180 systolic and 101 diastolic." At the time of the examination, his blood pressure was recorded to be 124/84, 126/84, and 124/80. No other pertinent physical findings, complications, conditions, signs or symptoms related to hypertension were noted, and the examiner stated that the Veteran's hypertension did not impact his ability to work. Specific to the Veteran's heart condition, the Veteran reported experiencing episodes of chest pain at least once per week, lasting for 25 to 30 minutes. He stated that with these episodes, he has palpitations and sensation of shortness of breath. Cardiac exam revealed a regular rate and rhythm. Sounds were essentially normal, lungs clear, no edema, and distal pulses were normal. The examiner indicated no obvious medical reason why the Veteran would not be capable of at least sedentary type job tasks. An echocardiogram was scheduled for February 2015, but it indicated that that test was rescheduled. A transthoracic echocardiogram was conducted in August 2015. (It does not appear from the record that an earlier echocardiogram was conducted in connection with the January 2015 VA examination.) Results of the examiner revealed that the left ventricle was normal in size, with a mild concentric left ventricular hypertrophy. The left ventricular ejection fraction was noted be normal, at 55 to 60 percent. A Grade I diastolic dysfunction was noted (abnormal relaxation pattern), but the walls, although not well seen, appeared normal. Upon review of the relevant evidence of record and in consideration of the applicable rating criteria, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent for hypertension with cardiomegaly at any point from July 1, 2006, through March 25, 2012, and in excess of 60 percent at any point from March 26, 2012. With respect to the period from July 1, 2006, to March 25, 2012, the Board has carefully reviewed the entire record, with particular attention to the VA clinical records, private clinical records, and VA and private examination reports corresponding to this period. Without exception, this evidence shows that the Veteran's diastolic blood pressure readings were consistently below 100, his systolic blood pressure readings were consistently below 160, and his hypertension did not require medication for control. Indeed, the Veteran has never contended otherwise. Under these circumstances, the Board finds that the criteria for a rating in excess of 30 percent under Diagnostic Code 7101 have not been met at any time between July 1, 2006, and March 25, 2012. Indeed, these findings would not warrant a compensable rating under Diagnostic Code 7101 during this period. Similarly, the Board finds that the record does not warrant the assignment of a rating in excess of 30 percent under Diagnostic Code 7007 during the period from July 1, 2006, to March 25, 2012. In that regard, the record shows that repeated examination has consistently shown that the Veteran exhibited no evidence of congestive heart failure during this period, or indeed at any time since service. For example, in August 2010, a VA radiologist specifically determined that an X-ray study was negative for evidence of congestive failure and during a November 2010 VA medical examination, the examiner expressly concluded that there was no evidence of congestive heart failure on examination. In addition, the Board notes that repeated diagnostic testing consistently showed that during the period from July 1, 2006, to March 25, 2012, the Veteran exhibited normal left ventricular function, with an ejection fraction of no less than 55 to 60 percent. For example, an October 2010 myocardial perfusion imaging study showed normal left ventricular systolic function with an estimated ejection fraction of 55-60 percent. In April 2012, the Veteran underwent an echocardiogram which was again normal, with a left ventricular ejection fraction of 55-60 percent. Finally, the Board notes that during the period from July 1, 2006, to March 25, 2012, the most probative evidence showed that the Veteran's estimated METs level was between 5 and 7. For example, in May 2010, Dr. Bash indicated that based on his review of the record and an examination of the Veteran, as well as his exquisite training and experience, it was his opinion that the Veteran's cardiac function had declined from a level of 8.5 METS to the level set forth in the criteria for a 30 percent rating under Diagnostic Code 7005, i.e. between 5 and 7 METS. Similarly, in an April 2011 opinion, a VA examiner indicated that based on a personal interview with Veteran and a review of the record, he estimated that the Veteran's true METs score was at least between 5 and 7. The Board has considered the findings of the November 2010 Bruce stress test, but notes that medical examiners consistently concluded that the results of that test were unsatisfactory, requiring an estimation of the Veteran's METS level during the period in question. The Board finds that there is no basis upon which to conclude that the Veteran exhibited a lower METS level during this period. Indeed, a follow-up Lexiscan stress test performed in December 2010 was essentially unremarkable. Under these circumstances, the Board assigns far more probative weight to the findings of the medical professionals in this case, both of whom agree that the Veteran's METs score was between 5 and 7 during the period in question. In view of these findings, the Board finds that the criteria set forth in Diagnostic Code 7007 for a rating in excess of 30 percent from July 1, 2006, to March 25, 2012, have not been met. As set forth above, as of March 26, 2012, the RO has assigned a 60 percent rating for the Veteran's hypertension with cardiomegaly under Diagnostic Codes 7101 and 7007. After carefully reviewing the record, the Board finds that the criteria for a rating in excess of 60 percent from March 26, 2012, have not been met. As a preliminary matter, the Board notes that the rating criteria set forth in Diagnostic Code 7101 do not provide a basis for a rating in excess of 60 percent. A 60 percent rating is the maximum available under that provision. In any event, given the Veteran's blood pressure reading history, i.e. diastolic blood pressure readings consistently below 100 and systolic blood pressure readings consistently below 160, there is no basis upon which to conclude that the criteria for a compensable rating under Diagnostic Code 7101 have been met, even with the recent notation that the Veteran now takes a small dose of medication for blood pressure control. With respect to the rating criteria set forth in Diagnostic Code 7007, the evidence does not show, nor has the Veteran contended, that his hypertension with cardiomegaly has been manifested since March 26, 2012, by chronic congestive heart failure, left ventricular dysfunction with an ejection fraction of less than 30 percent, or a workload of 3 METs or less. Indeed, the Board observes that VA clinical records and the April 2012 and January 2015 VA medical examination report indicate that the Veteran has no complications from his hypertension, it had no impact on his ability to work, and a chest X-ray and echocardiogram were both normal. During an exercise stress test in April 2012, the Veteran achieved 4.6 METS before the test was stopped due the Veteran's claims that he felt dizzy. Given this evidence, the Board can find no basis upon which to conclude that the criteria for a rating in excess of 60 percent under Diagnostic Code 7007 have been met from March 26, 2012. The above determinations are also based upon consideration of applicable rating provisions and Board finds that the level of severity and symptomatology are adequately compensated by the schedular criteria found in the rating schedule for the considered DCs. The Board has also considered whether referral for consideration of whether the Veteran may be entitled to higher ratings on an extraschedular basis is warranted. After reviewing the record, however, the Board finds no basis for further action on this question as there is no indication of an exceptional or unusual disability picture such that the schedular criteria for the Veteran's service-connected hypertension with cardiomegaly are inadequate. As discussed above, the symptoms associated with the Veteran's service-connected disability are specifically contemplated by the Rating Schedule. Referral for extraschedular consideration is therefore not required. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); 38 C.F.R. § 3.321(b)(1) (2016). For the foregoing reasons, the Board finds no basis upon which to assign a rating greater than the currently assigned 30 percent for the Veteran's service connected hypertension with cardiomegaly at any point from July 1, 2006, to March 25, 2012, or a rating in excess of 60 percent at any point from March 26, 2013. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the Veteran's claim for an increased rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to a rating in excess of 30 percent for hypertension with cardiomegaly from July 1, 2006, and in excess of 60 percent from March 26, 2012, is denied. REMAND As noted above, in a February 2016 rating decision, the AMC awarded a TDIU. The Veteran's award of a TDIU was made effective from June 1, 2014, which the AMC stated was the day after the Veteran had reportedly worked. In correspondence from the Veteran, dated in February 2016, the Veteran requested an earlier effective date for the assignment of a TDIU, stating that he worked only 5 months in 2014, that from 2011 to 2013, he was living well below poverty level, and that prior to 2012, he worked only half time for two years and three months. The Veteran provided a copy of his 2013 income tax return reflecting earned wages below the poverty threshold for one person. See http://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html. He also stated that he could provide documentation showing only part time work prior to 2012. As a threshold matter, the Board notes a TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disability. See 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2016). A veteran is eligible for a rating of TDIU if either one service-connected disability is rated at least 60 percent disabling or multiple service-connected disabilities yield a combined rating of 70 percent (with at least one of those disabilities rated 40 percent or more). 38 C.F.R. § 4.16(a). In the instant case, the Veteran has been in receipt of a combined 70 percent evaluation since March 26, 2012, and has been rated as 60 percent for hypertension with cardiomegaly since that date. Thus, the Veteran meets the threshold rating requirements necessary to establish entitlement to TDIU as of March 26, 2102. See 38 C.F.R. § 4.16(a). The Board also points out that although the when the percentage requirements of 38 C.F.R. § 4.16(a) were not met prior to March 26, 2102, the Veteran may still be entitled to a TDIU on an extraschedular basis if it is shown that the Veteran was unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b) (providing that "all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled"). Thus, regardless of whether and when the minimum rating requirements were met, the Veteran must first and foremost be shown to be unable to secure or follow substantially gainful employment in order to establish entitlement to TDIU. "Substantially gainful employment" for TDIU purposes is met where the annual earned income exceeds the poverty threshold for "one person," irrespective of the number of hours or days actually worked and without regard to any prior income history. Faust v. West, 13 Vet. App. 342, 355-56 (2000). Marginal employment, however, is not considered to be substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop) when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). Here, the Veteran has stated that he was living below the poverty threshold prior to 2014 and has provided documentation showing reported income for 2013 below the poverty threshold for one person. If the Veteran's earned income was less than the poverty threshold for one person, he would potentially be entitled to a TDIU even though he was working prior to June 1, 2014. See 38 C .F.R. § 4.16(a). Accordingly, the Board finds that the issue of whether a TDIU was warranted prior June 1, 2014, must be remanded for further development, as the Board does not have sufficient information regarding the Veteran's earned income during the relevant time period to fully adjudicate the matter at the present time. Accordingly, the case is REMANDED to the AOJ 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. The AOJ should contact the Social Security Administration (SSA) and request the Veteran's earning statements from 1999 to 2014. If the SSA informs the AOJ that it cannot provide earnings statements to VA without the Veteran's approval, the AOJ should undertake to obtain any documentation needed from to the Veteran to enable to AOJ to obtain his SSA earnings statements. 2. If SSA responds that they do not have the requested information, the AOJ should contact the Veteran and request that he provide information verifying his income for the years 1999 through and including May 2014. The Veteran should be informed that he can submit copies of W-2 forms or his tax returns, or statements from his previous employers verifying his income earned during those years. 3. After completing the requested actions and any additional notification and/or development deemed warranted, the AOJ should readjudicate the issue remaining on appeal. As part of its readjudication, the AOJ must consider whether the Veteran's pre-June 1, 2014, employment was of a marginal nature. The AOJ should also consider whether referral for consideration of entitlement to TDIU on an extraschedular basis prior to March 26, 2012, is warranted. If a benefit sought on appeal is not granted, the Veteran and his representative must be furnished an SSOC and afforded the appropriate time period for response. The Veteran 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 case must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). L. HOWELL BARBARA B. COPELAND Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals ________________________________ JAMES L. MARCH Veterans Law Judge Board of Veterans' Appeals Department of Veterans Affairs