Citation Nr: 1720719 Decision Date: 06/08/17 Archive Date: 06/21/17 DOCKET NO. 13-15 597 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to an initial rating in excess of 10 percent for ischemic heart disease. REPRESENTATION Veteran represented by: Susan Paczak, Esq. ATTORNEY FOR THE BOARD C. O'Donnell, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from June 1967 to June 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from February 2011 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA. The Board remanded the case for further development in June 2015. That development has been completed and the case has since been returned to the Board for appellate review. FINDINGS OF FACT 1. The Veteran's METs level due to solely to his cardiac condition is between 7 and 10 METs. 2. Resolving reasonable doubt in his favor, the Veteran's ischemic heart disease is shown to have been manifested by left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSION OF LAW 1. The criteria for an initial rating of 60 percent, but no higher, for ischemic heart disease have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159(c)(2), (3) (2016). Neither the Veteran nor his representative has contended otherwise and the Board has identified no procedural deficiencies which would change the outcome of this decision. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); see also Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). As noted in the introduction to this decision, this matter was remanded by the Board in June 2015 for additional development and that development has been completed. The Veteran is in receipt of a rating under diagnostic code 7005 for coronary heart disease, rated as 10 percent disabling since September 9, 2009. Under Diagnostic Code 7005, a 10 percent rating is warranted for coronary artery disease resulting in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; requiring continuous medication. A 30 percent rating is warranted for coronary artery disease resulting in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for coronary artery disease resulting in more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. For rating diseases of the heart, one MET (metabolic equivalent) 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. 38 C.F.R. § 4.104, Note 2. 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). Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but findings sufficient to identify the disease, the resulting disability, and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, VA has a duty to consider the possibility of assigning staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). The Board has reviewed all of the evidence of record. Cf. Gonzalez v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). Most recently, the Veteran was afforded a VA heart examination in October 2015. The examiner noted that the Veteran is required to take continuous medication for his heart condition, which was diagnosed as coronary artery disease. The examiner noted that the Veteran has not had a myocardial infarction, congestive heart failure, cardiac arrhythmia, or any heart valve condition. The examiner performed an echocardiogram test on the Veteran and noted that there was no evidence that the Veteran had cardiac hypertrophy, or cardiac dilation. The Veteran's left ventricular wall motion and wall thickness were normal. An exercise stress test was not performed on the Veteran because the examiner noted that the Veteran had a medical contraindication as a result of his chronic obstructive pulmonary disease (COPD). As a result, the examiner conducted an interview-based METs test. The Veteran reported dyspnea at 1 to 3 METs. The examiner noted that this METs limitation was due to the Veteran's COPD. The examiner opined that the Veteran's METs level due solely to his cardiac conditions was 7 to 10 METs. His rationale indicated that there was no evidence of a significant heart disease that would contribute to the Veteran's symptoms resulting in dyspnea at 1 to 3 METs. The examiner also noted that the Veteran had a significant respiratory disease, and that he was short of breath and mildly wheezing while seated in a chair during the examination, which the examiner opined was due solely to his respiratory condition. The examiner further opined that the Veteran's heart condition did not impact his ability to work. Thus, the Board finds that the Veteran's METs level due to solely to his cardiac condition is between 7 and 10 METs. The echocardiogram test showed that the Veteran's left ventricular ejection fraction was measured at 55 percent, with a degree of error of plus or minus 5 percent. Thus, resolving all doubt in favor of the Veteran, the Board finds that the evidence more nearly approximates the criteria for a 60 percent evaluation under Diagnostic Code 7005, as a measurement of 50 percent warrants a 60 percent evaluation. See Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990) ("[T]he 'benefit of the doubt' standard is similar to the rule deeply embedded in sandlot baseball folklore that 'the tie goes to the runner' . . . . [I]f . . . the play is close, i.e., 'there is an approximate balance of positive and negative evidence,' the veteran prevails by operation of [statute]."). The Board also finds that there are no other potentially applicable diagnostic codes. Indeed, Diagnostic Code 7005 specifically governs the evaluation of the Veteran's disability. Further, there has been no assertion that any other diagnostic code is applicable. ORDER Entitlement to an initial evaluation of 60 percent for ischemic heart disease is granted for the period on appeal, subject to the regulations governing monetary awards. ____________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs