Citation Nr: 1746715 Decision Date: 10/19/17 Archive Date: 10/31/17 DOCKET NO. 11-14 377 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 10 percent disabling prior to December 17, 2003, and from April 1, 2004 to February13, 2011; in excess of 30 percent disabling from February 14, 2011 to December 10, 2015; and in excess of 10 percent disabling thereafter, for coronary artery disease (CAD), status post coronary artery bypass graft. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1969 to December 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Huntington, West Virginia, Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction has since been transferred to the RO in St. Petersburg, Florida. By way of history, on August 26, 2003, the Veteran filed a statement asserting his desire to amend a previous service connection claim for diabetes mellitus type II to include a service connection claim for heart disease secondary to his diabetes. The Veteran's service connection claim for heart disease was denied in a January 2004 rating decision. In April 2004, the Veteran filed a timely notice of disagreement (NOD). A statement of the case (SOC) was issued in November 2004, and in January 2005 the Veteran filed a VA Form 9, substantive appeal. The Veteran's claim was granted in a March 2008 rating decision and assigned a 10 percent evaluation effective August 26, 2003. In a March 2009 rating decision, the Veteran was granted a temporary 100 percent evaluation effective December 17, 2003, based on surgical treatment necessitating convalescence. A 10 percent rating was continued as of April 1, 2004. With regard to the March 2008 rating decision, the Veteran filed a timely NOD in April 2009. In a December 2010 rating decision, the RO granted an earlier effective date of June 11, 2003; the date the Veteran filed his service connection claim for diabetes. The RO issued an SOC continuing the 10 percent evaluation in March 2011, and the Veteran filed a timely substantive appeal in May 2011. Thereafter, the case was certified to the Board. In an October 2015 decision, the Board remanded the matter to obtain a new VA examination, which was obtained in December 2015. The appeal was thereafter returned to the Board. In an August 2016 decision, the Board bifurcated the issue on appeal and granted a 30 percent evaluation from February 14, 2011 to December 10, 2015. The Board additionally remanded the Veteran's increased rating claim, including the period from February 14, 2011 to December 10, 2015, and instructed the Agency of Original Jurisdiction (AOJ) to obtain private cardiology medical records. In a September 2016 letter, the RO requested the Veteran to complete and return an enclosed VA Form 21-4142, Authorization to Disclose Information to the VA, and VA Form 21-4142a, General Release for Medical Provider Information to the VA, so that private treatment records could be obtained. The record shows that the Veteran did not complete and return the requested forms. The Board notes that VA's duty to assist in developing the facts and evidence pertinent to the Veteran's claim is not a one-way street, and it is his responsibility to work with VA with regard to development. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Accordingly, after reviewing the actions of the AOJ, the Board finds there was substantial compliance with the requested development. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Lastly, the Board notes that the Veteran's May 2011 substantive appeal included a statement asserting that the rating for his service-connected diabetes was insufficient. Prior to March 24, 2015, a claim could be either a formal or informal written communication "requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." See 38 C.F.R. § 3.1(p) (2014); see also 38 C.F.R. § 3.1(p) (2016) (now providing that a "claim" must be submitted on an application form prescribed by the Secretary); 79 Fed. Reg. 57,696 (Sept. 25, 2014) (eliminating informal claims by requiring that, effective March 24, 2015, claims be filed on standard forms). The Board interprets the May 2011 statement as an increased rating claim, however, a review of the claims file shows that the RO has not adjudicated this issue. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2016). FINDINGS OF FACT 1. Prior to December 17, 2003, the Veteran's CAD required continuous medication; prior to December 17, 2003, the Veteran's CAD was not manifested by a workload less than 7 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, nor was there evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. 2. From April 1, 2004 to February 13, 2011, the Veteran's CAD was not manifested by a workload less than 7 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, nor was there evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. 3. From February 14, 2011 to December 10, 2015, the Veteran's CAD was not manifested by a workload less than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. Additionally, the evidence does not show left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 4. From December 11, 2015 to April 7, 2017, the Veteran's CAD was not manifested by a workload less than 7 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, nor was there evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. 5. As of April 8, 2017, the Veteran's CAD was manifested by cardiac hypertrophy as evidenced by an echocardiogram; as of April 8, 2017, the Veteran's CAD was not manifested by a workload less than 5 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for CAD, prior to December 17, 2003, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7005 (2016). 2. The criteria for a rating in excess of 10 percent for CAD, from April 1, 2004 to February 13, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, DC 7005 (2016). 3. The criteria for a rating in excess of 30 percent for CAD, from February 14, 2011 to December 10, 2015, have not been met. 38 U.S.C.A. §§ 1155, 5107, 7104(a) (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, DC 7005 (2016). 4. The criteria for a rating in excess of 10 percent for CAD, from December 11, 2015 to April 7, 2017, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, DC 7005 (2016). 5. The criteria for a 30 percent evaluation, but not higher, for CAD, as of April 8, 2017, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, DC 7005 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.159 (2016); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA provided the Veteran with 38 U.S.C.A. § 5103(a)-compliant notices in September 2003, May 2006, May 2007 and September 2010. As noted above, in August 2016 the Board remanded this matter and instructed the RO to obtain private cardiology medical records. The Veteran was instructed to complete and return enclosed VA Form 21-4142, Authorization to Disclose Information to the VA, and VA Form 21-4142a, General Release for Medical Provider Information to the VA, to assist the RO in obtaining those records. The Veteran did not complete and return those forms and the RO subsequently was unable to obtain the relevant evidence. VA's duty to assist in developing the facts and evidence pertinent to the Veteran's claim is not a one-way street, and it is his responsibility to work with VA with regard to development. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Accordingly, the record shows that VA has fulfilled its obligation to assist the Veteran in developing the claim on appeal, including with respect to VA examinations of the Veteran. Neither the Veteran nor his representative has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2016). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2016). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2016); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14 (2016); Esteban v. Brown, 6 Vet. App. 259 (1995). Coronary Artery Disease The Veteran's CAD has been assigned an initial 10 percent disability rating prior to December 17, 2003, and 10 percent disabling from April 1, 2004 to February13, 2011. Additionally, from February 14, 2011 to December 10, 2015, the Veteran's CAD has been rated 30 percent disabling, and 10 percent disabling thereafter. Pursuant to DC 7005, a 10 percent rating is assigned for CAD when a workload greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or treatment requiring continuous medication. A 30 percent rating is assigned when a workload greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted when there is more than one episode of congestive heart failure in the past year; or a workload of 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted when there is 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. 38 C.F.R. § 4.104, DC 7005 (2016). One MET is defined as 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 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) (2016). Initially, the Board notes that the record shows the Veteran's CAD was primarily treated by a private medical provider. The record includes certain private medical records dating from 1997, prior to claim on appeal, and from December 2003, a period in which the Veteran is in receipt of a temporary total disability rating and which is, therefore, not on appeal. As noted above, following the Board's August 2016 remand, the RO attempted to assist the Veteran in obtaining any remaining private treatment records; however, the Veteran did not complete and return the requested forms necessary to obtain such records. Additionally, the Veteran has not submitted any such evidence. Accordingly, the Board will adjudicate the issues on appeal based on the evidence of record. The Board will first address the period on appeal prior to December 17, 2003. After a review of the record, the Board concludes that the criteria for an initial rating in excess of 10 percent for CAD have not been met or approximated. During this period on appeal, the evidence of record includes a July 2003 VA medical record noting that the Veteran had CAD since 1997, and that he was evaluated for chest pain and found to have coronary artery blockage. Following angioplasty and a stent placement in 1997, the Veteran underwent a stress test in December 2002 which was noted as negative. The Veteran reported chest pain approximately three times per month and the physician noted that the CAD was stable. The physician also noted that the Veteran's CAD was treated with Toprol XL which the physician changed to Metoprolol. No history of myocardial infarction was found. Based on the evidence of record, prior to December 17, 2003, the Veteran's CAD has not been documented with a workload less than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. In addition, the evidence of record does not note cardiac hypertrophy or dilation. The evidence of record does show that the Veteran's CAD did require continuous medication. Thus, prior to December 17, 2003, there is no competent evidence of record showing the Veteran's CAD was manifested by symptoms approximating a 30 percent or higher disability rating pursuant to DC 7005. The Board will now address the period on appeal from April1, 2004 to February 13, 2011. VA medical records show that the Veteran denied chest pain or dyspnea in April 2005. In July 2005, the Veteran again denied chest pain or dyspnea. The physician found the Veteran's CAD was clinically asymptomatic. In January 2006, the Veteran denied chest pain, dizziness, syncope or dyspnea. In July 2006, the Veteran denied any chest pain or dyspnea. A January 2007 VA medical record shows the Veteran denied chest pains, dizziness, orthopnea, or paroxysmal nocturnal dyspnea. At a June 2007 VA examination, the Veteran denied symptoms of angina, dyspnea, fatigue, dizziness or syncope. The examiner found that the CAD was not manifested by myocardial infarction, congestive heart failure, or rheumatic disease. The examiner also estimated the Veteran's METs at 9 based on the Veteran's inability to jog 6 miles per hour. The examiner further noted a normal echocardiogram and electrocardiogram (EKG). Additionally, the examiner found that the Veteran's heart condition did not affect his usual occupation. An April 2009 echocardiogram report noted a normal sinus rhythm with sinus arrhythmia, and a normal EKG when compared with an EKG performed in August 2003. Based on the evidence of record dating between April 2004 and February 2011, the Veteran's CAD has not been documented with a workload less than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. In addition, the evidence of record does not note cardiac hypertrophy or dilation. Accordingly, between April 2004 and February 2011, there is no competent evidence of record showing the Veteran's CAD was manifested by symptoms approximating a 30 percent or higher disability rating pursuant to DC 7005. The Board will now address the period on appeal from February 14, 2011 to December 10, 2015. At a February 2011 VA examination, the Veteran denied having chest pain but did report having shortness of breath with exertion. The Veteran stated that he had been evaluated every year by his private cardiologist, including yearly stress tests. The Veteran also reported that his previous stress test results were normal. The examiner noted no history of angina, dizziness, syncope, fatigue, myocardial infarction, or hypertensive heart disease including prosthetic valve or congestive heart failure. The Veteran was found positive for hypertension and dyspnea on moderate exertion. His heart disease required continuous medication. A stress test revealed METs ranging from 7 to 8. Left ventricular testing revealed an ejection fraction greater than 50 percent. The examiner noted that the Veteran's heart disease affected his occupational activities including problems with lifting, carrying, weakness and fatigue. Additionally, the Veteran reported increased absenteeism, although he further reported no time lost from work during the past 12 month period. A November 2014 VA medical record noted the Veteran denied chest pain, visual disturbance, shortness of breath or headaches. As noted above, in an August 2016 decision the Board granted an increased 30 percent evaluation. The Board found that a 30 percent evaluation was warranted based on the stress test conducted during the February 2011 VA examination which revealed a workload of 7-8 METs. Resolving reasonable doubt in the Veteran's favor, the Board granted a 30 percent disability rating. The Board also remanded the matter as the Veteran reported seeing a private cardiologist for treatment of his heart condition. As further noted above, the Veteran did not comply with the RO's request to return authorization forms necessary to obtain any outstanding medical treatment records. Therefore, no new evidence has been added to the claims file since the August 2016 Board decision. After a review of the evidence of record, the Board finds that a rating in excess of 30 percent from February 14, 2011 to December 10, 2015, is not warranted. Specifically, the evidence does not show the Veteran's CAD manifested by a workload less than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. Additionally, the evidence does not show left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Therefore, a rating in excess of 30 percent from February 14, 2011 to December 10, 2015, is not warranted. Finally, the Board will address the period on appeal as of December 11, 2015. The Veteran underwent a VA examination in December 2015. The Veteran's diagnosed CAD was noted as stable and the Veteran denied chest pain or shortness of breath. The Veteran also denied any new cardiac surgeries or procedures. The Veteran's CAD was noted to require continuous medication for control. The examiner did not find that the Veteran's heart condition was manifested by myocardial infarction, congestive heart failure, arrhythmia, heart valve conditions, infectious heart conditions, or pericardial adhesions. Diagnostic testing revealed no evidence of cardiac hypertrophy or cardiac dilation. An echocardiogram noted a left ventricular ejection fraction between 55 to 60 percent, a normal wall motion, and normal wall thickness. An interview based METs test shows the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. Lastly, the examiner noted that the Veteran's service-connected CAD did not impact his ability to work. In March 2017, the Veteran reported that he underwent a stress test at GRMC with results initially reported as good, but later he was contacted by his medical provider and told he may have some blockage. The Veteran's VA physician ordered the GRMC medical records and informed the Veteran that they would be reviewed with recommendations. An April 8, 2017 echocardiogram showed normal left ventricular systolic function with an ejection fraction around 60 percent. The physician noted mild concentric left ventricular hypertrophy. A nuclear stress test showed a mild perfusion defect in the apical wall with mild defect reversibility, and a mild perfusion defect in the inferior wall with no significant defect reversibility. The post stress ejection fraction was 53 percent and the global left ventricular systolic function was normal. The clinician noted an exercise capacity of 14 METs. Two weeks later, the Veteran was informed by his VA physician that a heart catheterization was not indicated at that time. Prior to April 8, 2017, the Board finds that a rating in excess of 10 percent disabling is not warranted. This is based on the December 2015 VA examiner's finding of a normal interview METs test showing the Veteran denied experiencing cardiac symptoms with any level of physical activity. Diagnostic testing conducted during that examination also showed no evidence of cardiac hypertrophy or cardiac dilation. As such, during this period on appeal, the Veteran's CAD did not more closely approximate a 30 percent evaluation. However, while an April 2017 stress test revealed METs greater than 10, an April 8, 2017 echocardiogram did evidence cardiac hypertrophy. Accordingly, as of April 8, 2017, the Board finds that the evidence of record supports a 30 percent evaluation. As the Veteran's heart condition during this period on appeal was not manifested by congestive heart failure or left ventricular dysfunction with an ejection fraction of 30 to 50 percent, a higher 60 percent evaluation is not warranted. In sum, the preponderant of the evidence is against an initial disability rating of 10 percent prior to December 17, 2003, and in excess of 10 percent disabling from April 1, 2004 to February13, 2011. Additionally, from February 14, 2011 to December 10, 2015, the preponderance of the evidence is against a disability rating in excess of 30 percent disabling. Between December 11, 2015 and April 7, 2017, the preponderance of the evidence is against a disability rating in excess of 10 percent disabling. As the preponderance of the evidence is against the above increased ratings, the benefit-of-the-doubt doctrine is inapplicable and those claims for higher ratings must be denied. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2016); Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Finally, as of April 8, 2017, the Board finds that the evidence of record supports an increased 30 percent disability rating, but not more, and that claim is granted. Extraschedular Consideration The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub. nom. Thun v. Shinseki, 573 F.3d 1366 (Fed Cir. 2009). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). The Board finds that referral for extraschedular consideration is not warranted. The evidence of record shows that, throughout the period on appeal, the Veteran's service-connected connected CAD was adequately contemplated by the regular schedular rating criteria. The primary symptoms of the Veteran CAD are cardiac hypertrophy, continuous medication, and a workload alternating between 7 and 14 with occasional symptoms of fatigue, but no dyspnea, angina, dizziness or syncope. The Veteran's CAD is currently rated under DC 7005, based on those symptoms. The Board finds that the rating criteria adequately describe the severity and symptomatology of the Veteran's CAD. Consequently, the Board finds that referral for extraschedular consideration is not required. The schedular rating criteria for the Veteran's CAD also provide for higher ratings for more severe symptomatology, which, as described above, are not shown. Therefore, there is no need to consider the downstream consideration of whether there is marked interference with the Veteran's employment or frequent hospitalizations. 38 C.F.R. § 3.321(b)(1) (2016); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Finally, the Board notes that the Veteran has not asserted that he was unemployable solely because of his service-connected CAD during this period. Thus, the Board finds that an implied claim for a total disability rating based on unemployability has not been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to an initial rating in excess of 10 percent, prior to December 17, 2003, for CAD is denied. Entitlement to a rating in excess of 10 percent, from April 1, 2004 to February13, 2011, for CAD is denied. Entitlement to a rating in excess of 30 percent, from February 14, 2011 to December 10, 2015, for CAD is denied. Entitlement to a rating in excess of 10 percent, from December 11, 2015 to April 7, 2017, for CAD is denied. Entitlement to a rating of 30 percent, but not more, as of April 8, 2017, for CAD is granted. ____________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs