Citation Nr: 1805364 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 14-14 799 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to April 27, 2016, for depressive disorder not otherwise specified (NOS). 2. Entitlement to an initial compensable rating from April 27, 2016, for unspecified anxiety disorder NOS. 3. Entitlement to an initial rating in excess of 10 percent prior to April 27, 2016, and in excess of 60 percent from April 27, 2016, for coronary artery disease (CAD). 4. Entitlement an effective date prior to April 27, 2016 for the grant of a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Allen Gumpenberger, Agent ATTORNEY FOR THE BOARD J. Cheng, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2013, January 2014, and June 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). During the pendency of the appeal, the RO reduced the Veteran's rating for his service-connected psychiatric disability from 30 percent to 0 percent, effective April 27, 2016 forward in a June 2016 rating decision (previously rated as depressive disorder, currently rated as unspecified anxiety disorder). At the time of the June 2016 rating decision, the Veteran already perfected his appeal as to the assigned rating for his psychiatric disability. Notably, neither the Veteran nor his representative has presented any argument concerning the propriety of the reduction, or otherwise suggested that appellate review of that reduction was being sought. Accordingly, the Board finds that the Veteran is not pursuing appellate review of the propriety of the rating reduction, and the issue currently before the Board has been characterized to reflect the Veteran's current staged rating. Additionally, the issue of entitlement to TDIU was previously remanded in November 2016 by the Board and subsequently, the RO granted entitlement to TDIU, effective April 27, 2016, in a June 2016 rating decision. However, the Veteran submitted a notice of disagreement in September 2016 in which he claimed for an earlier effective date for his entitlement to TDIU. The Board notes that the current VA regulation requires the filing of a VA Form 21-0958 to initiate a notice of disagreement is applicable to claims and appeals filed on or after March 24, 2015. See 38 C.F.R. §20.201; 79 Fed. Reg. 57660-57698 (Sept. 25, 2014). Here, the Veteran completed the required VA Form 21-0958 Notice of Disagreement form. After a statement of the case was completed in March 2017 that continued the TDIU effective date of April 27, 2016, the Veteran timely appealed the issue and the issue of an earlier effective date for the grant of TDIU was certified to the Board. As such, this issue is appropriately before the Board. FINDINGS OF FACT 1. For the period prior to April 27, 2016, the Veteran's depressive disorder NOS, at worst, has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; but not by occupational and social impairment with reduced reliability and productivity, by occupational and social impairment with deficiencies in most areas, or by total occupational and social impairment. 2. For the period from April 27, 2016, the Veteran's symptoms of unspecified anxiety disorder NOS are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 3. For the period prior to April 27, 2016, the Veteran's coronary artery disease is not manifested by a workload less than seven METs resulting in dyspnea, fatigue, angina, dizziness or syncope; or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. 4. For the period from April 27, 2016, the Veteran's coronary artery disease is not manifested by a workload of three or less METs resulting in dyspnea, fatigue, angina, dizziness or syncope; or evidence of chronic congestive heart failure; or evidence of left ventricular dysfunction with an ejection fraction of less than 30 percent. 5. The Veteran did not meet the schedular criteria for an award of TDIU benefits prior to April 27, 2016, nor does the evidence of record establish that he was otherwise unable to obtain or maintain a substantially gainful occupation as a result of service-connected disabilities prior to that date. CONCLUSIONS OF LAW 1. For the period prior to April 27, 2016, the criteria for the assignment of an initial rating in excess of 30 percent for the service-connected depressive disorder NOS have been not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.126, 4.130, Diagnostic Code 9434 (2017). 2. For the period from April 27, 2016, the criteria for the assignment of an initial compensable rating for the service-connected unspecified anxiety disorder NOS have been not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.126, 4.130, Diagnostic Code 9413 (2017). 3. For the period prior to April 27, 2016, the criteria for an initial rating in excess of 10 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). 4. For the period from April 27, 2016, the criteria for an initial rating in excess of 60 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). 5. The criteria for establishing entitlement to an effective date prior to April 27, 2016 for the grant of TDIU benefits have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veteran is challenging the evaluations assigned in connection with the grants of service connection for CAD and psychiatric disorders. Similarly, the Veteran's claim of entitlement to an earlier effective date arises from the initial grant of TDIU. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required with respect to this claim. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claim, including with respect to VA examination 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). Initial Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when assigning disability rating. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Mental Disorders In the current appeal, the Veteran's service-connected psychiatric disorders is rated 30 percent prior to April 27, 2016 for depressive disorder NOS and 0 percent thereafter for unspecified anxiety disorder NOS. The General Rating Formula for Mental Disorders provides for a noncompensable rating when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupation and social functioning or to require continuous medication. 38 C.F.R. § 4.130, DC 9413, 9434. A 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous mediation. Id. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if the evidence establishes there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Federal Circuit has emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Factual Background September 2013, September 2014, August 2015 VA treatment records noted the Veteran's appearance as alert and oriented and that he was in no apparent distress. An October 2013 VA treatment record noted the Veteran complained of frustration and irritability since his heart problems. He reported he got mad that he could not do what he used to. During evaluation, the Veteran denied anhedonia or feeling depressed. The provider noted there was no history of psychotherapy and that the Veteran appeared well developed, well nourished, and neatly groomed, with normal gait and station. The provider noted the Veteran's speech had normal rate, volume, articulation, coherence, and spontaneity and that his thought process was linear and goal directed. The provider noted there were no looseness of associations and there were no auditory or visual hallucinations, delusions, or paranoia. The Veteran denied suicidal and homicidal ideation, and was noted as having good insight, intact judgment, intact memory, intact language, and average fund of knowledge. The provider noted the Veteran was alert and oriented to time, person, and place and had no impairment of attention or concentration. The Veteran's mood was noted as anxious and irritable and his affect was noted as congruent with mood. The provider diagnosed depressive disorder NOS and assigned a GAF score of 60. The provider recommended psychotherapy but noted that the Veteran was not interested. In an October 2013 VA initial posttraumatic stress disorder (PTSD) disability benefits questionnaire (DBQ) examination, the examiner noted the Veteran did not meet the diagnostic criteria for PTSD but that the Veteran had a diagnosis of depressive disorder NOS. The examiner noted that the Veteran's had occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. During examination, the Veteran reported having a positive relationship with his wife, children, grandchild, and parents. The Veteran also endorsed having several friends but indicated that his fatigue prevented him from being as socially active as he desired. The Veteran reported that he worked as an electrician for 45 years following discharge from active service but that he was laid off after his heart attack in 2006. He reported that he went back to work after that but struggled to keep up with the demands due to his physical health and fatigue. The examiner noted the Veteran retired in 2010 and supported himself through Social Security. The Veteran reported that since the onset of his mental health symptoms in 2006 following his heart attack, he continued to endorse depressed mood, irritability, anxiety, and sleep disturbance. The Veteran reported he had depressed mood as a result of his reported loss of function. The Veteran denied suicidal or homicidal ideation. The examiner noted the Veteran's symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner assigned a GAF score of 65 and noted the Veteran had mild impairment associated with his depressive disorder. An August 2015 VA treatment record noted that the Veteran had a negative PTSD screen and a negative depression screen. The Veteran indicated that he did not experience little interest or pleasure in doing things and also did not experience feeling down, depressed, or hopeless. In an April 2016 VA Mental Disorders DBQ examination, the examiner diagnosed unspecified anxiety disorder. The examiner noted that a mental disorder had been formally diagnosed, but symptoms were not severe enough to interfere with occupational and social functioning or to require continuous medication. During examination, the Veteran reported a generally positive relationship with his wife whom he referred as to "his crutch." The Veteran reported that he and his wife continued to reside with and provide around the clock care for their adult son with special needs. The Veteran described sharing positive relationships with all of his children. The Veteran described continued active involvement in two different veterans organization. He reported he attended social gatherings and meetings for both organizations and also continued to visit and dine with friends weekly. The Veteran reported he had become more socially distant compared to how he was in the past. The April 2016 VA examiner noted there was no significant social impairment and no significant difficulties establishing and maintaining effective social relationships. The examiner noted the Veteran had been retired since 2010 and had worked as an electrician and also in construction for most of his adulthood. The examiner noted the Veteran's reports that he was unable to find consistent work after he suffered a heart attack in 2006. The Veteran reported that he had been unable to keep up with the physical demands because of his poor physical health and that many companies were unwilling to give him work because of his inabilities to keep up with the physical demands of the jobs and the liabilities associated with employing an individual with poor physical health. The examiner noted that it appeared that most if not all of his impairments in occupational functioning were related to his physical health and not to his mental health. The Veteran denied experiencing any significant interpersonal problems while working and denied missing days/time from work from working. The examiner noted there were no significant occupational problems reported except for being unable to keep up with the physical demands of the jobs after his heart attack in 2006. The examiner noted there were no significant difficulties establishing or maintaining effective work relationships and there were no indications that the Veteran's diagnosed unspecified anxiety disorder would preclude him from securing and maintaining substantially gainful employment consistent with his education and occupational experience. The April 2016 VA examiner noted that on examination, the Veteran presented with a description of symptoms consistent with unspecified anxiety disorder including generalized feelings of anxiety, irritability, and poor energy. The examiner indicated the Veteran's poor energy was most likely due to the side effects of his heart medications. The examiner acknowledged that a review of records show the Veteran had previously endorsed depressed mood but the Veteran denied experiencing depressed mood during examination, noting that the Veteran was generally happy and positive in mood and attitude. The Veteran denied experiencing any sleep impairments and he reported he generally slept well and did not have any complaints about his sleep. The examiner noted that the Veteran sometimes thought of his combat related experiences in Vietnam and that he was reminded of his experience when triggered by certain smells and sounds. However, the Veteran indicated he did not dwell on them. The Veteran denied experiencing significant intrusive symptoms and was generally not avoidant of triggers. The examiner noted the Veteran's willingness and desire to share his stories with other veterans in veterans organizations. The Veteran denied significant alterations in cognition and mood and denied significant arousal symptoms other than irritability. The Veteran denied suicidal or homicidal ideation and was in no persistent danger of hurting himself or others. The Veteran denied problems with impulse control. He denied delusions, hallucinations, or panic attacks. The examiner noted there were no indications that the Veteran was experiencing any difficulties understanding complex commands and there were no reported impairments in short and long term memory, judgment, abstract thinking, and motivation. The April 2016 VA examiner noted the Veteran was appropriately groomed and dressed in casual attire, was able to function independently, and was fully capable of performing ADLs. The examiner noted the Veteran and his wife continued to adequately and appropriately care for their son with special needs without any problems which the examiner found demonstrated the Veteran's ability to adapt to stressful circumstances. The Veteran was noted as oriented to person, place, and time. He was noted as pleasant, polite, and cooperative, and rapport was established and maintained throughout the examination. The examiner noted the Veteran made consistent eye contact, his mood appeared euthymic, with affect appropriate to expressed mood. The examiner noted the Veteran became teary-eyed as he spoke about the loss of his friend to cancer. The Veteran's thought process was noted as generally linear and goal-directed with no cognitive deficits noted and no abnormalities noted in speech. The examiner noted the Veteran had fair insight and judgment. After examination, the April 2016 VA examiner found that the Veteran did not meet the full diagnostic criteria for PTSD. The examiner acknowledged the Veteran's reports of becoming more socially withdrawn; however, the examiner found that the Veteran did not appear to be experiencing any significant social impairment. Analysis After a review of the evidence, the Board finds that prior to April 27, 2016, the Veteran's symptoms are, at worst, consistent with a 30 percent rating. During this period on appeal, the Veteran's depressive disorder NOS was manifested by symptoms of decreased ability to perform occupational tasks only during periods of significant stress, symptoms controlled by continuous medication, depressed mood, anger, irritability, anxiety, and sleep disturbance. The Board finds that symptomatology is consistent with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the criteria for a 30 percent rating. The Board recognizes that the symptoms noted in the rating schedule are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, even though not all the listed symptoms compatible with a 30 percent rating are shown, the Board concludes that the type and degrees of symptomatology contemplated for a 30 percent rating appear to be demonstrated throughout this period on appeal. The Board finds that a rating higher than 30 percent is not warranted. The Veteran has not demonstrated significant deficiencies in work or family relations. Although he reported fatigue had prevented him from being as socially active as he wanted, he reported positive relationships with his wife, children, grandchild, and parents, and that he maintained friendships. There is no evidence of an inability to establish and maintain effective relationships or more severe symptomatology such as total occupational or social impairment that would warrant any higher rating. From April 27, 2016, the Board finds that compensable rating for the service-connected unspecified anxiety disorder NOS is not warranted. The Board places great probative weight on the observations, diagnosis, and assessment provided by the April 2016 VA examiner who found that a mental disorder had been formally diagnosed, but symptoms were not severe enough to interfere with occupational and social functioning or to require continuous medication. The Board notes that the April 2016 VA examiner considered the Veteran's statements and entire claims file in making this finding. Specifically, the Veteran had indicated he was more socially distant compared to how he was in the past. The examiner also noted the Veteran's reports of anxiety, irritability, and poor energy. However, the examiner highlighted the Veteran's general happy and positive mood and attitude, denial of sleep impairments, and ability to adapt to stressful circumstances. The examiner also noted that despite the Veteran's reports of becoming more socially withdrawn, the Veteran did not appear to be experiencing any significant social impairment as he continued to share positive relationships with his wife, children, friends, and two veterans organizations. The examiner also specifically found that most if not all of his occupational impairments were related to his physical health and not his mental health. The examiner ultimately found that there were no indications that the Veteran's diagnosed mental health disorder precluded him from securing and maintaining substantially gainful employment. As such, the Board finds that a compensable rating is not warranted for this period on appeal. While the Veteran reported irritability and anger, the evidence shows that he is able to manage his symptoms and maintained independent functionality. The evidence of record does not show symptoms causing occupational and social impairment or with deficiencies in most areas. Symptomatology commensurate with a 100 percent schedular rating, demonstrating total occupational and social impairment, is also not shown. The Veteran maintained a good relationship with his wife, family, and friends during the appeal, which would not be expected in someone with more severe deficiencies in social impairment, with deficiencies in most areas, or with total occupation and social impairment. Therefore, the Board finds that the preponderance of the evidence is against a finding of a greater level of occupational or social impairment than those currently assigned. The Board acknowledges that the Veteran is competent to report symptoms of a psychiatric disability. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). However, the Veteran is not competent to identify a specific level of impairment of a psychiatric disability according to the appropriate diagnostic code. Competent evidence concerning the nature and extent of his service-connected psychiatric disorders has been provided by VA medical professionals who have examined and treated him. The medical findings directly address the criteria under which the disability is evaluated. The Board finds these records to be competent and probative evidence of record, and therefore is accorded greater weight than the Veteran's claim that he warrants higher ratings. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Furthermore, the opinions and observations of the Veteran alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.130 with respect to determining the severity of his service-connected psychiatric disorders. Moray v. Brown, 2 Vet. App. 211 (1993); 38 C.F.R. § 3.159(a)(1) and (2). In reaching its decision, the Board considered the benefit-of-the-doubt rule. However, the preponderance of the evidence is against the Veteran's claim for an increased initial evaluation. Therefore, an initial evaluation in excess of 30 percent for depressive disorder NOS prior to April 27, 2016, and a compensable evaluation for unspecified anxiety disorder NOS thereafter is not warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. CAD The Veteran's CAD is rated 10 percent from May 16, 2011 to April 26, 2016, and rated 60 percent from April 26, 2017, under Diagnostic Code (DC) 7005. 38 C.F.R. § 4.104, DC 7005. 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. Id. 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. Id. 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. Id. 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. Id. 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). Factual Background In a July 2012 letter from the Veteran's treating cardiologist, Dr. C.A.W., the provider noted the Veteran remained free of any angina symptoms status post stent placement to the left anterior descending artery in July 2007. The provider noted that his EKG showed normal sinus rhythm with nonspecific ST-T wave changes. The provider noted the Veteran's mild claudication symptoms but indicated he was not walking much and that the Veteran was urged to start walking again. In a November 2012 VA ischemic heart disease (IHD) DBQ examination, the examiner noted the Veteran's CAD had a date of diagnosis of 2007. The examiner noted the Veteran's had an angioplasty with stent to the left anterior descending artery in July 2007. The Veteran reported his last nuclear stress test was six months ago and he reported that he did well with no complaint of chest pain or shortness of breath but had to stop because of claudication. The Veteran denied chest pain and shortness of breath but reported that he fatigued more easily, had less endurance, and intermittently got dizzy. The Veteran reported that doing chores around the house had become more difficult because of claudication. The examiner noted the Veteran did not have a history of myocardial infarction, coronary bypass surgery, heart transplant, implanted cardiac pacemaker, implanted automatic implantable cardioverter defibrillator (AICD), or congestive heart failure. The examiner noted that the most recent diagnostic test in December 2011 showed the Veteran had METs level of 8.5 and a left ventricular ejection fraction (LVEF) of 73 percent. The examiner noted that repeat testing was not indicated as there was no change in condition. The examiner also noted there was no evidence of cardiac hypertrophy or dilation. The examiner noted the Veteran's IHD impacted his ability to work, specifically regarding the Veteran's reports that he fatigued more easily, had less endurance, and intermittently got dizzy with exertion. The examiner found the Veteran had mild functional impairment and noted the Veteran was currently unemployed and remained a level I in activities of daily living (ADLs). In a December 2012 letter from the Veteran's treating cardiologist, Dr. C.A.W., the provider noted the Veteran's symptoms of chest pain were quite atypical and was suspected as not angina. The provider suspected that the chest pains were brought on by stress. The provider also noted the Veteran's blood pressure seemed well controlled. VA treatment records from 2011 to 2015 show that the Veteran was consistently negative for shortness of breath, chest pain, or palpitations. These VA treatment records also noted the Veteran's EKG during this period consistently showed normal sinus rhythm and no ischemic changes. In an April 2016 private treatment record from the Veteran's treating cardiologist, Dr. C.A.W., the provider noted the Veteran's lungs were clear and his cardiac examination was normal. The provider noted that his EKG showed sinus bradycardia with nonspecific T-wave changes. The provider also noted the Veteran's peripheral arterial disease and severe right internal carotid artery disease. The provider noted the Veteran remained free of any angina symptoms. The provider indicated she was not 100 percent certain whether or not the Veteran's leg pain was due to his peripheral arterial disease or if there was a component of statin myopathy. The provider noted that the Veteran had an ankle-brachial index done in November 2011 that showed severe aortoiliac disease on the right and mild disease on the left. In an April 2016 VA IHD DBQ examination, the examiner noted the Veteran's CAD had a date of diagnosis of 2007. The examiner noted the Veteran's had an angioplasty with stent to the left anterior descending artery in July 2007. The examiner noted the Veteran was retired from construction electrician work. The examiner noted the Veteran presented with diaphoresis and numbness of upper extremities and that his medications continued to make him tired and that the Veteran found it difficult to function. The Veteran reported he did not get chest pains but reported that he was limited and unable to do things that he used to do and that he bled easily due to his blood thinner. The Veteran also reported that he got lightheaded. The examiner noted that a nuclear perfusion scan was done in December 2011 that showed normal myocardial perfusion imaging with Tc-99 sestamibi, no evidence of ischemia or infarction, normal LV systolic function, and a calculated LVEF of 73 percent. The examiner noted the Veteran did not have a history of myocardial infarction, coronary bypass surgery, heart transplant, implanted cardiac pacemaker, implanted AICD, or congestive heart failure. Upon physical examination, the Veteran's heart rate and rhythm were noted as normal. Heart sounds were noted as normal and auscultation of the lungs was clear. Peripheral pulses were noted as diminished in the dorsalis pedis. The examiner noted that the most recent EKG in April 2016 showed the Veteran had sinus bradycardia, nonspecific ST abnormality and had METs level of greater than 3, but not greater than 5 with symptoms of dyspnea, fatigue, and dizziness. The examiner also noted there was no evidence of cardiac hypertrophy or dilation and that the Veteran had not had any other hospitalizations for the treatment of his heart disorders. The examiner noted the Veteran's IHD impacted his ability to work, specifically regarding the Veteran's reports that he continued to experience fatigue, lightheadedness, and shortness of breath. The examiner found the Veteran had mild to moderate functional impairment and noted the Veteran's cardiac disability precluded him from securing gainful employment doing physical labor but did not preclude him from sedentary jobs. Analysis The Board will first address the period on appeal prior to April 27, 2016 in which the Veteran is assigned a 10 percent rating for his CAD. After reviewing the evidence of record, the Board finds that an evaluation in excess of 10 percent is not warranted. The objective evidence of record does not show that the Veteran's METs levels were less than 7. Moreover, there was no objective evidence of cardiac hypertrophy or dilatation, or left ventricular ejection fracture of 50 percent or less during this period on appeal. At worst, during the relevant period on appeal from May 16, 2011, the Veteran's LVEF was 73 percent. The treatment records during this period on appeal showed the Veteran's heart consistently had normal sinus rhythm with no angina symptoms and that the Veteran's heart disability required continuous medication for treatment. Thus, the evidence of record does not show that the Veteran's CAD warrants a rating in excess of the assigned 10 percent during this period on appeal. During the remaining period on appeal from April 27, 2016, the Veteran was assigned a 60 percent rating for his CAD. After a thorough review of the record, the Board finds that a disability rating in excess of 60 percent is not warranted from April 27, 2016. The evidence does not demonstrate chronic congestive heart failure, or a workload of three METs or less resulting in the appropriate symptoms, or left ventricular dysfunction with an ejection fraction of less than 30 percent. Instead, during the April 2016 VA examination, the examiner noted the Veteran had METs of greater than three but less than five. These findings approximate a level of severity that does not warrant the next higher rating of 100 percent but more closely approximates the assigned 60 percent rating. Therefore, for this period of appeal, a higher disability rating is not warranted. The Board points out that to the extent the Veteran believes he meets the pertinent rating criteria, he is not competent as a layperson to opine as to his specific METs level or the percentage of left ventricular dysfunction, and is not competent to identify the presence of congestive heart failure, cardiac hypertrophy or dilation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Confirmation of those symptoms requires precise medical testing. Thus, the current severity of his coronary artery disease must be determined based on the medical evidence of record, which the Board finds support the assignment of the ratings noted above. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.104, Diagnostic Code 7005. No additional higher or alternative ratings under different diagnostic codes are warranted in the instant case as the Veteran's service connected disability has consistently been characterized as coronary artery disease. All potentially applicable diagnostic codes have been considered. 38 C.F.R. § 4.104, Diagnostic Codes 7005-7017; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Earlier Effective Date The Veteran also contends that he is entitled to an effective date prior to April 27, 2016, for the grant of TDIU benefits. However, the preponderance of the evidence of record demonstrates that an earlier effective date for TDIU benefits is not warranted. The record reflects that TDIU benefits were granted in a June 2016 rating decision, effective as of April 27, 2016. The rating decision indicates that the Veteran had a 60 percent combined schedular rating and the RO found, after providing benefit of the doubt, that the Veteran's service-connected CAD prevented the Veteran from being gainfully employed. The RO indicated that April 27, 2016 was the earliest date that the Veteran met the schedular criteria for individual unemployability. The record shows that the effective date for the award of increased rating for the CAD to 60 percent was established on April 27, 2016. Entitlement to TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). TDIU claim is a claim for increased compensation, and the effective date rules for increased compensation apply to a TDIU claim. Hurd v. West, 13 Vet. App. 449 (2000). The effective date of an award of increased compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application is received within one year from such date. Otherwise, the effective date will be the date of VA receipt of the claim for increase, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a),(b)(2); 38 C.F.R. § 3.400(o); Hazan v. Gober, 10 Vet. App. 511 (1997); Harper v. Brown, 10 Vet. App. 125 (1997); VAOPGCPREC 12-98. In the present case, the Veteran's TDIU has been based on the service-connected CAD with an evaluation of 60 percent since April 27, 2016. As such, the schedular criteria for an award of TDIU benefits have been met as of April 27, 2016. However, prior to April 27, 2016, the Veteran's combined disability evaluation was only 40 percent from July 1, 2013, and only 10 percent from May 16, 2011. Specifically, the record shows that from May 16, 2011 to June 30, 2013, the sole service-connected disability was CAD rated as 10 percent disabling; and from July 1, 2013 to April 27, 2016, the service-connected disabilities included CAD rated as 10 percent disabling and depressive disorder NOS associated with CAD rated as 30 percent disabling. As such, the schedular criteria for an award of TDIU benefits have not been met at any time prior to April 27, 2016. 38 C.F.R. § 4.16(a). While a TDIU can still be established under 38 C.F.R. § 4.16(b) when a veteran is unable to obtain or maintain a substantially gainful occupation even if they do not meet the schedular criteria under 38 C.F.R. § 4.16(a). Where the percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. §§ 3.321 (b), 4.16(b). The Board is precluded from assigning an extraschedular rating in the first instance. See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008); see also Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). After a review of the evidence of record, the Board finds that a remand for referral of the Veteran's claim for consideration of a TDIU on an extraschedular basis prior to April 27, 2016 is not warranted. The weight of the competent and credible evidence establishes that the service-connected disabilities did not preclude substantially gainful employment prior to April 27, 2016. The competent and credible evidence shows that the Veteran reported that he was unable to work due to his service-connected disabilities. See July 2013 statement in support of TDIU claim. The weight of the competent and credible evidence shows that the service-connected disabilities did not prevent the Veteran from securing substantially gainful employment prior to April 27, 2016. Preliminarily, the Board notes that the grant of entitlement to TDIU is based solely on the Veteran's CAD, and not based on the Veteran's psychiatric disorder. The April 2016 VA examiner had specifically noted that there were no indications that the Veteran's diagnosed psychiatric disorder would preclude him from securing and maintaining substantially gainful employment consistent with his education and occupational experience. As such, the Veteran's unemployability based on his service-connected CAD is at issue. However, there is no objective evidence of record noting the Veteran was totally unemployable due to his CAD. The November 2012 VA examiner noted the Veteran had mild functional impairment and that the Veteran's CAD impacted his ability to work but failed to specifically note he was unemployable due to the service-connected disability. The April 2016 VA examiner noted the Veteran had mild to moderate functional impairment and noted the Veteran's cardiac disability precluded him from securing gainful employment doing physical labor but did not preclude him from sedentary jobs. Both VA examinations also noted the Veteran was functionally independent. The Board finds that the weight of the competent and credible evidence shows that the service-connected CAD does not prevent the Veteran from securing substantially gainful employment prior to April 27, 2016 but that the cardiac disability caused mild to, at worst, moderate occupational impairment. In conclusion, the Board finds that the weight of the evidence of record shows that the service-connected CAD does not prevent the Veteran from securing and following all forms of substantially gainful employment consistent with work and educational background prior to April 27, 2016. Thus, it is not factually ascertainable that TDIU is warranted prior to April 27, 2016. Therefore, referral to the Director of Compensation and Pension Service for extraschedular consideration is not required. The Board considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Accordingly, in this case, the preponderance of the evidence is against the Veteran's claim for TDIU prior to April 27, 2016 and it is denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). (Continued on the next page) ORDER Entitlement to an initial disability rating in excess of 30 percent prior to April 27, 2016, for depressive disorder NOS is denied. Entitlement to an initial compensable rating from April 27, 2016, for unspecified anxiety disorder NOS is denied. Entitlement to an initial disability rating in excess of 10 percent prior to April 27, 2016, and in excess of 60 percent from April 27, 2016, for CAD is denied. Entitlement to an effective date prior to April 27, 2016 for the grant of TDIU benefits is denied. ____________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs