Citation Nr: 1805601	
Decision Date: 01/29/18    Archive Date: 02/07/18

DOCKET NO.  16-20 746	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in San Diego, California


THE ISSUE

Entitlement to an increased evaluation of coronary artery disease, currently 10 percent disabling.


REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of the United States


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

C. Banks, Associate Counsel

INTRODUCTION

The Veteran had active duty from November 1967 to November 1970.   

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California.  The Veteran testified in a Board hearing before the undersigned Veterans Law Judge in September 2017.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017).  38 U.S.C. § 7107(a)(2) (2012).


FINDING OF FACT

Evidence of cardiac dilatation has been shown on x-ray during the period on appeal; that said, the Veteran's coronary artery disease has not been characterized by a workload of less than 5 metabolic equivalents (METs) resulting in dyspnea, fatigue, angina, dizziness, or syncope; congestive heart failure; or left ventricular dysfunction with an ejection fraction of less than 50 percent.


CONCLUSION OF LAW

The criteria for a 30 percent disability rating for coronary artery disease have 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).


REASONS AND BASES FOR FINDING AND CONCLUSION

As a preliminary matter, the Board has reviewed the claims file and finds that there exist no deficiencies in VA's duties to notify and assist that would be prejudicial and require corrective action prior to a final Board determination.  See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159; see also Bryant v. Shinseki, 23 Vet. App. 488 (2010) (regarding the duties of a hearing officer); Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (corrective action to cure a 38 C.F.R. § 3.159(b) notice deficiency); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (timing of notification).

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities.  Ratings are based on the average impairment of earning capacity.  Individual disabilities are assigned separate diagnostic codes.  See 38 U.S.C. § 1155; 38 C.F.R. § 4.1.  Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings.  See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2.  Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings.  The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim.  See generally Hart v. Mansfield, 21 Vet. App. 505 (2007).  

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned.  See 38 C.F.R. § 4.7.  In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met.  38 C.F.R. § 4.31.

Pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005, a 10 percent evaluation is warranted when a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication is required.  A 30 percent evaluation is warranted when there is 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 dilation on electrocardiogram, echocardiogram, or x-ray.  A 60 percent evaluation is warranted when there is more than one episode of acute congestive heart failure (CHF) in the past year; 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 evaluation is warranted when there is chronic CHF; or a 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.

In this case, the Veteran has indicated that he was recently diagnosed with coronary artery disease and has received treatment therefor at the VA Medical Center (VAMC) on La Jolla Village Drive in San Diego, California.  See, e.g., VA Form 21-526b, Veteran's Supplemental Claim for Compensation, received in February 2015.  His VA treatment records from that facility reflect little indication of whether the Veteran's coronary artery disease is manifested by the symptoms mentioned above in relation to the 30, 60 and 100 percent disability ratings under Diagnostic Code 7005.  A notable exception, however, is found in November and December 2014 treatment notes.  The November 2014 treatment note indicates an ejection fraction (EF) of 67 percent, apparently upon echocardiogram study.  The December 2014 note discusses the findings of a computed tomography (CT) scan/study, and it indicates, in most relevant part, that the interpreting physician's impression was that the Veteran had "right ventricular dilatation which could indicate pulmonary arterial hypertension in spite of a normal size main pulmonary artery."
 
The Veteran was afforded a VA examination in April 2015.  The examiner diagnosed him with coronary artery disease and noted that he has not had congestive heart failure (CHF), nor does he have cardiac arrhythmia, any heart valve conditions, infectious cardiac conditions, pericardial adhesions, cardiac hypertrophy or dilatation.  The examiner noted that an EKG, chest x-ray, and an electrocardiogram were performed within the few weeks prior to the exam, and all findings were normal, except for a normal variant of sinus bradycardia being found on EKG.  An interview-based METs test was also performed within the few weeks prior to the examination, and the examiner indicated that the Veteran's METs level was determined to be greater than 7 but not greater than 10 METs.  

VA also obtained a Disability Benefits Questionnaire (DBQ) completed by another VA examiner in March 2016.  This second examiner opined that the Veteran's ventricular dilatation, noted in the December 2014 VA treatment note, is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected CAD.  As a supporting rationale for that conclusion, the examiner explained that CTs are less accurate than echocardiograms for purposes of looking at, imaging and studying disorders of the heart.  The examiner explained that, based on the less reliable CT study and the more accurate echocardiogram study results mentioned above, the Veteran does not have right ventricular dilatation or pulmonary hypertension.  The examiner further explained that the Veteran's one vessel coronary artery disease would not be expected to cause right ventricular dilatation, for at least two reasons.  First, the OM-2 vessel does not provide significant perfusion to the right ventricle.  Second, his OM-2 vessel had retrograde flow.

After having considered all evidence of record, the Board finds that it is at least as likely as not that the Veteran's service-connected coronary artery disease has resulted in evidence, on x-ray, of cardiac dilatation.  As indicated above, the December 2014 VA treatment note reflects that there was evidence of cardiac dilatation on CT.  A CT, in this context, refers to a computerized x-ray imaging procedure in which a narrow beam of x-rays is aimed at a patient and quickly rotated around the body, producing signals that are processed by the machine's computer to generate cross-sectional images - or "slices" - of the body.  See, e.g., https://www.nibib.nih.gov/science-education/science-topics/computed-tomography-ct.  Thus, the Veteran's VA treatment records reflect that there is evidence of cardiac dilatation on x-ray.  While the March 2016 VA examiner opined that the Veteran does not actually have cardiac dilatation, based on more accurate echocardiogram results, Diagnostic Code 7005 does not require a conclusive finding of cardiac dilatation for a 30 percent disability evaluation thereunder.  Rather, it simply requires some evidence of it on electrocardiogram, echocardiogram, or x-ray.  Here, while there may not be evidence of cardiac dilatation on electrocardiogram or echocardiogram, there is noted evidence of it on CT scan.  

However, the evidence does not show that the Veteran's coronary artery disease has been characterized by a workload of less than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; congestive heart failure; or left ventricular dysfunction with an ejection fraction of less than 50 percent.  In fact, the Veteran does not even argue as much; he simply contends that his coronary artery disease should be rated as 30 percent disabling.  See, e.g., Transcript of Hearing Before the Board of Veterans' Appeals, dated in September 2017.  Furthermore, neither the Veteran's VA treatment records, the April 2015 VA examination report, nor the March 2016 DBQ indicate that any such symptoms are present.  Accordingly, the Board finds that the criteria for a 30 percent evaluation under Diagnostic Code 7005, but no greater, have been met.

In closing, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record.  See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).  Furthermore, the evidence and contentions of record do not suggest that the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has been raised in this case.  Rice v. Shinseki, 22 Vet. App. 447 (2009).


ORDER

Entitlement to a 30 percent evaluation of coronary artery disease, but no greater, is granted, subject to the laws and regulations governing the payment of monetary benefits.


____________________________________________
A. C. MACKENZIE
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs