Citation Nr: 18140799 Decision Date: 10/05/18 Archive Date: 10/05/18 DOCKET NO. 16-16 040 DATE: ORDER Entitlement to an initial rating in excess of 30 percent for coronary artery disease, status post coronary artery bypass graft, is denied. FINDING OF FACT The Veteran’s coronary artery disease is manifested by a workload of greater than 5 but not greater than 7 METs (metabolic equivalents), without evidence of acute congestive heart failure in the past year, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for the Veteran’s service-connected coronary artery disease, status post coronary artery bypass graft, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7017. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Army from March 1967 to March 1969. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The January 2015 rating decision granted service connection for coronary artery bypass graft with an evaluation of 100 percent, effective October 29, 2014 and an evaluation of 30 percent from February 1, 2015. Prior to the Veteran’s December 2014 claim for temporary total disability, the Veteran was previously rated under Diagnostic Code 7005 for coronary artery disease. The January 2015 rating decision also granted service connection for status post coronary artery bypass graft non tender linear scar with a noncompensable evaluation, effective October 29, 2014. The decision granted service connection for status post coronary artery bypass graft donor site superficial, non tender scars with a noncompensable evaluation, effective October 29, 2014. Lastly, the decision increased the Veteran’s previously service-connected scars rated under Diagnostic Code 5311 from 10 percent to 20 percent, effective October 29, 2014. Following the January 2015 rating decision, the Veteran appealed all of the issues in a December 2015 notice of disagreement. The RO then continued all of the ratings in a February 2016 statement of the case. In February 2016, the Veteran submitted a new application for disability compensation and related compensation benefits that included the issue of heart problems. The RO construed this as the Veteran’s substantive appeal on the assigned rating for the status post coronary artery bypass graft and issued a supplemental statement of the case in October 2016 that continued the 30 percent rating. The RO noted that the Veteran did not file a substantive appeal on the issues of the scars that were adjudicated in the February 2016 statement of the case. Therefore, those issues were no longer on appeal. Likewise, as no VA Form 9, Substantive Appeal, was filed on those issues, those issues are not before the Board and will not be further discussed. Increased Rating for Coronary Artery Disease, Status Post Coronary Artery Bypass Graft The Veteran and his representative generally contend he is entitled to a rating in excess of 30 percent for his coronary artery disease, status post coronary artery bypass graft. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Since the expiration of the period of the temporary total disability, the Veteran has been assigned a 30 percent rating for coronary artery disease, status post coronary artery bypass graft, pursuant to the criteria of Diagnostic Code 7017. 38 C.F.R. § 4.104. Under Diagnostic Code 7017, a 30 percent disability rating is warranted for 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 when there is 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 that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fracture of 30 percent to 50 percent. A 100 percent rating is warranted for congestive heart failure, or; a workload of 3 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fracture of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7017. Based on a review of the relevant evidence and the applicable law and regulations, the Board finds that the evidence most nearly approximates the criteria associated with the currently assigned 30 percent rating throughout the period on appeal based on there being no evidence of more than one acute episode of congestive heart failure, a workload of 5 METs or less, or an ejection fraction of 50 percent or less. The Veteran attended VA examinations for an evaluation of his heart condition in December 2014 and May 2016. Both VA examination reports reflect that the Veteran had an ejection fraction of 60 percent and the interview-based METs test revealed METs of greater than 5 but not greater than 7 that resulted in dyspnea, fatigue, angina, and dizziness. They also reflect that the Veteran had not experienced congestive heart failure. The Veteran reported at the December 2014 VA examination that he becomes a little short of breath when walking up and down stairs. He reported he was able to do his activities of daily living without any limitations or episodes of chest pain, shortness of breath, syncope, orthopnea, or paroxysmal nocturnal dyspnea. The December 2014 VA examiner noted that the functional impact of the Veteran’s disability is that the Veteran becomes very short of breath after one to two flights of stairs and has to take breaks to alleviate the symptoms. At the May 2016 VA examination, the Veteran reported he had increasing symptoms of dyspnea on exertion. He indicated he did not experience any episodes of shortness of breath while exercising at the gym and had no issues with his activities of daily living on a regular basis. Prior to the December 2014 VA examination, the Veteran underwent an exercise stress test in September 2014 where the Veteran’s METs were 6.5. The Veteran underwent his coronary artery bypass graft in October 2014. A December 2014 VA cardiology note reflects the Veteran walks two to three miles daily on a treadmill and that he has no issues going up and down one flight of stairs. Further, the December 2014 cardiology note reflects the Veteran is able to do his activities of daily living without limitation, he has no episodes of chest pain, shortness of breath, orthopnea, or syncope. The Veteran reported at an April 2015 VA primary care visit that he walks on a treadmill daily. An April 2016 VA cardiology treatment note reflects the Veteran reported shortness of breath when walking, and the Veteran reported he goes to the gym for about 45 minutes 4 to 5 days per week. He reported no shortness of breath when exercising. The Board has considered the Veteran’s subjective reports at the VA examinations and to VA treatment providers that illustrate he experiences shortness of breath upon exertion. However, even when considering the Veteran’s statements, the evidence of record fails to illustrate the Veteran has had an ejection fraction of 50 percent or less or METs of 5 or less at any point during the appeal. Therefore, the evidence most nearly approximates the criteria for the 30 percent rating currently assigned. The Board has also considered whether the Veteran is entitled to a separate or higher rating under any other diagnostic code. However, all other diagnostic codes under 38 C.F.R. § 4.104 require more than one acute episode of congestive heart failure, a workload of 5 METs or less, or an ejection fraction of 50 percent or less. Regarding whether referral for an extraschedular rating is appropriate, such has not been raised by the claimant or reasonably raised by the record and will not be further discussed herein. Doucette v. Shulkin, 28 Vet. App. 366, 369−70 (2017). In sum, as a preponderance of the evidence is against a finding of METs of 5 or less or an ejection fraction of 50 percent or less, a rating in excess of 30 percent is not warranted at any point during the appeal period. Therefore, the criteria for a rating in excess of 30 percent for coronary artery disease, status post coronary artery bypass graft, have not been met. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel