Citation Nr: 18142344 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 14-25 017 DATE: October 15, 2018 ORDER An initial rating in excess of 10 percent prior to October 22, 2014, in excess of 30 percent from October 22, 2014 to March 10, 2014, and in excess of 60 percent thereafter for coronary artery disease is denied. FINDINGS OF FACT 1. Prior to October 22, 2014, the Veteran’s coronary artery disease required continuous medication, including Lisinopril and Metoprolol; evidence of cardiac hypertrophy on electrocardiogram, echocardiogram, or X-ray, evidence of cardiac dilatation on electrocardiogram, echocardiogram, or X-ray, and dyspnea, fatigue, angina, dizziness, or syncope resulting from a workload greater than 5 METs, but not greater than 7 METs, have not been shown. 2. Between October 22, 2014 and March 10, 2015, the Veteran’s coronary artery disease manifested itself with a workload of greater than 5 METs, but not greater than 7 METs, that resulted in dyspnea; more than one episode of acute congestive heart failure, dyspnea, fatigue, angina, dizziness, or syncope resulting from a workload greater than 3 METs, but not greater than 5 METs, and left ventricular dysfunction with an ejection fraction of 30 to 50 percent have not been shown. 3. Since March 11, 2015, the Veteran’s coronary artery disease has manifested itself with a workload of greater than 3 METs, but not greater than 5 METs, that resulted in dyspnea and fatigue; chronic congestive heart failure, dyspnea, fatigue, angina, dizziness, or syncope resulting from a workload of 3 METs or less, and left ventricular dysfunction with an ejection fraction of less than 30 percent have not been shown. CONCLUSION OF LAW 1. The criteria for an initial rating in excess of 10 percent for coronary artery diseases prior to October 22, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for a disability rating in excess of 30 percent for coronary artery diseases from October 22, 2014 to March 10, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.104, DC 7005. 3. The criteria for a disability rating in excess of 60 percent since March 11, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.104, DC 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1968 to April 1972. 1. Entitlement to an initial disability rating in excess of 10 percent prior to October 22, 2014, in excess of 30 percent from October 22, 2014 to March 10, 2014, and in excess of 60 percent thereafter for coronary artery disease The Veteran is seeking increased staged ratings for his service-connected coronary artery disease. Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already 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). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Prior to October 22, 2014 Prior to October 22, 2014, the Veteran’s service-connected coronary artery disease was assigned a disability rating of 10 percent under 38 C.F.R. § 4.104, DC 7005. In order to warrant a 30 percent rating under DC 7005, the evidence must show either (i) a workload of greater than 5 METs, but not greater than 7 METs, results in dyspnea, fatigue, angina, dizziness, or syncope or (ii) cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104, DC 7005. After a review of the evidence of record, the Board determines that a rating in excess of 10 percent prior to October 22, 2014 is not warranted. Here, no evidence shows that a workload of greater than 5 METs, but not greater than 7 METs, results in dyspnea, fatigue, angina, dizziness, or syncope and no electrocardiogram, echocardiogram, or X-ray shows cardiac hypertrophy or dilatation. Specifically, the August 2010 VA examiner reported that a cardiovascular stress test showed that exercise was stopped at a workload of 13.2 METs due to exhaustion. The August 2010 VA examiner did not note any dyspnea, fatigue, angina, dizziness, or syncope at a workload less than 13.2 METs. The August 2010 VA examiner also noted that evaluation of the Veteran’s left ventricle showed an approximate ejection fraction of 73 percent. The August 2010 VA examiner did not report any evidence of cardiac hypertrophy or dilatation. The lack of any reference to cardiac hypertrophy or dilatation is supported by the report from October 2014 VA examination, which indicated that there was no evidence of cardiac hypertrophy or dilatation. The treatment records further confirm that the Veteran does not meet the criteria for a 30 percent rating prior to October 22, 2014. Specifically, the treatment records from prior to October 22, 2014 do not provide evidence of cardiac hypertrophy or dilatation on an electrocardiogram, echocardiogram, or X-Ray. Additionally, no other METs testing was performed. In fact, the treatment records from prior to October 22, 2014, including records from November 2009, August 2010, and September 2013 reflect that the Veteran’s heart had a regular rate and rhythm. Additionally, an October 2012 treatment record reflects that serial echocardiograms were negative for ischemic changes and neither cardiac hypertrophy nor dilatation were noted in the record. By virtue of the foregoing, the Board concludes that a rating in excess of 10 percent prior to October 22, 2014 is not warranted. From October 22, 2014 to March 10, 2014 From October 22, 2014 to March 10, 2014, the Veteran’s service-connected coronary artery disease was assigned a disability rating of 30 percent under 38 C.F.R. § 4.104, DC 7005. In order to warrant a 60 percent rating under DC 7005, the evidence must show any of the following: (i) there is more than one episode of acute congestive heart failure in the past year, (ii) a workload of greater than 3 METs, but not greater than 5 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or (iii) left ventricular dysfunction with an ejection fraction of 30 to 50 percent. After a review of the evidence of record, the Board determines that a rating in excess of 30 percent from October 22, 2014 to March 10, 2015 is not warranted. Here, no evidence shows any episodes of acute congestive heart failure 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. Specifically, the October 2014 VA examination report reflects that the Veteran had not had congestive heart failure. The October 2014 VA examiner also reported that a workload of greater than 5 METs, but not greater than 7 METs, resulted in dyspnea, and that a cardiovascular stress test showed an ejection fraction of 65 percent. Thus, the findings documented by the October 2014 VA examination report show that the Veteran does not meet the criteria for a 60 percent rating. Treatment records from October 22, 2014 to March 10, 2015 also show that the Veteran does not meet the criteria for a 60 percent rating. No treatment records from October 22, 2014 to March 10, 2015 report that the Veteran experienced congestive heart failure or indicate an ejection fraction of 30 to 50 percent. Additionally, the treatment records reflect that no other METs testing was performed between October 22, 2014 and March 10, 2015. In fact, treatment records, including treatment records from November 2014 and January 2015, indicate that the Veteran’s heart had a regular rate and rhythm. By virtue of the foregoing, the Board concludes that a rating in excess of 30 percent from October 22, 2014 to March 10, 2015 is not warranted. Since March 11, 2015 Since March 11, 2015, the Veteran’s service-connected coronary artery disease has been assigned a disability rating of 60 percent under 38 C.F.R. § 4.104, DC 7005. In order to warrant a 100 percent rating under DC 7005, the evidence must show any of the following: (i) chronic congestive heart failure, (ii) a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or (iii) left ventricular dysfunction with an ejection fraction of less than 30 percent. After a review of the evidence of record, the Board determines that a rating in excess of 60 percent since March 11, 2015 is not warranted. Here, no evidence shows chronic congestive heart failure, that a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. Specifically, the February 2016 VA examination report reflects that the Veteran had not had congestive heart failure. The February 2016 VA examiner also reported that a workload greater than 3 METs, but not greater than 5 METs, resulted in dyspnea and fatigue, and that an echocardiogram showed an ejection fraction of 55 to 60 percent. Thus, the findings documented by the February 2016 VA examination report show that the Veteran does not meet the criteria for a 100 percent rating. The report from the November 2016 VA examination also shows that the Veteran does not meet the criteria for a rating in excess of 60 percent since March 11, 2015. Indeed, the November 2016 VA examination report reflects that the Veteran had not had congestive heart failure, that a workload greater than 3 METs, but not greater than 5 METs, resulted in dyspnea and fatigue, and that the Veteran had a normal echocardiogram. Treatment records since March 11, 2015 also fail to establish that the Veteran meets the criteria for a 100 percent rating. Specifically, no treatment records report that the Veteran experienced congestive heart failure, an August 2015 echocardiogram showed an ejection fraction of 45 to 50 percent, and no other METs testing was performed. By virtue of the foregoing, the Board concludes that a rating in excess of 60 percent since March 11, 2015 is not warranted. In considering the appropriate disability ratings, the Board has also considered the statements from the Veteran that his coronary artery disease is worse than the rating he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Although the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his coronary artery disease according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). On the other hand, such competent evidence concerning the nature and extent of the Veteran’s coronary artery disease has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with their evaluations. The medical findings (as provided in the examination reports and treatment records) directly address the criteria under which this disorder is evaluated. Specifically, with respect to his coronary artery disease, although the Veteran reported fatigue and dyspnea, these symptoms were discussed and addressed by the VA examiners and other treating physicians. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (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). In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran’s level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidence does not indicate that the Veteran’s disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all of the Veteran’s symptoms related to his coronary artery disease, including limitations with activities of daily living, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic code. Thus, the Veteran’s symptoms are not so unusual that they are outside the schedular criteria. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran’s disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), that a total rating based on individual unemployability, due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Board notes that the Veteran was granted TDIU on March 11, 2015. In this case, however, the record does not suggest, and the Veteran does not allege, that his service-connected coronary artery disease prohibited him from working prior to March 11, 2015. Indeed, the August 2010 VA examiner and the October 2014 VA examiner both opined that the Veteran’s coronary artery disease did not prohibit the Veteran from working based upon in-person examinations of the Veteran and their reviews of the Veteran’s records. Thus, Rice is inapplicable in this case. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Crosnicker, Associate Counsel