Citation Nr: 18143629 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 14-42 838 DATE: October 19, 2018 ORDER An initial increased rating for coronary artery disease in excess of 10 percent prior to May 10, 2013 and in excess of 30 percent thereafter is denied. VETERAN’S CONTENTIONS The Veteran contends that his service-connected coronary artery disease warrants a disability rating higher than the 10 percent and 30 percent staged ratings currently assigned under 38 C.F.R. § 4.104, Diagnostic Code 7005. FINDINGS OF FACT 1. For the period prior to May 10, 2013, the evidence shows a workload greater than 7 METs but not greater than 10 METs, and symptoms such as dyspnea, fatigue, angina, dizziness, and syncope. There is no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. 2. For the period from May 10, 2013, ejection fraction is more objective than the METs when considering the Veteran’s coronary artery disease, and the evidence does not show left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSIONS OF LAW 1. For the period prior to May 10, 2013, the criteria for a disability rating in excess of 10 percent for coronary artery disease are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7005. 2. For the period from May 10, 2013, the criteria for a disability rating in excess of 30 percent for coronary artery disease are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to May 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. 1. Entitlement to an initial increased rating for coronary artery disease in excess of 10 percent prior to May 10, 2013 and in excess of 30 percent thereafter. Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations 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 (2017). 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 compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2017); see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7 (2017). Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, the Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." Fenderson v. West, 12 Vet. App. 119 (1999). One MET is 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 of METs by exercise testing 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. Under Diagnostic Code 7005, a 10 percent rating is warranted when a workload greater than 7 metabolic equivalents (METs) but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or continuous medication is required. A 30 percent rating is warranted when a workload of 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 was more than one episode of acute congestive heart failure in the past year; when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Lastly, a 100 percent rating is warranted for chronic congestive heart failure; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of less than 30 percent. Following review of the record, the Board finds that for the period prior to May 10, 2013, a higher 30 percent rating is not warranted, as the evidence does not show 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. Turning to the relevant medical evidence of record, the Veteran underwent VA cardiovascular examination in February 2011. The examination report documented no history of congestive heart failure, and no evidence of cardiac hypertrophy, or dilatation. The examiner estimated a METs value of 1-3, but noted that the Veteran’s exercise intolerance was mainly due to his back and hip conditions, although somewhat limited by dyspnea. The examiner also noted a left ventricular ejection fraction of 57 percent was documented in January 2009. In a March 2011 addendum opinion, the examiner clarified that, based on the ejection fraction of 57 percent and ignoring the limitations placed on the Veteran by his back and hip, the Veteran’s estimated METs by ejection fraction would be 8 plus. Additionally, Scott & White private medical records include an April 2010 general examination which documents that the Veteran was doing some restoration on a car and did that type of work regularly, and November 2012 VA medical records document that the Veteran denied angina and syncope. The Veteran’s ability to engage in these activities without experiencing angina and syncope suggests that his METs level was greater than7. The Board acknowledges that the Veteran submitted a buddy statement from an acquaintance dated May 2011 which attests that the Veteran did not work on the restoration of his car between February 2010 and September 2010. However, the Board finds the statements made in the course of seeking medical treatment to be highly probative as statements made to clinicians for the purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also GRAHAM C. LILLY, AN INTRODUCTION TO THE LAW OF EVIDENCE 245-46 (2nd ed. 1987) (noting that many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). As the totality of the evidence discussed above does not show that the Veteran's coronary artery disease resulted in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; nor that he had evidence of cardiac hypertrophy, or dilatation on electrocardiogram, echocardiogram, or X-ray; an initial rating higher than 10 percent for the period prior to May 10, 2013 is not warranted. Turning to the period from May 10, 2013, the Board finds that a higher 60 percent rating is not warranted, as the evidence dated since then does not show 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 results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The medical evidence in this regard includes a May 2013 VA cardiovascular examination. The examination report documented no evidence of cardiac hypertrophy or dilatation. The examiner noted the Veteran stated he “couldn’t take the heat” and he “gets dizzy, sweats profusely”. See May 2013 VA Cardiovascular Examination. The examiner estimated a METs value of 5 -7. The Board notes that the May 2013 VA examiner indicated that the claims file was not available for review. However, the Board finds that the Veteran's claim has not been prejudiced. In this regard, when the issue is the rating of a disability that has already been service-connected, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Cf. Mariano v. Principi, 17 Vet. App. 305, 311-312 (2003) (holding that, on orthopedic examination that range of motion measurements are not conclusions drawn by a VA examiner that would be affected by review of the claims file; as such, the failure to review the Veteran's claims file did not undermine the objective (range of motion) findings recorded by the VA examiner). (Continued on the next page)   The medical evidence also includes a March 2017 VA cardiovascular examination. After reviewing the claims file and examining the Veteran, the examiner documented left ventricular ejection fraction of 55 to 60 percent and documented no evidence of cardiac hypertrophy, or cardiac dilatation. The examiner also estimated a METs value of 3 to 5 and noted that the estimated METs level was due solely to the cardiac condition. The examiner further estimated that the METs value due to the Veteran’s cardiac condition alone was 5. However, the examiner ultimately opined that the normal ejection fraction suggested adequate cardiac function and indicated that the ejection fraction offers a more objective measurement of the severity of the Veteran’s cardiovascular condition than METs. As the totality of the evidence discussed above shows that ejection fraction is more objective than the METs when considering the Veteran’s coronary artery disease, and the Veteran's coronary artery disease resulted in left ventricular ejection fraction of 55 to 60 percent, an initial rating higher than 30 percent for the period from May 10, 2013 is not warranted. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith-Jennings, Associate Counsel