Citation Nr: 18146742 Decision Date: 11/01/18 Archive Date: 10/31/18 DOCKET NO. 16-38 408 DATE: November 1, 2018 ORDER Entitlement to an initial rating greater than 30 percent prior to May 13, 2017, for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation is denied. Entitlement to a rating of 100 percent from May 13, 2017, for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation is granted. Entitlement to an initial 10 percent rating for residual surgical scars, status post coronary artery bypass graft, anterior trunk, and bilateral medial knees from vein harvest associated with coronary artery disease, is granted. Entitlement to special monthly compensation (SMC) at the housebound rate pursuant to 38 U.S.C. § 1114(s)(1) is granted from May 13, 2017. FINDINGS OF FACT 1. Prior to May 13, 2017, the Veteran’s coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation, was manifested by workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope and an ejection fraction of 55 to 60 percent. 2. From May 13, 2017, the Veteran’s coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation, is manifested by a METs level of 3 or less with dyspnea, fatigue, angina, and dizziness. 3. The Veteran’s residual surgical scar of the anterior trunk is subjectively painful and unstable, while the scars to the bilateral medial knees from vein harvest associated with coronary artery disease are not painful or unstable. 4. From May 13, 2017, the evidence of record supports the conclusion that the Veteran has a service-connected disability rated as total and additional service-connected disabilities independently ratable at 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating greater than 30 percent prior to May 13, 2017, for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 3.321, 4.7, 4.104, Diagnostic Code (DC) 7005 (2018). 2. The criteria for entitlement to a rating of 100 percent from May 13, 2017, for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 3.321, 4.7, 4.104, DC 7005 (2018). 3. The criteria for entitlement to an initial rating of 10 percent for residual surgical scars, status post coronary artery bypass graft, anterior trunk, and bilateral medial knees from vein harvest associated with coronary artery disease, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.118, DC 7804 (2018). 4. The criteria for SMC at the housebound rate are met from May 13, 2017. 38 U.S.C. §§ 1114(s), 5101, 5103, 5103A, 5107, 5121 (2012); 38 C.F.R. § 3.350 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from November 1966 to November 1968. As an initial matter, the Board notes that the July 2016 Statement of the Case (SOC) included the issues of entitlement to increased ratings for the Veteran’s coronary artery disease and scars associated with the coronary artery disease and related surgery. The subsequent August 2016 VA Form 9 substantive appeal submitted by the Veteran ostensibly limited the ongoing appeal to the increased rating for the scars. In context, however, the Veteran’s tenor of overall argument throughout the course of his appeal demonstrates his belief in a worsening of his overall heart disability that was worse than the ratings assigned. For example, the July 2016 notice of disagreement requested a 20 percent disability rating for the scars and a 40 percent disability rating for the coronary artery disease. The subsequent SOC continued the ratings and did not grant the requested increased ratings. Additionally, during the pendency of the appeal in April 2017, the Veteran submitted a claim for a total disability rating based on individual unemployability (TDIU) in part due to his coronary artery disease. The RO ordered and obtained additional VA examinations to determine the status of the heart disease. In light of the entirety of the evidence of record, the Board concludes that the entirety of the Veteran’s heart disability claim remains on appeal (i.e. both the rating for the coronary artery disease and the scars associated with the coronary artery disease). The Board also acknowledges that additional evidence has been added to the claims file since the last adjudication of the above claims. That said, with respect to the coronary artery claim the additional evidence warrants a 100 percent rating for the relevant time period and the additional evidence does not show a change or worsening in the Veteran’s scars and, as such, essentially are duplicative of evidence previously of record. In light of the foregoing, the Veteran is not prejudiced by the Board’s adjudication of the claims. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2018). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2018). VA must consider whether the Veteran is entitled to “staged” ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2018). The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 1. Entitlement to an initial rating greater than 30 percent prior to May 13, 2017, for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation The Veteran’s coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation is rated at 30 percent pursuant to 38 C.F.R. § 4.104, DC 7005. As will be discussed immediately below, the Board finds that a 100 percent rating is warranted from May 13, 2017. As noted above, the Veteran did not explicitly appeal the 30 percent rating for his heart disability, but in context it is clear that he does not believe that the current rating accurately reflects his condition. DC 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease), and requires documented coronary artery disease. Arteriosclerotic heart disease (coronary artery disease) resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required, is rated 10 percent disabling. Arteriosclerotic heart disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; 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, is rated 60 percent disabling. Arteriosclerotic heart disease resulting in chronic congestive heart failure, or; 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, is rated 100 percent disabling. 38 C.F.R. § 4.104, DC 7005 (2018). A Note to DC 7005 provides that, if non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, the adjudicator is to request a medical opinion as to which condition is causing the current signs and symptoms. 38 C.F.R. § 4.104. For rating diseases of the heart, one MET (metabolic equivalent) 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 rating, 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. In September 2014, the Veteran was diagnosed with double vessel arteriosclerotic occlusive coronary artery disease with proximal left anterior descending coronary artery stenosis and ascending aortic aneurysm and underwent a double vessel heart bypass. In April 2015, the Veteran denied excessive fatigue, dizziness, syncope, or rest or exertional dyspnea. On multiple other occasions, the Veteran also denied dyspnea, dizziness, and/or syncope. A September 2015 Heart Conditions (Including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire (DBQ) indicated diagnoses of coronary artery disease and an ascending aortic aneurysm in 2014. The Veteran was on multiple medications, including Lisinopril for his heart. There was noted atrial fibrillation and a condition involving the tricuspid valve. There was slight cardiac dilation of the right ventricle. The examiner did not provide an estimated METs level. In March 2016, the Veteran underwent another examination for the heart. The resulting DBQ noted diagnoses of coronary artery disease, coronary artery bypass graft, atrial fibrillation, and mild mitral, pulmonic, and tricuspid regurgitation. The Veteran reported general activity intolerance, but such problems were primarily due to his orthopedic problems and general deconditioning and believed that his heart had suffered relatively little damage due to his myocardial infarction in 2014. The Veteran was on continuous medication for his heart disabilities. The Veteran did not have congestive heart failure, infectious heart condition, or pericardial adhesions. Echocardiogram showed a left ventricular ejection fraction between 55 and 60 percent that was considered representative of a Grade 2 diastolic dysfunction. An exercise stress test was not required as part of the Veteran’s current treatment plan and the test was not without significant risk. As such, an exercise stress test was not conducted. An interview-based METs test suggested overall METs between 1 and 3 with symptoms of dyspnea and fatigue, but that the estimated METs level due solely to the cardiac condition was greater than 5 to 7 METs. The functional impact due to the cardiac condition would be mildly reduced capacity for heavy physical work, especially over time. Based on the evidence of record, for the period prior to May 13, 2017, the Board concludes that a rating greater than 30 percent for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation, is not warranted. The Veteran’s ejection fraction was shown to be 55 to 60 percent. His METs due to his service-connected heart disability (as opposed to orthopedic and other issues) was greater than 5 but not greater than 7 METs. The Veteran did not have chronic congestive heart failure or more than one episode of acute congestive heart failure in the past year. Such findings would not warrant a rating greater than 30 percent. Again, the foregoing results apply to the period prior to May 13, 2017. The Board has considered the other DCs related to the heart and concludes that no rating greater than 30 percent otherwise is warranted under DCs 7000 through 7123. Therefore, in light of the evidence of record outlined above, the Board finds that a rating greater than 30 percent for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation, is not warranted for any period prior to May 13, 2017. See 38 C.F.R. § 4.104, DC 7005. 2. Entitlement to an initial rating greater than 30 percent from May 13, 2017, for coronary artery disease status post myocardial infarction and coronary artery bypass graft, to include atrial fibrillation A May 13, 2017, Heart Conditions (Including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) DBQ is of record. In relevant part, the examiner concluded that the results of interview-based METs testing demonstrated a level of 1 to 3 METs with symptoms during activity of dyspnea, fatigue, angina, and dizziness. The estimated METs level was due solely to the Veteran’s heart disability. The examiner indicated the Veteran’s METs level better reflected his current cardiac functional status than his ejection fraction, as the tested ejection fraction was within normal limits. The examiner noted that heart block inherently evolved due to coronary artery disease and such a finding was supported by EKG findings. Based on the foregoing, the Board finds that a 100 percent disability rating is warranted from May 13, 2017, under DC 7005. This represents the highest rating available and a complete grant of benefits from that date. The Board acknowledges that the symptoms noted during the May 13, 2017, examination almost certainly did not have their onset on the day of examination, but as there is not a clear date of onset of such worsening symptoms the Board finds that May 13, 2017, is the most appropriate date for the assignment of the 100 percent rating. 3. Entitlement to a compensable initial rating for residual surgical scars, status post coronary artery bypass graft, anterior trunk, and bilateral medial knees from vein harvest associated with coronary artery disease The Veteran’s multiple scars associated with his coronary artery bypass graft currently are rated as noncompensably disabling under DC 7805. The Veteran contends that the current rating does not accurately depict the severity of his condition. There are multiple DCs designated for scars, located under DCs 7800-7805, depending on the location, size and severity of the scar. 38 C.F.R. § 4.118, DCs 7800-7805 (2018). DCs 7800-7802 involve burn scars. As the Veteran’s scars on appeal are not burn scars these DCs are inapplicable. DC 7804 provides for a 10 percent rating for 1 or 2 scars that are unstable or painful. A 20 percent rating is warranted for 3 or 4 painful or unstable scars. A 30 percent rating is warranted for 5 or more unstable or painful scars. Note (1) for that DC defines an unstable scar as one where, for any reason, there is frequent loss of skin covering over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. 38 C.F.R. § 4.118, DC 7804 (2018). DC 7805 provides that scars and other effects of scars not considered in a rating provided under DCs 7800-7804 should be evaluated under the appropriate DC. As will be discussed, the Veteran’s scar is most appropriately rated under DC 7804. A September 2015 Heart Conditions (Including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) DBQ noted that the Veteran had scars associated with his heart disability, but no scars that were painful and/or unstable or with a total area greater than or equal to 39 square centimeters (6 square inches). There was a mid-sternal scar that measured 31 by 1.2 centimeters and 3 by 0.4 centimeter bilateral medial knee scars from vein harvest. In his August 2016 substantive appeal, the Veteran indicated that skin came off his sternum scar every week and that when he reached out his arms there was pain in the sternum. During a May 2017 Heart Conditions DBQ, the Veteran reported that he continued to have chest pain due to sternum scar tissue compressing the esophagus. The examiner noted chest wall pain due to sternum surgery and hiatal hernia. Movement of the chest wall increased the pain. That said, later in the DBQ, the examiner indicated that the Veteran did not have any associated scars that were painful and/or unstable or with a total area greater than or equal to 39 square centimeters. The sternum scar was noted to be 34 by 1 centimeter and a 4 by 1 centimeter scar to the left upper abdomen. The Board finds that a 10 percent rating is warranted for the Veteran’s sternum scar under DC 7804, based on the Veteran’s subjective reports of tenderness, pain, and pulling due to the scar tissue. The scars on the medial knees are neither painful or unstable and, as such, no rating is warranted for these scars. The Board has considered whether a higher rating than 10 percent is warranted, but concludes that it is not. The Board acknowledges the Veteran’s reports that his sternum scar is unstable, based on skin flaking at the scar. The Board acknowledges that Note (2) to DC 7804 provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Thus, a 20 percent rating potentially would be available if the Veteran’s sternum scar were to be found both painful and unstable. That said, Note (1) defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. The Veteran’s reports do not constitute an unstable scar, as defined above. The Veteran does not report loss of covering of the skin, but merely flaking of the top layer(s) of skin without overall loss of covering. Multiple examiners have found no evidence of an unstable scar and the above lay reports do not constitute an unstable scar for VA compensation purposes. As such, the Board concludes that a higher rating is not warranted under DC 7804. The Board has considered the other DCs of 38 C.F.R. § 4.118, but finds that a higher or separate rating is not warranted under any of these DCs. In summary, for the reasons and bases set forth above, the Board concludes that a 10 percent rating, but no higher, is warranted under DC 7804. 4. Entitlement to special monthly compensation (SMC) at the housebound rate pursuant to 38 U.S.C. § 1114(s)(1) Of relevance to the instant claim, SMC is payable at the housebound rate where the claimant has a single service-connected disorder rated as totally disabling and one or more distinct service-connected disabilities, which are independently ratable at 60 percent or more and involve different anatomical segments or bodily systems. 38 U.S.C. § 1114(s)(1); 38 C.F.R. § 3.350(i). Based on the above decision, from May 13, 2017, the Veteran is in receipt of a 100 percent disability rating for his coronary artery disease. In addition, for that period the Veteran has multiple other service-connected disabilities, including a 70 percent rating for persistent depressive disorder and anxiety disorder. Thus, the Veteran meets the criteria for SMC payable at the housebound rate from May 13, 2017. 38 C.F.R. §§ 4.25, 4.26 (2018). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel