Citation Nr: 18152760 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 13-31 459A DATE: November 27, 2018 ORDERS 1. Entitlement to an initial rating in excess of 10 percent for supraventricular tachycardia, prior to October 2017, and a rating in excess of 60 percent thereafter is denied. 2. Entitlement to an initial rating in excess of 10 percent for irritable bowel syndrome (IBS) is denied. FINDINGS OF FACT 1. Prior to October 25, 2017 the Veteran’s supraventricular tachycardia was not shown to have a workload of less than 7 metabolic equivalents (METs), and did not result in dyspnea, fatigue, angina, dizziness, or syncope, or show evidence cardiac hypertrophy or dilatation in electrocardiogram, echocardiogram or X-ray. 2. From October 25, 2017, the Veteran’s supraventricular tachycardia has not been shown to be productive of chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction (LVEF) of less than 30 percent. 3. The Veteran’s IBS is manifested by, at worst, intermittent diarrhea and abdominal distress, which is not constant. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for supraventricular tachycardia prior to October 2017, and in excess of 60 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, DC 7011 (2017). 2. The criteria for an initial rating in excess of 10 percent for irritable bowel syndrome (IBS) have not been met. 38 U.S.C. § 1155; 38 C.F.R. 4.114, DC 7319 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1993 to February 2000. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2008 and August 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In September 2017, the Board remanded the Veteran’s appeal with instruction to obtain relevant records, to include private medical treatment records and conduct VA examinations. The appropriate records were obtained and examinations conducted. The Board is therefore satisfied that the instructions in its remand of September 2017 have been satisfactorily complied. See Stegall v. West, 11 Vet. App. 268 (1998). 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 (West 2014); 38 C.F.R. § 4.1 (2017). 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 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2017). 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. 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). In cases where, as here, the question for consideration is the propriety of the initial disability rating assigned, however, an evaluation of the medical evidence since the grant of service connection and a consideration of the appropriateness of a “staged rating” is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). A staged rating compensates the veteran for variations in the disability’s severity since the effective date of his or her award. 1. Entitlement to an initial rating in excess of 10 percent for supraventricular tachycardia prior to October 2017 and in excess of 60 percent thereafter. The Veteran’s service-connected heart condition was rated as 10 percent disabling under DC 7011 for ventricular arrhythmias (sustained) prior to October 25, 2017 and 60 percent thereafter. 38 C.F.R. § 4.104, DC 7011 (2017). The Veteran contends that the current disability rating does not accurately reflect the severity of her symptoms. Under DC 7011, ventricular arrhythmias 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. The next higher rating of 30 percent is awarded for ventricular arrhythmias 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. Ventricular arrhythmias 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. Ventricular arrhythmias 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 7011. 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. Service treatment records show that the Veteran had multiple episodes of supraventricular tachycardia which required a catheter ablation in 1998. On VA examination in March 2009, it was noted that the Veteran had intermittent arrhythmia episodes but none were documented during EKG or Holter monitor testing. The Veteran reported no syncope, angina and occasional dyspnea and dizziness, and frequent fatigue. The Veteran did not have a history of cardiac trauma, or congestive heart failure. The examiner opined by history, the Veteran’s activity level is greater than 4 METS, but did not give an upper range. The Veteran’s private treatment records from Chesapeake & Washington Heart Care PC from October 2013 show the Veteran had one episode of atrial fibrillation and an LVEF of over 60 percent. On VA heart examination in November 2017, the Veteran reported taking Procardia for her heart condition. She did not have a history of myocardial infarction, congestive heart failure, cardiac arrhythmia, heart valve condition, infectious cardiac conditions, or pericardial adhesions. She did not have any other hospitalizations or treatment of heart conditions, other than her catheter ablation in 1998. Physical examination revealed regular heart rhythm. There was no evidence of cardiac hypertrophy or dilation. A cardiac echocardiogram was performed in November 2017 which revealed a left ventricular ejection fraction of 60 percent. Wall motion and wall thickness were normal. An interview based MET’s test revealed METs >3-5 METs. The Veteran reported fatigue and syncope. The Board finds that, for the period prior to October 25, 2017, a rating in excess of 10 percent for the Veteran’s heart condition is not warranted. The Board notes that a historical activity level of greater than 4 METs bolsters this conclusion and it is further supported by the absence of evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray, required for a higher 30 percent rating under Diagnostic Code 7011. As such, the Board finds that an increased rating is not warranted for the service-connected heart condition for the period prior to October 25, 2017. The Board also finds that, for the period from October 25, 2017, a rating in excess of 60 percent for the Veteran’s heart condition is not warranted. The Board notes that there is no evidence that the Veteran has ever had chronic congestive heart failure. Thus, the only way to warrant a higher rating is to either show that she is restricted to a workload of three METs or less (that results in dyspnea, fatigue, angina, dizziness, or syncope) or that LVEF is less than 30 percent. Results from the October 2017 VA examination report do not find MET level of 3 or less. The examination report revealed that an interview based MET’s test revealed METs were greater than the 3-5 range. Moreover, the Veteran’s ejection fraction was 60 percent. Accordingly, there is no basis upon which the next higher, 100 percent, rating may be granted for the Veteran’s heart condition from October 25, 2017. The preponderance of the evidence is against this claim, the benefit of the doubt rule does not apply, and the appeal must be denied. Entitlement to an initial rating in excess of 10 percent for irritable bowel syndrome (IBS). The Veteran’s irritable bowel syndrome (IBS) is currently evaluated as 10 percent disabling effective April 19, 2008, under 38 C.F.R. § 4.114, DC 7319 (irritable colon syndrome). A 10 percent rating is assigned under DC 7319 for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. Id. The Veteran contends that her IBS is getting worse even after dietary adjustments. She has 5 or 6 days of constipation followed by 2 to 3 days of diarrhea, several times a month. See Form 9. For the reasons described below, the Board concludes that an initial rating greater than 10 percent for IBS is not warranted. VA intestines examination in October 2008 documented complaints of upset stomach and diarrhea. A history of vomiting and diarrhea was noted. The Veteran reported vomiting less than weekly and diarrhea at least several times a week. Physical examination found mild diffuse abdominal tenderness. A diagnosis of irritable bowel syndrome with no occupational effects was determined. VA examination dated November 2017 noted complaints of abdominal pain, bloating, diarrhea and constipation with disturbances occurring for 2 weeks in a row. The only medication she is currently taking for her condition is fiber. The Board finds that the Veteran's IBS is manifested by, at worst, moderate symptoms with frequent episodes of bowel disturbance with abdominal distress throughout the appeal period. See 38 C.F.R. § 4.114, DC 7319. The record does not show that the Veteran experiences severe symptoms and diarrhea with more or less constant abdominal distress, as to warrant an evaluation in excess of 10 percent at any time during the appeal period. Accordingly, the Board finds that the criteria for an initial rating greater than 10 percent for irritable bowel syndrome is not indicated. See 38 C.F.R. § 4.114, DC 7319. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Jaigirdar, Associate Counsel