Citation Nr: 18153637 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 15-04 485 DATE: November 29, 2018 ORDER Reduction of the rating for service-connected coronary artery disease from 60 percent to 30 percent was proper; restoration of a rating in excess of 30 percent is denied. FINDING OF FACT Throughout the appeal, VA outpatient records and examination reports have shown exercise tolerance to be between 5 and 7 METs, with ejection fraction never noted to be below 50; there has been no documented evidence of an episode of acute congestive heart failure. CONCLUSION OF LAW The criteria for restoration of a 60 percent rating for coronary artery disease have not been met; a rating in excess of 30 percent is denied. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.344, 4.104 Diagnostic Code (Code) 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant, served on active duty from October 1966 to October 1968. In March 2018, a videoconference hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran’s claims file. Entitlement to restoration of a 60 percent rating for coronary artery disease. The Veteran’s claim arises from an April 2013 rating decision that reduced the rating of the Veteran’s coronary artery disease from 60 percent to 10 percent, effective July 1, 3013. During the pendency of the appeal, the 10 percent rating was increased to 30 percent, effective the date of the initial reduction, but not restored to the 60 percent rating that had been in effect previously. The Veteran contends that the reduction in his disability rating is not warranted because his disability has not improved, and that, as his arteries continue to clog, his heart worsens. In testimony at the Board hearing in March 2018 he stated that, while he may show some improvement on testing after each of the therapeutic procedures that have been performed, his overall coronary condition continues to deteriorate. As a preliminary matter, the Board notes that the Veteran does not contend, and the evidence does not reflect, noncompliance with the procedural requirements for rating reductions. See 38 C.F.R. § 3.105(e) (requiring, inter alia, notification of the proposed reduction in evaluation, a statement of the facts and reasons for such reduction, and an opportunity to submit evidence against a proposed reduction). Moreover, the Board finds the notice provisions have been satisfied. Therefore, the Board will focus only upon the propriety of the reduction. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, 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. With documented coronary artery disease resulting in chronic congestive heart failure, or work load 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, a 100 percent rating is warranted. With 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, a 60 percent rating is warranted. With a workload greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray, a 30 percent rating is warranted. With a workload greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or’ continues medications required, a 10 percent rating is warranted. 38 C.F.R. § 4.104, Code 7005. Examinations less full or complete than those on which payments were authorized or continued will not be used as a basis for reduction. Ratings on account of diseases subject to temporary or episodic improvement which have been in effect for 5 years or more will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. 38 C.F.R. § 3.344. To reduce the veteran’s disability rating the regulations require that the VA examination performed prior to the rating reduction be full and complete, and that the extent of the medical examinations made prior to this VA examination, with their findings and conclusions, be discussed by the Board. Following this, the VA examination on which the reduction was based must be shown to be as full and complete as the prior examinations. Then, the Board must make a specific finding that the veteran’s condition has actually improved, or that there has been “material improvement” that was “reasonably certain...(to) be maintained under the ordinary conditions of life.” See Brown v. Brown, 5 Vet. App. 413 (1993). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The United States Court of Appeals for Veterans Claims (Court) has held that “staged” ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The record includes a medical opinion regarding the etiology of the Veteran’s heart disease was rendered by VA in January 2006. At that time, it was noted that the Veteran’s ejection fraction was 45 percent and his exercise capacity was to 9 METs. The Veteran underwent several procedures for coronary artery disease, including a four-vessel coronary artery bypass procedure in May 2010. In September 2010, he underwent a Bruce protocol stress test that showed he was able to exercise to 6 METs. At that time, he overall ejection fraction was noted to be 61 percent. In January 2012, the Veteran presented to the VA cardiology clinic for follow-up. His coronary artery disease was noted to be stable and no changes were made to his therapy. His treatment providers also noted that his blood pressure and lipids were under good control and he was tolerating a good level of exercise with change in functional capacity or anginal symptoms. In July 2012, the Veteran followed up with his VA primary care physician. His coronary artery disease was again noted to be stabled. Based upon the January 2012 VA treatment record, the Agency of Original Jurisdiction requested that the Veteran be scheduled for a VA examination; this was conducted in September 2012. At that time, the diagnosis was coronary artery disease. It was noted that the Veteran took several medications to treat his heart disease, including Amlodipine, Metoprolol, Niacin, Aspirin, a Nitroglycerin patch, and Simvastatin. He had a history of coronary artery bypass surgery, but had not had a myocardial infarction. There was no evidence of congestive heart failure. A diagnostic exercise test has not been recently conducted, but the examiner estimated that the Veteran would be able to exercise to between 7 and 10 METs, limited by dyspnea. There was evidence of cardiac hypertrophy or dilatation as found on EKG and echocardiogram. A left ventricular ejection fraction of between 60 and 65 percent had been noted in May 2010. The examiner stated that the Veteran’s heart disease did not impact his ability to work. It was remarked that, while the Veteran had coronary artery disease, there were no other co-existing heart conditions. There was mild left ventricular hypertrophy on a May 2010 echocardiogram but this was no related to ischemic heart disease, as this did not cause hypertrophy. Given the stability of the Veteran’s heart disease and lack of interval ischemic events, the echocardiogram of May 2010 echocardiogram was believed to represent the current heart function. VA outpatient treatment records show that the Veteran underwent a nuclear stress test in July 2013. The examiner stated that the Veteran exercised to an adequate cardiac workload with decreased functional aerobic capacity demonstrated. & METs out of an expected 8.5 METs, with a variable of plus or minus 1 MET. There was normal hemodynamic response to exercise. There was an overall ejection fraction of 52 percent with regional wall motion abnormalities. The left ventricle was at the upper limits of normal to mildly increased on both rest and stress images, without significant change at stress. In a September 2013 statement, the physician who supervised the July 2013 stress test indicated that an August 2013 coronary angiogram had shown severe 3-vessel coronary artery disease as seen in 2010, as well as an occluded graft and three other grafts that were patent with some disease. His condition had not improved since his last angiogram, but was managed with a significant amount of medications. Regarding a prognosis, the examiner stated that appropriate mediations could prevent progression, but that it was not known to what extent. It was concluded that while the Veteran would never be free of coronary artery disease, the treatment regimen was intended to stabilize and slow the progression as well as improve symptoms of angina. In a July 2014 VA follow-up evaluation, the examiner noted that the Veteran had been walking about 3 to 4 miles in a mall but had begun having tightness in the chest after about 1/3 of a mile in early June. The discomfort resolved after about 3 minutes rest after which he was able to complete the remainder of his walk. This was described as being virtually unchanged from his last appointment. Another examination was conducted by VA in November 2014. At that time, the diagnosis was coronary artery disease. The Veteran’s history of cardiac disease, including a myocardial infarction in 2003, was reported. He did not have congestive heart failure, arrhythmia, or valvular disease. He had a history of angioplasty and coronary artery bypass surgery. Heart sounds were normal and rhythm was regular. There was no peripheral edema. There was no evidence of hypertrophy or dilatation. A current echocardiogram showed an ejection fraction of between 60 and 65 percent. An interview-based METs test disclosed symptoms of dyspnea, fatigue, and angina. The Veteran was found to exercise to between 5 and 7 METs. Any MET limitation was due solely to the heart condition. The heart condition was not found to impact the Veteran’s ability to work. The examiner remarked that the coronary artery disease was still symptomatic with angina, dyspnea and easy fatigue despite multiple stent placements, bypass surgery, and intensive medical management. It was opined that the heart disease had definitely worsened and that any request for an increase in compensation was reasonable despite the normal-appearing echocardiogram. The question before the Board regarding the proper evaluation of the Veteran’s heart disease involves whether there was sustained improvement since the 60 percent rating that had been in effect. After review of the record, the Board finds that there has been improvement to the point where the criteria for a rating in excess of 30 percent have not been shown to be warranted. In this regard, it is noted that at the time of the initial rating for heart disease, he had an ejection fraction of only 45 percent. This alone is a sufficient criterion on which to base a 60 percent rating. At the time of the 2012 VA examination on which the 2013 rating reduction was based, the examiner found an ejection fraction of 60 to 65 percent. The examiner also found that the Veteran’s exercise tolerance was to between 7 and 10 METs. While subsequent evaluations, including VA outpatient and examination results, show exercise tolerance to be between 5 and 7 METs, the ejection fraction has never been noted to be below 50 and the most recent evaluation showed this diagnostic quantification to be between 60 and 65 percent. Neither has one episode of acute congestive heart failure in the past year been documented. While the November 2014 examiner indicated a worsening of the Veteran’s heart disability, this worsening is found to be as compared with the 2012 VA examination report. As such, overall improvement being demonstrated, the Board can find no basis for a restoration to the prior 60 percent rating and the appeal is denied. For these reasons, the Board also finds that a preponderance of the evidence is against the Veteran’s claim for increased rating for coronary artery disease, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. (Continued on the next page) A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Joseph P. Gervasio