Citation Nr: 18159863 Decision Date: 12/21/18 Archive Date: 12/20/18 DOCKET NO. 16-62 919 DATE: December 21, 2018 ORDER Entitlement to an initial disability rating in excess of 30 percent for coronary artery disease (CAD), status post coronary artery bypass graft (CABG), prior to October 21, 2014, and entitlement to an increased disability rating in excess of 60 percent from February 1, 2015, is denied. FINDINGS OF FACT 1. Prior to October 21, 2014, the Veteran’s CAD, status post CABG, was manifested by no worse than a workload of greater than 5 metabolic equivalents (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. 2. From February 1, 2015 the Veteran’s CAD, status post CABG, was manifested by no worse than 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; without any congestive heart failure. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 30 percent for coronary artery disease (CAD), status post coronary artery bypass graft (CABG), prior to October 21, 2014, and entitlement to an increased disability rating in excess of 60 percent from February 1, 2015, have not been met. 38 U.S.C. §§ 1155, 5107, (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code (DC) 7017 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service from February 1969 to October 1970. The May 2015 rating decision on appeal also granted a temporary 100 percent disability rating for the Veteran’s CAD, effective October 24, 2014 through January 31, 2015, based on required hospital treatment. Given that the Veteran is in receipt of the maximum benefit for this staged rating period, it need not be addressed herein. Rather, the Board has limited its consideration of the Veteran’s claim to the rating periods prior to October 24, 2014 and from February 1, 2015. To the extent that the Veteran has asserted generally that the VA examinations of record are inadequate, the Board finds that the VA examinations of record are adequate to rate the Veteran’s service-connected CAD for the entire period on appeal, as the examiners properly considered the Veteran’s lay history, medical records, and made findings which permit application of the rating criteria. The Veteran also asserts that there was clear and unmistakable error (CUE) in the May 2015 rating decision; however, as that rating decision is currently on appeal, and therefore not final, a motion for revision of that rating decision on the basis of CUE is premature, as an argument for CUE applies to a rating decision that has become final. Finally, to the extent that the Veteran previously requested a hearing before a decision review officer (DRO), he failed to appear at a scheduled DRO hearing in August 2016 without good cause and his request is considered withdrawn. Moreover, he did not request an optional hearing before the Board in conjunction with his appeal. Entitlement to an initial disability rating in excess of 30 percent for coronary artery disease (CAD), status post coronary artery bypass graft (CABG), prior to October 21, 2014, and entitlement to an increased disability rating in excess of 60 percent from February 1, 2015. 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. Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. With respect to the Veteran’s initial rating claim on appeal, the Board has considered the claim from the initial effective date, which the Veteran has not appealed, as well as the appropriateness of the assigned staged rating periods. The Veteran’s coronary artery disease (CAD), status post coronary artery bypass graft (CABG), is currently rated as 30 percent disabling prior to October 21, 2014, and as 60 percent disabling from February 1, 2015, under Diagnostic Code (DC) 7017. 38 C.F.R. § 4.104, DC 7017 (2017). Thereunder, a 30 percent disability rating is warranted when a workload of greater than 5 metabolic equivalents (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. A 60 percent disability rating is warranted for more than one episode of acute, congestive heart failure in the past year, or; 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 (LV) dysfunction with an ejection fraction (EF) of 30 to 50 percent. Finally, a maximum schedular 100 percent disability rating is warranted for chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; LVEF of less than 30 percent. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2) (2016). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination 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. Id. A review of the evidence of record prior to October 21, 2014 documents that the Veteran underwent a private treadmill stress test and perfusion scan on October 13, 2014. At that time, he reached a workload of 7 METs, after which the test was ended due to fatigue; his LVEF was normal at 68 percent. The following day, he underwent a heart catheterization which demonstrated significant coronary artery disease with LVEF of 60 percent. A subsequent private disability benefits questionnaire (DBQ) submitted on October 26, 2014 documents the Veteran’s diagnosis of CAD, without any congestive heart failure, and a LVEF of 64 percent on October 21, 2014. Turning to the evidence of record from February 1, 2015, upon VA heart examination in May 2015, the VA examiner noted that the Veteran continued to experience some shortness of breath, fatigue, and slight chest pain with overexertion, though his overall condition was stable. The examiner noted there was no history of congestive heart failure and that the most recent exercise stress test in October 2014 documented an LVEF of 60 percent. The examiner noted that an interview-based METs test was most appropriate, and estimated that the Veteran could achieve a level of greater than 5 METs and less than 7 METs after which he reported dyspnea, fatigue, and angina. Private treatment records from December 2015 document the Veteran’s reported inability to finish mowing his yard or use a push broom, each of which caused extraordinary fatigue; the physician noted that he displayed a normal LVEF of greater than 65 percent. Upon VA examination in September 2016, a VA examiner utilized an interview-based METs test to conclude that the Veteran would be capable of an estimated workload of greater than 3 METs and less than 5 METs. The examiner noted that a METs level of 1 to 3 would be reserved for those individuals that would have functional limitations due to cardiac-related symptoms that would occur with such activities as eating, dressing, taking a shower, or walking a pace of 2 miles an hour for 1 to 2 blocks; however, the Veteran appeared to be capable of functionally performing activity levels at a level greater than that, although he may at times experience some occasional chest wall pain at less activity levels and primary fatigue with exertion. The examiner noted that a recent stress test and myocardial perfusion demonstrated no ischemia, with a normal ejection fraction, which suggested that the Veteran would not be experiencing functional limitations as a direct result of ischemia with such activities as eating, dressing, or walking at a slow pace for 1-2 blocks, although he was likely unable to briskly walk for any degree of distance at 3-4 miles per hour, as he reported fatigue and some pain with even light yard work. Therefore, based on the totality of the Veteran’s clinical presentation, including his description of the various symptoms and the various scenarios in which he describes such symptoms, and in light of the objective cardiac testing with no current evidence of ischemia or congestive heart failure and a normal ejection fraction, the examiner concluded that the Veteran’s METs level would be most consistent with a greater than 3 and less than 5 METs. Notably, the preponderance of the objective evidence of record, including as discussed above, does not document that the Veteran’s CAD resulted in an episode of acute, congestive heart failure in the past year, or a workload of greater than 3 METs but not greater than 5 METs which resulted in dyspnea, fatigue, angina, dizziness, or syncope; or a LVEF of 30 to 50 percent at any time prior to October 21, 2014. Similarly, the preponderance of the objective evidence of record does not document that the Veteran’s CAD resulted in chronic congestive heart failure, or a workload of 3 METs or less which resulted in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of less than 30 percent at any time from February 1, 2015. As such, the preponderance of the objective evidence of record weighs against the Veteran’s claim for the entire period on appeal. The Board has also considered the Veteran’s lay statements of record. The Veteran has reported that he still has two small blockages that are 50 to 60 percent blocked following his CABG surgery and that he has been prescribed five additional medications for his heart condition, for which he has also had to change his diet. He reported symptoms including erratic episodes of chest tightness, left arm pain, achiness, and pulsating pain due to his heart condition and stated that his private treatment providers have advised him to avoid physical activities such as shoveling snow or using a snow blower, to keep his face covered with a scarf or mask in cold weather, and to restrict strenuous activities likely for the rest of his life. The Veteran has disputed his ability to reach a METs level between 3 and 5 and has reported that he was pushed hard during diagnostic tests, which he feels he cannot maintain; rather, he has asserted that his METs level is restricted to between 1 and 3 given his ongoing fatigue and chest pain with mild exertion such as slow walking outdoors, after carefully lifting and carrying groceries into your house, and/or slowly walking up and down stairs from the basement. Additionally, the Veteran has disputed the appropriateness of the applicable rating criteria; specifically, he has stated that LVEF is not an appropriate measure of his actual limitations and symptoms of his CAD. Instead, he feels that an inability to complete a treadmill stress test is a vital piece of medical evidence that should be not disregarded. While the Board has considered the Veteran’s lay statements, to the extent that such statements assert that the Veteran’s service-connected CAD results in a METs level worse than that identified by the objective evidence of record discussed above, the Board affords such statements less probative value given the Veteran’s lack of medical and cardiac expertise. Moreover, the two objective VA examinations of record clearly document that the examiners based their estimation of the appropriate METs level on an interview-based test which included consideration of the Veteran’s statements and history, rather than simply upon consideration of the Veteran’s LVEF, which he has disputed as an appropriate measure. Thus, the Board concludes that the preponderance of the probative lay and medical evidence of record weighs against the Veteran’s claim of entitlement to an initial disability rating in excess of 30 percent for CAD, status post CABG, prior to October 21, 2014, and entitlement to an increased disability rating in excess of 60 percent from February 1, 2015. As the preponderance of evidence is against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Chad Johnson, Counsel