Citation Nr: 1806971	
Decision Date: 02/02/18    Archive Date: 02/14/18

DOCKET NO.  17-21 230	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Columbia, South Carolina


THE ISSUE

Entitlement to a rating in excess of 60 percent for service connected coronary artery disease (CAD) status-post bypass grafting. 


REPRESENTATION

Veteran represented by:	The American Legion


ATTORNEY FOR THE BOARD

B. Lewis, Associate Counsel






INTRODUCTION

The Veteran served on active duty in the U.S. Marine Corps from June 1954 to August 1985.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Veteran filed a Notice of Disagreement (NOD) in October 2015 and a Statement of the Case (SOC) was issued in April 2017.  The Veteran filed his Substantive Appeal via a VA Form 9 in April 2017.  Thus, the Veteran perfected a timely appeal of the issue. A Supplemental Statement of the Case was issued in October 2017.

This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record, as well as the Veteran's Virtual VA paperless claims file.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017).  38 U.S.C.A. § 7107(a)(2) (West 2014).


FINDING OF FACT

The Veteran's CAD, status-post bypass graft has been manifested by production of a workload of 5 to 7 METs and ejection fraction of 55 percent with fatigue. 


CONCLUSION OF LAW

The criteria for a rating in excess of 60 percent for CAD are not met. 38 U.S.C. §§ 1155, 5103, 5103A (2012); 38 C.F.R. § 4.104, Diagnostic Code 7017 (2017).


REASONS AND BASES FOR FINDING AND CONCLUSION

I. Duty to Notify and Assist

VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claim submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. § 5103 (a) (2012); 38 C.F.R. § 3.159 (b) (2017). In regards to increased rating claims, VA is required to provide the Veteran with generic notice - that is, the type of evidence needed to substantiate the claim. This includes evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA's duty to notify was satisfied by an April 2015 letter.

Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007).

VA has a duty to provide assistance to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c).  The record contains the Veteran's post-service VA and private treatment records; service treatment records; the Veteran's statements; and reports of VA examinations. The Veteran was provided VA medical examinations in May 2015 and May 2017.  These examination reports are adequate for rating purposes because they are based upon consideration of the relevant facts particular to this Veteran's medical history, describe the disability in sufficient detail so that the Board's evaluation is a fully informed one, and contain reasoned explanations.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008).  Thus, the Board finds that VA's duty to assist has been met.


II. Increased Ratings 

Applicable Laws and Regulations

Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7.

The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has 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). Here, the relevant evidentiary window begins one year before the Veteran filed his claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). 

In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).

After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2016).

Coronary artery disease 

The Veteran contends that he is entitled to an evaluation in excess of 60 percent for his service-connected CAD.

The Veteran's CAD has been rated under Diagnostic Code 7017. Diagnostic Code 7017 provides that for three months following hospital admission for coronary bypass surgery, a 100 percent rating is assigned. 

Thereafter, a 100 percent rating contemplates chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. 

A "MET" (metabolic equivalent) 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.

The Veteran was granted service connection for coronary artery disease status post coronary artery bypass grafting in a January 2011 rating decision. The Veteran's disability was evaluated as 30 percent disabling with an effective date of July 19, 2010. 

In a September 2012 rating decision, the Veteran's CAD was assigned a 60 percent evaluation, effective November 2011.

In April 2015, the Veteran submitted a claim for an increased rating for his service-connected CAD, citing new issues concerning his heart. Additionally, the Veteran submitted a letter from Dr. D.H. at Beaufort Memorial Cardiology. Dr. D.H. indicated that the Veteran had been under his care for the past two years for CAD, hypertension, and hyperlipidemia. He noted that the Veteran's CAD required bypass grafting as well as two separate stent procedures which the doctor believed all contributed to the Veteran's disability. A recent cardiac catheterization also demonstrated chronic total occlusion of his right coronary, as well as the right coronary graft which was not amendable to percutaneous intervention. The letter from Dr. D.H. was accompanied by treatment notes and records from Beaufort Cardiology.

The Veteran underwent a VA examination in May 2015. The examiner noted the Veteran's history of percutaneous coronary intervention (PCI) (angioplasty) with stent placement in August 2012 and catheterization in May 2015, as well as his 2001 coronary artery bypass surgery. The examiner noted that an EKG had been performed in April 2015 with normal results. A chest x-ray was noted as abnormal with sternal wires and left-sided mediastinal clips noted. The heart was not enlarged. An April 2015 echocardiogram revealed left ventrical ejection fraction (LVEF) of 55 percent with normal wall motion and abnormal wall thickness. An exercise stress test was not performed because exercise stress testing was not required as part of the Veteran's current treatment plan and the test was noted to not be without significant risk. Additionally, the examiner noted that a nuclear stress test had been conducted in March 2015 prior to catheterization. See May 2015 VA Heart Conditions Disability Benefits Questionnaire. 

An interview-based METs test was conducted which revealed fatigue attributable to the Veteran's cardiac condition with METs level of 5 to 7 METs. The examiner noted that this METs level limitation was due solely to the Veteran's heart conditions. Functional impact was noted as impacting the Veteran's ability to work in that he was unable to walk more than one hour and unable to climb more than one flight of stairs. Id.

Based upon the May 2015 VA examiner's observations of scarring, the Veteran was service connected for residual scars, secondary to his service-connected CAD, with an evaluation of 0 percent from Mary 7, 2015.  However, the Veteran's claim for an increased evaluation for CAD was denied because the results of his May 2015 examination indicated that he did not have a workload of 3 METs or less and did not exhibit left ventricular dysfunction with an ejection fraction of less than 30 percent. 

In July 2015 the Veteran submitted another letter from his private cardiologist Dr. D.H. who stated that the Veteran had been under his care for CAD for three years. He again noted that the Veteran's CAD had required bypass surgery and two separate stent procedures. A cardiac catheterization done four months prior to the letter demonstrated an occluded graft to his anterior descending, an occluded graft to his right coronary artery and total occlusion of his native right coronary artery. The doctor expressed his opinion that there was no question that the Veteran had significant and severe coronary artery disease which had resulted in functional limitations. See July 2015 Letter from Beaufort Memorial Cardiology. 

The Veteran underwent a VA examination in May 2017. The Veteran reported experiencing tightness in his chest with moderate activity. The examiner noted that the Veteran was evaluated by his cardiologist with no significant new findings. The Veteran did not have myocardial infarction (MI), congestive heart failure (CHF), arrhythmia, heart valve conditions, infectious heart conditions, or pericardial adhesions. See May 2017 VA Examination Report.  

The Veteran was noted as having had a percutaneous coronary intervention (PCI) (angioplasty) in August 2012 and March 2015 and coronary artery bypass surgery in 2001. An echocardiogram revealed left ventricular ejection fraction (LVEF) of 58 percent with normal wall motion and wall thickness. On METs testing, the examiner noted fatigue and a METs level between 5 and 7, noting that this METs level has been found to be consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing a lawn with a push mower, and doing heavy yard work such as digging. The examiner noted that the limitation in METs level was due to multiple medical conditions including the heart condition and that it was not possible to accurately estimate the percent of METs limitation attributable to each of the Veteran's medical conditions. The examiner noted that her opinion was based on a review of VBMS and CPRS with particular emphasis on the examination that was conducted that day. The Veteran's current functional status permitted physical and sedentary employment but was obviated by efforts to avoid prolonged activity due to service-connected CAD. Id.

In June 2017, the Veteran submitted an additional letter from Dr. D.H. of Beaufort Memorial Cardiology which contained essentially the same remarks as the previous two letters. This letter was accompanied by treatment records from Beaufort Memorial Cardiology. A treatment record from April 2017 noted that the Veteran exhibited ejection fraction of 60 to 65 percent with a normal size left ventricle. Moderate concentric left ventricular hypertrophy and mild aortic valve thickening were noted. See June 2017 Letter from Dr. D.H. and April 2017 Beaufort Memorial Cardiology Treatment Notes. 

After thorough review of the evidence of record and consideration of the Veteran's contentions, the Board finds that the assigned 60 percent rating is most appropriate for the entire appeal period. Chronic congestive heart failure, a workload of 3 METs or less, or LVEF of less than 30 percent are not shown by the lay or medical evidence; thus, an increased rating of 100 percent is not warranted.
 
The medical evidence of record shows that the Veteran's disability was productive of a workload of 5 to 7 METs for the entirety of the appeal period. LVEF has been measured no lower than 55 percent. Further, the evidence does not show that the Veteran suffered chronic congestive heart failure during the appeal period.

The Veteran is competent to describe his symptoms, including chest pain and fatigue, and their effects on his functionality. See Layno, 6 Vet. App. at 465. While he is credible to the extent that he sincerely believes he is entitled to a higher rating, he is not competent to identify a specific level of disability according to the appropriate Diagnostic Code, as this is a complex medical determination outside the realm of common knowledge of a lay person. See, e.g., Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Board acknowledges that the Veteran is sincere in his belief that his condition warrants a higher rating. However, although the Board accepts the Veteran's testimony with regard to the matters he is competent to address, it affords greater probative weight to the competent evidence provided by medical professionals regarding the specialized evaluation of his functional impairment, symptom severity, and details of clinical features of the heart condition.

Accordingly, a rating in excess of 60 percent is not warranted for the Veteran's CAD during the period on appeal. The record does not reflect that the Veteran has chronic congestive heart failure, or that he has an ejection fraction of less than 30 percent. On the contrary, LVEF has been measured at no lower than 55 percent. His METs levels have been in the range of 5 to 7, which is above the workload of three METs or less required for a 100 percent rating. 

In the absence of competent evidence meeting the criteria for a rating in excess of 60 percent, the Board must deny the claim. The preponderance of the evidence is against the Veteran's claim for an increased rating.


ORDER

Entitlement to an increased rating in excess of 60 percent for coronary artery disease status-post bypass grafting is denied. 



____________________________________________
TANYA SMITH
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs