Citation Nr: 18101030 Decision Date: 04/26/18 Archive Date: 04/26/18 DOCKET NO. 14-15 979 DATE: April 26, 2018 ISSUES DECIDED: 1 ISSUES REMANDED: 0 ORDER Since June 9, 2014, a disability rating in excess of 10 percent for the service-connected heart valve disease, status-post aortic valve replacement, is denied. FINDING OF FACT Since June 9, 2014, the service-connected heart valve disease, status-post aortic valve replacement, has been manifested by the need for continuous medication, with normal METs testing, ejection fraction of 60 to 65 percent, and with no evidence of cardiac hypertrophy or dilatation, congestive heart failure. CONCLUSION OF LAW Since June 9, 2014, the criteria for a disability rating in excess of 10 percent for the service-connected heart valve disease, status-post aortic valve replacement, have not been satisfied. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.100, 4.104, Diagnostic Code 7016 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a veteran (the Veteran) who had active duty service from August 2007 to May 2010. In June 2015, the Veteran presented testimony at a Board hearing, chaired via videoconference by the undersigned Veterans Law Judge, and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e) (2017). The Veteran was informed of the basis for the denial of his claim and he was informed of the information and evidence necessary to substantiate the claim. A transcript of the hearing is associated with the claims file. 38 C.F.R. § 3.103 (2017). In October 2015, the Board remanded this issue for additional evidentiary development. The appeal has since been returned to the Board for further appellate action. The Board also denied an increased rating for the period prior to June 9, 2014, an issue on appeal at that time. The Board's decision with respect to that claim is final. See 38 C.F.R. § 20.1100 (2017). Disability ratings 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. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of 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 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017). A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The current appeal arises from a claim of entitlement to service connection for heart valve disease, received at VA on November 3, 2011. In a July 2012 rating decision, VA granted service connection for valvular heart disease status-post heart valve replacement and assigned an initial rating of 10 percent under Diagnostic Code 7016, effective November 3, 2011. In October 2015, the Board denied a disability rating higher than 10 percent for the period prior to June 9, 2014, resolving the appeal of that matter. Certain provisions govern the application of the evaluation criteria for diagnostic codes 7000-7007, 7011, and 7015-7020. These provisions specify that: (a) whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X–ray) is present, the need for continuous medication must be ascertained in all cases; (b) even if the requirement for a 10 percent rating (based on the need for continuous medication) or 30 percent rating (based on the presence of cardiac hypertrophy or dilatation) evaluation is met, METs testing is required in all cases except: (1) when there is a medical contraindication; (2) when the left ventricular ejection fraction has been measured and is 50% or less; (3) when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; (4) when a 100% evaluation can be assigned on another basis; (c) and, if left ventricular ejection fraction (LVEF) testing is not of record, the condition is to be evaluated based on the alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran's cardiovascular disability. 38 C.F.R. § 4.100. Under Diagnostic Code 7016, a prosthetic heart valve replacement is assigned a 100 percent rating for an indefinite period following the date of hospital admission for valve replacement 6 months following hospital discharge, the appropriate disability rating shall be determined by mandatory VA examination, at which point the disability is to be rated on the basis of residuals. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). In this case, VA never assigned a 100 percent rating because the heart valve replacement took place on May 14, 2009, while the Veteran was still on active duty. VA compensation cannot be assigned for any period during which a claimant is performing active service. As the initial rating of 10 percent was assigned after the 6-month period following hospital discharge, there was no rating reduction in this case and the provisions of 38 C.F.R. § 3.105(e) do not apply. The criteria for rating residuals of prosthetic heart valve replacement provide that a 100 percent rating is for assignment with residual chronic congestive heart failure, or; where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; with left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent rating is for assignment with more than one episode of acute congestive heart failure in the past year, or; where workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; with left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 30 percent rating is for assignment where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; with evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X–ray. A 10 percent rating is for assignment where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; where continuous medication is required. Results of METS testing have been completely normal in this case. The report of VA examination in June 2014 reveals METs testing on June 9, 2014, produced no symptoms with any level of physical activity. Regarding the alternative requirements for a 30 percent rating, the evidence regarding cardiac hypertrophy and dilation is negative. The June 2014 examination report notes that there was no cardiac hypertrophy or dilatation (Record 06/09/2014). An ECG on December 11, 2014, reveals normal valve function (Record 01/15/2015 at 71). Regarding the criteria for higher ratings, an echocardiogram dated January 6, 2012, reveals an ejection fraction of 60-65 percent. The report also reveals a normally functioning aortic valve, as well as normal left ventricle size, thickness, and function (Record 01/15/2015 at 85). The June 2014 VA examination report notes that there was no congestive heart failure. The examiner noted that continuous medication (warfarin or Coumadin) was required for the Veteran’s heart condition; however, the need for continuous medication is contemplated under the 10 percent rating. Based on the clinical results in this case, the criteria for a rating in excess of 10 percent have not been met. And, based on the absence of criteria for ratings higher than 30 percent, it also cannot be said that the criteria for any higher rating are more nearly approximated than those for the 10 percent rating. The Board has considered whether any other diagnostic code would provide for a higher rating; however, there appear to be no symptoms or findings that would support a rating under other codes. The June 2014 examination report notes that there was no ischemic heart disease present, no congestive heart failure, no arrhythmia, no infectious cardiac condition, and no pericardial adhesions. There was also no history of myocardial infarction. The Board acknowledges the Veteran’s testimony that he experiences chest pain and has been hospitalized for evaluation (Record 06/11/2015 at 6). This assertion was reviewed by the June 2014 VA examiner who noted the Veteran’s complaint that, about once or twice per year, he will get sharp left-sided chest pain. The examiner reviewed Emergency Department notes reflecting several visits with complaint of chest pain of unclear etiology. Testing revealed these episodes were likely musculoskeletal in origin. The Board notes that a December 22, 2010, discharge summary showed an assessment of chest pain, likely non-cardiac, “[p]ossibly it is musculoskeletal such as costochondritis.” The Veteran was subsequently seen in the emergency department on November 15, 2011, for stabbing chest pain aggravated by deep breathing. The diagnosis was simply chest pain (Record 11/30/2012 at 10). The Veteran was seen on February 6, 2013, with chest pain of uncertain cause. It was noted that the pain does not appear to be coming from the heart (Record 03/27/2013). Based on the June 2014 VA examiner’s review of the evidence regarding ongoing complaints of chest pain, and other similar findings, the Board finds that a preponderance of the evidence is against attribution of these symptoms to the Veteran’s service-connected heart valve disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so). The June 2014 examiner noted that the effect of the disability on the Veteran’s ability to work was described as the need for chronic Coumadin therapy. This means that he cannot be employed in jobs that would put him at high risk of cutting himself or bleeding. The Board finds that this condition is not unreasonably limiting. In sum, the Veteran’s service-connected heart valve disability is manifested by the need for continuous medication, with normal METs testing, ejection fraction of 60 to 65 percent, and with no evidence of cardiac hypertrophy or dilatation, congestive heart failure. The rating criteria for the 10 percent rating fully encompass such symptomatology and the criteria for a higher rating are not met. The Board notes that none of the criteria for ratings above 10 percent are met, and it cannot be said that the Veteran’s disability picture more nearly approximates that contemplated for the 30 percent rating, or any higher rating. The preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Cramp, Counsel