Citation Nr: 18115293 Decision Date: 06/29/18 Archive Date: 06/29/18 DOCKET NO. 12-34 158 DATE: June 29, 2018 ORDER The claim for an initial rating for coronary artery disease (CAD) greater than 10 percent prior to February 9, 2017, and greater than 30 percent thereafter, is denied. FINDINGS OF FACT 1. For the period prior to February 9, 2017, the Veteran’s CAD was not shown to be manifested by multiple episodes of acute congestive heart failure in a year or chronic congestive heart failure; a workload of greater than 5 but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray; or left ventricular dysfunction with an ejection fraction of 50 percent or less. 2. Since February 9, 2017, the Veteran’s CAD has been shown to be manifested by a workload of greater than 5 but not greater than 7 METs resulting in angina but not manifested by more than one episode of acute congestive heart failure in the past year, or; 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 50 percent or less; or, chronic congestive heart failure, or; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. CONCLUSIONS OF LAW 1. For the period prior to February 9, 2017, the criteria for an initial disability rating greater than 10 percent for CAD are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.1, 4.104, Diagnostic Code 7005 (2018). 2. For the period since February 9, 2017, the criteria for a disability rating greater than 30 percent for CAD are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.1, 4.104, Diagnostic Code 7005 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from September 1965 to April 1969. This appeal was previously remanded by the Board in November 2016 for further development. Such development having been completed, the appeal is ready for further disposition. Entitlement to an initial rating for coronary artery disease that is greater than 10 percent prior to February 9, 2017, and greater than 30 percent thereafter. Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran’s symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2018). Disability evaluations are determined by assessing the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). If there is a question as to which evaluation should be applied to the veteran’s disability, the higher evaluation 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 (2018). To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire period involved. See Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Secretary shall give the benefit of the doubt to the Veteran when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service connection for the Veteran’s CAD was granted in a November 2010 rating decision, at which time a 10 percent rating was assigned effective in November 2009. The present appeal arises from the Veteran’s disagreement with the amount of the disability rating assigned. The Veteran’s CAD has been evaluated pursuant to 38 C.F.R. § 4.104, DC 7005. This diagnostic code evaluates arteriosclerotic heart disease (coronary artery disease), and provides a 10 percent rating when documented CAD produces dyspnea, fatigue, angina, dizziness, or syncope with a workload of greater than 7 METs but not greater than 10 METs, or when continuous medication is required. A 30 percent rating is assigned when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned 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; for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005 (2018). One MET 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 evaluation, 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). The Veteran was afforded a VA examination in March 2010 to evaluate the severity of his CAD. The examiner noted that the Veteran had a history of CAD with angina for the past three years. The examiner also noted that the Veteran had two stents, recurrent anginal pain, chest pain that the Veteran described as severe and required nitroglycerin at times, as well as significant fatigue and weakness. The examiner noted that the Veteran’s estimated METs level was between 7 and 8. VA treatment records dated prior to February 13, 2017, are consistent with the findings at the March 2010 VA examination. The Veteran was provided with another VA examination on February 13, 2017. At that time, the Veteran reported that his angina had gradually increased over the last two years but that he had not had any follow-up with a cardiologist. The Veteran also denied having a history of congestive heart failure. He reported having angina during activity. The examiner noted that the Veteran’s estimated METs level was greater than 5 but less than 7 METs. Additionally, the February 2017 VA examiner noted that the Veteran had an echocardiogram in December 2016 with left ventricular ejection fraction of 55-60 percent. The examiner also noted that the estimated METs level was the most accurate measurement in this case. There is no evidence of record to suggest that the Veteran’s CAD was more severe than described at the February 2017 VA examination. Applying the rating criteria to facts above, the Board finds that a rating greater than 10 percent is not warranted prior to February 13, 2017, or greater than 30 percent thereafter. Regarding the period prior to February 13, 2017, the evidence demonstrates that the Veteran’s CAD produced fatigue and angina with a workload of greater than 7 METs but not greater than 10 METs, and that he required medication for his CAD. There is no indication that the criteria for the next-higher 30 percent disability rating was warranted prior to February 13, 2017. In this regard, there is no evidence that the Veteran’s CAD resulted in dyspnea, fatigue, angina, dizziness, or syncope with a workload of greater than 5 METs but not greater than 7 METs. Similarly, there was no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. It naturally follows that if the rating criteria for the next-higher 30 percent disability rating were not met, the criteria for the 60 and 100 percent disability ratings were not met. For the period from February 13, 2017, the evidence demonstrates that the Veteran’s CAD resulted in fatigue and angina with a workload of greater than 5 METs but not greater than 7 METs. There is no evidence that the Veteran had more than one episode of acute congestive heart failure in a 12-month period, or that his CAD resulted in dyspnea, fatigue, angina, dizziness, or syncope with a workload of greater than 3 METs but not greater than 5 METs, or; that the Veteran had left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Again, during the February 2017 VA examination, the Veteran specifically denied having a history of congestive heart failure and left ventricular ejection fraction was not shown to be less than 50 percent at any time. The Board acknowledges the Veteran’s belief that his CAD is of such severity as to warrant higher ratings; however, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. Therefore, the Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, more probative than the Veteran’s assessment of the severity of his CAD. The Board has considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected CAD; however, the Board finds that his symptomatology has been stable throughout the currently assigned appeal periods. Therefore, additional staged ratings for CAD are not warranted. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Donna D. Ebaugh, Counsel