Citation Nr: 18130636 Decision Date: 08/29/18 Archive Date: 08/29/18 DOCKET NO. 16-48 696 DATE: August 29, 2018 ORDER Entitlement to a higher initial evaluation of 100 percent for chronic ischemic heart disease (IHD) is granted. FINDING OF FACT The medical evidence shows the service-connected chronic IHD is productive of not greater than 3 metabolic equivalents (METs), at its most limited, during the period on appeal. CONCLUSION OF LAW The criteria for an initial evaluation of 100 percent for the service-connected chronic IHD have are satisfied. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.14, 4.104, Diagnostic Code 7005 (2017).   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran serviced on active service from July 1966 to May 1968. It is noted that in his January 2016 notice of disagreement, the Veteran identified four of the seven issues of the September 2015 rating decision with which he disagreed: 1) the 10 percent evaluation initially assigned chronic IHD, 2) service connection for glaucoma (claimed as an eye condition), 3) service connection for an erectile dysfunction, and 4) service connection for diabetes mellitus, as the result of exposure to herbicides. However, after receiving the March 2016 statement of the case, the Veteran checked block 8A on the VA Form 9, substantive appeal, and indicated he wished to appeal only the issue of a higher initial evaluation for the service-connected chronic IHD. The record shows no other document was received indicating the Veteran wished to appeal any other issue that that of an initial evaluation greater than 10 percent for the service-connected chronic IHD within the deadline he had to perfect his appeal, in this case, September 2017. 38 C.F.R. § 20.302(b) (2017). Thus, this is the only issue certified for appeal in the October 2016 VA Form 8. In June 2018, the Veteran’s representative submitted an informal hearing presentation (IHP) identifying all four issues the Veteran identified on his January 2016 NOD. However, the IHP was presented in June 2018, which is outside the time periods in which these issues could have been perfected on appeal. Thus, the Board recognizes that the only issue on appeal is that of entitlement to an initial evaluation greater than 10 percent for the service-connected chronic IHD. Increased Evaluation Disability ratings are assigned in accordance with the VA’s Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C. § 1155; 38 C.F.R. § 3.321(a), 4.1. Separate diagnostic codes identify the various disabilities. See 38 U.S.C. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Importantly, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998); 38 C.F.R. § 3.102. “Staged” ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The agency of original jurisdiction (AOJ) evaluated the Veteran’s service-connected chronic IHD under Diagnostic Code 7005, as arteriosclerotic heart disease or coronary artery disease (CAD). A 10 percent evaluation under Diagnostic Code 7005 is warranted for documented CAD resulting in: a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent evaluation is warranted for documented CAD resulting in: a workload of greater than 5 METs 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. A 60 percent evaluation is warranted for documented CAD resulting in 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 resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent evaluation is warranted for documented CAD resulting in 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. 38 C.F.R. § 4.104, Diagnostic Code 7005. The regulations further explain that 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). Entitlement to a higher initial evaluation for chronic IHD In this case, a September 2015 rating decision awarded service-connection for chronic IHD. An initial evaluation of 10 percent was assigned, effective April 23, 2014. The Veteran and his representative argue that a higher initial evaluation is warranted. In this case, there is dispute as to which disorder or disorders, the service-connected chronic IHD or the nonservice-connected COPD and osteoarthritis/osteoporosis, resulted in the METs test results measuring 3 METs or less. Both the 2015 VA examination report and the 2015 private DBQ examination report reflect interview stress test findings or reference actual stress test results conducted by VA, both which provide findings measuring 1-3 METs. However, both examiners stated that the results were attributable not only to the service-connected chronic IHD but to a constellation of diagnoses including IHD. Specifically, the 2015 VA examiner conducted an interview stress test and reported an estimated finding of 1-3 METs, which the VA examiner pointed out could not be solely the result of the chronic IHD, as the Veteran was also diagnosed with severe COPD and osteoarthritis (OA)/osteoporosis(OP). Yet, the 2015 VA examiner also opined that it was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. Similarly, Dr. A.K., M.D., provided the 2015 private DBQ examination, referencing January 2015 stress test exercise results conducted by VA and measuring 1-3 METs. Yet, Dr. A.K. annotated the results were due cardiopulmonary symptoms, essentially indicating that the results were due to both heart and lung conditions. It is noted that Dr. A.K. is the Veteran’s treating VA physician. See May 2015 VA Examination for Heart Conditions; and December 2015 private DBQ Examination for IHD. To determine what level of METs were due to the Veteran’s service-connected chronic IHD as compared to what level of METs were due to the nonservice-connected COPD and OA/OP, an additional VA medical opinion was requested. In 2016, a VA examiner opined that the Veteran’s actual METs level based solely on the service-connected chronic IHD measured 7-10 METs rather than 1-3 METs. The 2016 VA examiner’s rationale was based on a records review without examination or interview of the Veteran. See 2016 VA Examination, Medical Opinion, pp. 3-4. Critically, however, this review did not include the January 2005 stress test results, which were referenced by Dr. A.K. in a 2014 private DBQ examination as being the diagnostic exercise stress test for IHD. See May 2014 private DBQ Examination for IHD. The 2005 stress test results showed an estimated workload of 5 METs. The stress test was stopped after 3.0 minutes due to severe dyspnea and non-sustained ventricular tachycardia, and it was reported that test findings showed borderline exercise induced inferior ischemic ST segment changes, then described as mild. CAPRI Treatment Records (rec’d 9/25/2015), p. 139 of 174. Further review of these records show that COPD was diagnosed in 2003, while chronic IHD was diagnosed in 2005—a period of 2 years later. Because the 2016 VA opinion was based on an incomplete review of the record, it cannot be probative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In the remaining two opinions of record, the VA examiner and Dr. A.K., the former who examined the Veteran and the latter who treated the Veteran and examined him, stated they cannot differentiate between the symptoms of service-connected chronic IHD from those of the nonservice-connected COPD and OA/OP in the finding of the workload of 1-3 METs resulting in dyspnea. The Board therefore attributes the finding of 1-3 METs resulting in dyspnea to the service-connected chronic IHD. See Mittleider, supra; 38 C.F.R. § 3.102. Accordingly, and resolving all reasonable doubt in the Veteran’s favor, the medical evidence supports the assignment of a 100 percent for chronic IHD. See 38 C.F.R. § 4.104, Diagnostic Code 7500. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L.J. Bakke, Counsel