Citation Nr: 19190853 Decision Date: 12/03/19 Archive Date: 12/03/19 DOCKET NO. 16-14 910 DATE: December 3, 2019 ORDER Entitlement to an initial disability rating of 60 percent for coronary artery disease (CAD) from June 25, 2011 to January 7, 2016 is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial disability rating higher than 60 percent for CAD for the entire appeal period is denied. FINDINGS OF FACT 1. Prior to January 7, 2016, the evidence is approximately evenly balanced as to whether the symptoms of the Veteran’s CAD more nearly approximated more than one episode of acute congestive heart failure (CHF) in the past year, or workload of greater than 3 metabolic equivalents (METs) but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction (LVEF) of 30 to 50 percent. 2. For the entire appeal period, the Veteran’s CAD symptoms did not more nearly approximate chronic CHF, or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of less than 30 percent. CONCLUSIONS OF LAW 1. Prior to January 7, 2016, the criteria for an initial disability rating of 60 percent for CAD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code (DC) 7005. 2. For the entire appeal period, the criteria for an initial disability rating in excess of 60 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.104, DC 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1967 to January 1969. This case comes to the Board of Veteran’s Appeals (Board) on appeal from a July 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for CAD and assigned a disability rating of 10 percent effective July 25, 2011. The Veteran filed a timely notice of disagreement with this rating decision in May 2014. In March 2016, the RO issued a rating decision increasing the evaluation for the Veteran’s service-connected CAD to 60 percent, effective January 7, 2016, thereby creating staged ratings. As the Veteran has not indicated satisfaction with either rating, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he indicates otherwise). In September 2018, the Board remanded the claim for further development to obtain updated treatment records and a VA examination. The agency of original jurisdiction (AOJ) has substantially complied with the Board's remand instructions by obtaining outstanding medical records and, as demonstrated by the discussion below, an adequate medical opinion. Thus, no further action is necessary in this regard. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with). Entitlement to a higher initial disability rating for CAD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran’s entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1. Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119 (1999). As indicated above, the Veteran is currently in receipt of a staged disability rating of 10 percent prior to January 7, 2016, and 60 percent from that date. Here, as shown below, the evidence warrants a uniform 60 percent initial disability rating from June 25, 2011 to January 7, 2016. The Veteran’s CAD is currently evaluated under DC 7005. DC 7005 evaluates arteriosclerotic heart disease, including CAD, and provides a 10 percent rating when workload greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, or syncope, or; continuous medication is required. A 30 percent rating is assigned when 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 workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or 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 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. Under Note (2) of 38 C.F.R. § 4.104, 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. 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. An October 2012 VA examination report noted the Veteran’s diagnoses of ischemic heart disease and myocardial infarction in 2009. The VA examiner indicated that the Veteran took continuous medication for the diagnosed condition and had a history of percutaneous coronary intervention and coronary bypass surgery in 2000. The Veteran did not have congestive heart failure. The VA examiner conducted an interview-based METs test and found that the Veteran had METs between 7 to 10 with fatigue. The VA examination report noted the Veteran’s May 2009 echocardiogram with LVEF at 60 to 65 percent. An October 2012 private treatment record indicated that the Veteran’s LVEF was 50 to 55 percent. An October 2014 echocardiogram showed LVEF was 35 to 40 percent. A January 2016 VA examination report noted the Veteran’s ischemic heart disease (IHD) and paroxysmal atrial fibrillation. The VA examiner indicated that the Veteran took continuous medication for control of his heart condition and had a myocardial infarction in 2009. The Veteran did not have congestive heart failure, a heart valve condition, an infectious cardiac condition, or pericardial adhesions, but he did have an intermittent cardiac arrhythmia. The Veteran had coronary artery bypass surgery in 2000, underwent percutaneous coronary intervention in 2009, and had an atrial fibrillation ablation in 2015. There was no evidence of cardiac hypertrophy or cardiac dilatation. An October 2014 echocardiogram indicated LVEF was 35 to 40 percent and a 2009 coronary artery angiogram noted LVEF was 25 percent. The VA examiner conducted an interview-based METs test and found that the Veteran had METs between 3 to 5 with dyspnea and chest heaviness. The VA examiner noted that the Veteran was likely not able to perform work that required moderate or more exertion without mechanical or other type of assistance in light of his CAD/IHD. A July 2019 VA examination report noted the Veteran’s coronary artery disease and paroxysmal atrial fibrillation. The VA examiner indicated that the Veteran took continuous medication for control of the Veteran’s heart condition and had a myocardial infarction in 2009. The Veteran did not have congestive heart failure, a heart valve condition, an infectious cardiac condition, or pericardial adhesions, but he did have an intermittent cardiac arrhythmia. The Veteran underwent percutaneous coronary intervention in 2009, had coronary artery bypass surgery in 2000, and had atrial fibrillation ablations in 2015 and 2017. There was no evidence of cardiac hypertrophy or cardiac dilatation. A June 2019 echocardiogram indicated LVEF was 45 to 50 percent and an October 2012 coronary artery angiogram noted LVEF was normal. The VA examiner conducted an interview-based METs test and found that the Veteran had METs between 3 to 5 with fatigue and chest pain. The VA examiner noted that the Veteran was likely not able to perform work that required moderate or more exertion without mechanical or other type of assistance in light of his CAD/IHD. The Veteran's CAD warrants a rating of 60 percent, but not higher, from June 25, 2011 to January 7, 2016. Although the Veteran’s LVEF ranges from October 2012 to June 2019 did not exactly meet the criteria of DC 7005 requiring LVEF of 30 to 50 percent, his LVEF ranges from June 25, 2011 to January 7, 2016 more nearly approximated 30 to 50 percent. Specifically, the Veteran’s LVEF ranged from 50 to 55 percent in October 2012, 35 to 40 percent in October 2014, and 45 to 50 percent in June 2019. He also experienced METS greater than 3 but no greater than 5 in January 2016. Therefore, the evidence of record reflects that the Veteran’s CAD symptoms from June 25, 2011 to January 7, 2016 more nearly approximated the criteria for a disability rating of 60 percent. Moreover, there is a lack of evidence of record establishing that the Veteran’s CAD symptoms suddenly became worse in October 2012. In this regard, an “effective date should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that [the Veteran’s disability] first manifested.” Swain v. McDonald, 27 Vet. App. 219, 224 (2015). Considering there is a lack of any medical evidence of record of LVEF testing between the July 2011 grant of the claim for service connection for CAD and October 2012, and in light of the medical evidence of record indicating that the disability has been of approximately the same severity throughout the appeal period and did not suddenly get worse on the date of the October 2012 LVEF test, it is at least as likely as not that the Veteran’s CAD symptoms more closely approximated LVEF of 30 to 50 percent from June 25, 2011 to January 7, 2016. The evidence of record does not reflect that the Veteran’s CAD symptoms more nearly approximated chronic congestive heart failure, or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of less than 30 percent throughout the entirety of the appeal period. Thus, the criteria for a 100 percent disability rating have not been met for the entirety of the appeal period. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's CAD symptoms have more nearly approximated the criteria for a 60 percent rating from June 25, 2011 to January 7, 2016. Accordingly, entitlement to an initial disability rating of 60 percent for service-connected CAD from June 25, 2011 to January 7, 2016 is warranted. As the preponderance of the evidence is against a higher disability rating for any portion of the appeal period, the benefit of the doubt doctrine is not otherwise for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board has considered the Veteran’s claim and decided entitlement based on the evidence. The Veteran has not raised any other issues, and no other issues have been reasonably raised by the record, with respect to his claim. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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 Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Styer, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.