Citation Nr: 20002001 Decision Date: 01/09/20 Archive Date: 01/09/20 DOCKET NO. 14-27 719 DATE: January 9, 2020 ORDER Entitlement to an evaluation in excess of 60 percent for coronary artery disease (CAD) is denied. FINDING OF FACT Throughout the period on appeal, the Veteran’s CAD has been manifested by a workload of greater than three metabolic equivalents of task (MET) that resulted in dyspnea and fatigue, and a left ventricular ejection fraction (LVEF) greater than 30 percent and no acute congestive heart failure. CONCLUSION OF LAW The criteria for a rating in excess of 60 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.104, Diagnostic Code (DC) 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1964 to September 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2012 rating decision of a U.S. Department of Veterans Affairs (VA) Regional Office in Winston-Salem, North Carolina. Entitlement to an evaluation in excess of 60 percent for coronary artery disease is denied. Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a “staged” rating is required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran is claiming that he is entitled to a higher rating for his CAD. His claim was received by VA in August 2010. The Veteran is rated under Diagnostic Code (DC) 7005 as 60 percent disabling which provides for more than one episode of acute congestive heart failure in the past year; a workload of greater than three METs but not greater than five METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or a left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 38 C.F.R. § 4.104.   For the next higher rating of 100 percent rating, the evidence must show chronic congestive heart failure, or a workload of three METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. In this case, the evidence of record does not establish that the Veteran warrants a higher rating for CAD. January 2010 VA heart examination showed normal rate and rhythm (“RRR”) with no murmurs. In April 2011, VA examination resulted in an estimation that the Veteran’s activity level to be “more than 3 up to 5” METs. May 2011 VA physical therapy examination also showed a “normal” heart. July and October 2011 and February and May 2013 VA clinical notes found “RRR without gallop, rub or murmur.” January and July 2018 VA clinical notes found the heart condition “quiescent” and “stable.” In October 2018, a VA anesthesiologist found no congestive heart failure and “moderate” exercise tolerance. An April 2019 VA echocardiogram report found “normal left ventricular size and ejection fraction.” The Veteran attended a VA examination in May 2019. The examination report includes the finding that the Veteran did not have congestive heart failure; however, his mitral inflow velocities were “consistent” with diastolic dysfunction and a “trivial” tricuspid regurgitation was noted. An April 2019 VA echocardiogram yielded a left ventricular ejection fraction rate of 56 percent. The Veteran underwent an interview-based METs test, which resulted in a finding that the Veteran has the symptoms of dyspnea and fatigue at greater than five but not greater than seven METs. The examiner concluded that, although the Veteran was retired, his CAD and diastolic dysfunction could cause occasional symptoms of chest pain, shortness of breath, and fatigue that would impact his ability to work. The examiner estimated that these symptoms could cause him to miss up to one week of work per year. The examiner changed the Veteran’s diagnosis to “diastolic dysfunction and valvular heart disease . . . a progression of the previous diagnosis.” The examiner explained that the “Veteran has long history of myocardial infarctions x 3 secondary to coronary artery disease has over time [caused the] condition of the heart to change and current echo shows these changes.”   The Veteran, through his representative, contended that the May 2019 VA examiner did not “have any particular expertise, experience, training, or competence in commenting on Cardiovascular disorders” and therefore the May 2019 VA examination report was “wholly inadequate for VA purposes.” The Board finds this argument to without merit. The Board may assume the competency of a VA medical examiner as long as the examiner is qualified through education, training, or expertise to offer medical diagnoses, statements, or opinions. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (citing 38 C.F.R. § 3.159 (a)(1)). In this case, the VA medical opinion of record was rendered by a Nurse Practitioner. As a nurse practitioner has medical education and training, the Board finds the VA examiner’s opinion to be competent medical evidence. See, e.g, id. (noting that “[a] nurse practitioner, having completed medical education and training, thus fits squarely into the requirement of [38 C.F.R.] § 3.159(a)(1) as one competent to provide diagnoses, statements, or opinions”). Furthermore, no specific challenges were raised regarding the examiner’s competency. The Veteran did not challenge the VA examiner’s objective clinical findings required for an accurate disability evaluation, only that the VA examiner somehow lacked “the requisite expertise to evaluate cardiovascular disorders” because the examiner was “merely” a “Nurse Practitioner (NP), rather than a Cardiologist (MD).” Furthermore, the VA examiner’s clinical findings were consistent with treatment notes from the Veteran’s VA nurse practitioner that did specialize in cardiology. A March 2019 cardiac stress test, conducted by the Veteran’s VA cardiology nurse practitioner, showed that the Veteran achieved 9.7 METs, a score more consistent with a 10 percent disability rating. A review of the medical record showed other objective evidence supporting the May 2019 VA examiner’s clinical findings and current disability rating. For example, a February 2013 VA echocardiogram report showed an ejection fraction rate of 42 percent. While the Veteran believes the severity of his symptoms has increased, he is not competent to medically attribute this to a worsening of his CAD disability. The issue is medically complex, as it requires the ability to interpret complicated diagnostic medical testing and there is no indication that the Veteran has had the formal medical training to do so. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, including the objective clinical findings of the May 2019 VA examiner and the March 2019 treating VA nurse practitioner specializing in cardiology. The Board finds that a rating in excess of 60 percent is not warranted at any time. The record shows the Veteran’s left ventricular ejection fraction rate was at least 42 percent with no history of more than one episode of acute congestive heart failure per year. Additionally, when considering CAD only, the Veteran’s interview-based METs test established dyspnea and fatigue at greater than five METs, which is consistent with no higher than a 60 percent disability rating; thus, suggesting an improvement of the Veteran’s CAD compared to his April 2011 VA examination. The Board finds that a preponderance of the evidence shows that the Veteran’s CAD most closely matches the severity of a 60 percent rating; therefore, an increased rating is not warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 60 (1990). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James Hekel, 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.