Citation Nr: 20002891 Decision Date: 01/14/20 Archive Date: 01/13/20 DOCKET NO. 17-59 253 DATE: January 14, 2020 ORDER From February 1986 to March 1986, entitlement to a rating in excess of 30 percent for coronary artery disease is denied. From May 1987 to July 2013, entitlement to a rating in excess of 30 percent for coronary artery disease is denied. Since July 2013, entitlement to a rating in excess of 60 percent for coronary artery disease is denied. FINDINGS OF FACT 1. From February 1986 to March 1986, the evidence indicates that the Veteran’s coronary artery disease manifested in unstable angina, which shortly thereafter required a four-vessel coronary bypass graft. However, the evidence did not indicate that he experienced 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 30 to 50 percent. 2. From May 1987 to July 2013, the Veteran’s coronary artery disease was limited to a workload greater than 5 METs but not greater than 7 METs resulting in angina and dizziness. However, the evidence fails to show his coronary artery disease manifested in more than one episode of acute congestive heart failure within a year or a workload of 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. 3. Since July 2013, the Veteran’s coronary artery disease was limited to a workload greater than 3 METs, but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness or syncope. However, the evidence failed to show that he had chronic congestive heart failure, or status post coronary bypass surgery with a workload of 3 METs or else resulting in dyspnea, fatigue, angina and dizziness, or syncope or left ventricular dysfunction with an ejection fraction of less than 30 percent or a second coronary bypass surgery requiring hospital admission. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for coronary artery disease have not been met from February 1986 to March 1986 and from May 1987 to July 2013. 38 U.S.C. §§ 1155, 5103A; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7017. 2. Since July 2013, the criteria for a rating in excess of 60 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5103A; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7017. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the U.S. Army from August 1963 to August 1966. The Veteran is a recipient of a Purple Heart. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Notably, a September 2017 rating decision granted the claims for an earlier effective date for the grant of individual unemployability and Dependent’s Educational Assistance under 38 U.S.C. chapter 35 with a new effective date of November 13, 2003 for both claims. The Veteran did not appeal the effective dates assigned. Therefore, those claims have been resolved, and are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement (NOD) must thereafter be timely filed to initiate appellate review of the claim concerning “downstream” issues, such as the compensation level assigned for the disability and the effective date); see, too, 38 C.F.R. § 20.200. Therefore, the only claim remaining on appeal is a claim for entitlement to an increased rating for coronary artery disease. 1. Coronary Artery Disease Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities. 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 their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two ratings shall 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. Different disability ratings at different times over the life of the claim, a practice known as a “staged rating,” is 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. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The Veteran is currently assigned a staged rating for his coronary artery disease under DC 7017. From February 1986 to March 1986, he was assigned a 30 percent rating. He then was assigned a non-schedular 100 percent rating from March 1986 for three months following hospital admission or surgery; in this case, for his four-vessel coronary bypass graft as it was a surgical treatment that necessitated convalescence. He was also assigned a second 100 percent rating for one year following his coronary artery bypass after which period the condition is required to be rated according to the extent of disabling residuals or for residual findings of congestive heart failure, angina on moderate exertion, or if more than sedentary employment is precluded. A 30 percent rating was assigned from May 1987, the minimum evaluation following the one year for bypass surgery, plus one month for convalescence. Since July 2013, he was assigned a 60 percent rating for worsening of his heart condition based on a July 2013 VA examination that reflected his coronary artery disease was limited to a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness or syncope. DC 7017 addresses coronary bypass surgery, and the Veteran has a history of such surgery. For the purposes of this decision, the rating criteria are identical to those of DC 7005, which addresses coronary artery disease specifically. Under DC 7017, a 30 percent evaluation is assigned when a workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is assigned under DC 7015 when there is 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 where there is left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. A 100 percent evaluation is assigned under DC 7015 for chronic congestive heart failure; or when there is a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 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 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). Prior to January 12, 1998, DC 7017 stated that a 100 percent evaluation was warranted for one year following bypass surgery, and thereafter, the disorder was to be rated as arteriosclerotic heart disease, with a minimum rating of 30 percent. Under DC 7005 for arteriosclerotic heart disease, a 100 percent evaluation was warranted for arteriosclerotic heart disease during and for six months following acute illness from coronary occlusion or thrombosis, or circulatory shock, etc. A 100 percent evaluation was also warranted for arteriosclerotic heart disease after six months, with chronic residual findings of congestive heart failure or angina on moderate exertion or more than sedentary employment precluded. A 60 percent evaluation was for application when there was arteriosclerotic heart disease following typical history of acute coronary occlusion or thrombosis, as above, all with history of substantiated repeated anginal attacks, more than light manual labor was not feasible. A 30 percent evaluation was assigned following typical coronary occlusion or thrombosis or with a history of substantiated anginal attack and ordinary manual labor feasible. 38 C.F.R. § 4.104, DC 7005 (1995). A. February 1986 to March 1986 From February 1986 to March 1986, a rating in excess of 30 percent is not warranted. The Veteran filed for service connection for a heart condition in February 1986. VA medical records reflect he sought treatment earlier that month for unstable angina. Medical imaging of his chest showed segmental atelectasis of both lower lungs medially with haziness of the left CP angle suggestive of small left pleural effusion and or infiltration. He was ultimately diagnosed with left anterior hemiblock. Follow up was advised. Less than a week later, in March 1986, he underwent a scheduled stress test and coronary catheterization. He also underwent a coronary artery bypass graft after Cardiology work up found significant coronary artery disease. This evidence most closely approximates the criteria of a 30 percent rating as he experienced angina and dyspnea with medical imaging indicating a heart abnormality that required coronary bypass surgery. However, the evidence failed to show a history of more than one episode of acute congestive heart failure in the year prior 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 30 to 50 percent to warrant the higher 60 percent rating. The evidence also failed to show chronic congestive heart failure or status post coronary bypass surgery with a 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 or a second coronary bypass surgery to warrant a 100 percent rating. Therefore, a rating in excess of 30 percent for this period is not warranted. B. May 1987 to July 2013 The Veteran contends that he is entitled to a higher rating because the RO failed to consider his treatment records in denying his claim. However, after a close review of the medical records, the evidence fails to indicate a rating in excess of 30 percent is warranted from May 1987 to July 2013. August 1987 records reflect the Veteran underwent two subsequent percutaneous transluminal coronary angioplasties in May 1987 and July 1987. He reported that he was doing well until two days prior when he started to experience chest aches with minimal exertion, walking 100 yards on level ground. The pain typically lasted less than 10 minutes. He continued to complain of recurrent chest pain at September 1987 and in October 1987 visits. As a result, his physicians increased his medication. However, stress tests in May 1986 and September 1987, reflected workloads of 7.1 METs and 9.8 METs respectively; these results most closely approximate a 30 percent rating. Notably, there appears to be a significant gap of treatment. The record is relatively silent for treatment for his coronary artery disease from 1987 until August 2003 when he complained of dull substernal chest pain and shortness of breath. He was instructed to continue medication management and lifestyle modifications. Nevertheless, in November 2003, his estimated ejection fraction was 55 to 60 percent. His left ventricular wall thickness showed mild concentric left ventricular hypertrophy. He also was diagnosed with mild pulmonary hypertension. A stress test was conducted in November 2003 and reflected a workload of 5.8 METs, which continued to meet the criteria for a 30 percent rating. There are no other treatment records during this period that reflect exercise stress test was conducted to determine his workload level in METs, ejection fraction or suggest worsening of his heart condition. VA attempted to obtain the Veteran’s Social Security Administration records, but they reported that they were destroyed. A higher 60 percent rating is not warranted. The evidence failed to show a history of more than one episode of acute congestive heart failure in the year prior 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 30 to 50 percent to warrant the higher 60 percent rating. The evidence also failed to show chronic congestive heart failure or status post coronary bypass surgery with a 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 or a second coronary bypass surgery to warrant a 100 percent rating. C. Since July 2013 Since July 2013, he was assigned a 60 percent rating for worsening of his heart condition based on a July 2013 VA examination that reflected his coronary artery disease was limited to a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness or syncope. The Veteran submitted a private Ischemic Heart Disease Disability Benefits Questionnaire dated November 2013. The examiner stated that an exercise test was performed in April 2008, but he failed to attach the report or provide an estimate for workload in METs. He also noted that the Veteran’s left ventricular ejection fraction (LVEF) was 55 percent. The remainder of his medical records reflect continued medication management. Therefore, a rating in excess of 60 percent is not warranted. The evidence a failed to show chronic congestive heart failure or status post coronary bypass surgery with a 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 or a second coronary bypass surgery to warrant the higher rating of 100 percent rating. There is no basis for a higher rating at any point during the appellate period. Therefore, the claim for an increased rating for coronary artery disease is denied. Michael Sanford Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.