Citation Nr: 20021349 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 14-35 133A DATE: March 25, 2020 ORDER Entitlement to an effective date prior to April 9, 2010 for the Veteran’s award of service connection for left ventricular hypertrophy is denied. Entitlement to an effective date prior to April 9, 2010 for the Veteran’s award of service connection for supraventricular arrhythmia, also diagnosed as sinus tachycardia, is denied. Entitlement to an effective date prior to April 9, 2010 for the Veteran’s award of service connection for hypertension is denied. Entitlement to an increased evaluation for hypertension, currently rated as zero percent disabling, is denied. Entitlement to an evaluation in excess of 10 percent for supraventricular arrhythmia, also diagnosed as sinus tachycardia, is denied. REMANDED Entitlement to a disability rating in excess of 30 percent for left ventricular hypertrophy is remanded. Entitlement to special monthly compensation is remanded. FINDINGS OF FACT 1. The Veteran filed his initial claim for service connection for hypertension in November 1987; the Agency of Original Jurisdiction (AOJ) denied the claim in June 1988 and the Veteran appealed that decision to the Board, which issued its own decision denying the claim in April 1990; the Veteran did not seek to appeal the April 1990 decision to the United States Court of Appeals for Veterans Claims, nor did he file a motion to the Board asking it to reconsider its decision. 2. The AOJ did not receive the Veteran’s request to reopen his previously denied claim for service connection for hypertension or his initial claim for service connection for a heart condition until April 9, 2010. 3. Although he requires continuous medication for control of his service-connected hypertension, the Veteran does not have a history of diastolic pressure of 100 or more. 4. Throughout the period on appeal, the medical and lay evidence indicates that the Veteran has experienced intermittent episodes of atrial fibrillation and sinus tachycardia. However, at no point has the medical or lay evidence of record indicated these events occur more than four times per year. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to April 9, 2010 for service connection for hypertension have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 2. The criteria for an effective date prior to April 9, 2010 for service connection for left ventricular hypertrophy have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 3. The criteria for an effective date prior to April 9, 2010 for service connection for supraventricular arrhythmia have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 4. The criteria for an increased compensable disability rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7101. 5. The criteria for a disability rating in excess of 10 percent for supraventricular arrhythmia or sinus tachycardia have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7010. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1972 to April 1983. This case comes to the Board of Veterans’ Appeals (Board) from decisions of the Agency of Original Jurisdiction (AOJ) issued in February 2014 and May 2018. The issue of special monthly compensation (SMC) was not decided in either decision, but it was raised by the Veteran’s attorney in the course of her arguments in favor of a total disability rating for individual unemployability (TDIU). See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). The AOJ’s February 2014 decision denied the request for a TDIU rating and, after further proceedings, the Board dismissed that claim as moot, while remanding the SMC claim for further development. In its May 2018 decision, the AOJ granted service-connected disability compensation for left ventricular hypertrophy, supraventricular arrhythmia, and hypertension. For each of these benefits, the AOJ assigned an effective date of April 9, 2010 and initial disability ratings of 30 percent, 10 percent, and zero percent, respectively. The Veteran timely appealed all the effective dates and initial ratings assigned in the AOJ’s May 2018 decision. Earlier Effective Date Claims Under 38 U.S.C. § 5110(a), the effective date of an award based on several categories of claim, including an original claim for compensation shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. The remaining subsections of 38 U.S.C. § 5110 establish exceptions to the general rule for claims filed within one year of certain specific events. See Gaston v. Shinseki, 605 F.3d 979, 982-83, n. 2 (Fed. Cir. 2010). For example, the effective date of disability compensation may be the date of a Veteran's discharge or release from service, but only if the application is received within one year from the date of discharge or release. 38 U.S.C. § 5110(b)(1). In November 1987, the Veteran filed his initial claim seeking compensation for hypertension. The AOJ issued a decision denying this claim, along with a separate claim for service connection for a nervous condition, in June 1988. Although the Veteran timely appealed the June 1988 decision, the Board issued its own decision denying both claims in April 1990. The Veteran did not submit a motion to reconsider the Board’s April 1990 ruling denying service connection for hypertension. Nor did he seek to appeal that ruling to the United States Court of Appeals for Veterans Claims (Court). Accordingly, the April 1990 decision is final. See 38 C.F.R. § 19.104(a) (1990). Moreover, the Board is bound by its ruling in an August 2016 decision, in which it determined that the Veteran submitted new and material evidence sufficient to reopen the previously denied claim for service connection for hypertension. In order to reach this conclusion, the Board first decided that the April 1990 decision was final. In general, Board decisions are not precedential. Yet under the doctrine of res judicata, the Board’s ruling that the April 1990 decision became final is binding on the Veteran in this case. He was a party to, and he participated in, the August 2016 appellate proceeding; he had the opportunity to appeal the finding of finality to the Court, but did not do so; the issue of finality was essential to the August 2016 determination that he had submitted new and material evidence to reopen the previously denied hypertension claim; with respect to the finality issue, the August 2016 decision was a final and valid judgment; and precisely the same issue – the finality of the April 1990 decision – is essential to the resolution of today’s appeal of the appropriate effective date of the award of service connection for hypertension. See Porriello v. Shulkin, 30 Vet. App. 1, 6-9 (2018). After April 1990, none of the communications submitted to VA by or on behalf of the Veteran mentioned hypertension until February 1995, when his former representative indicated that the Veteran was suffering from hypertension in a written statement supporting a separate claim for service connection for a psychiatric disorder. The Board finds that this statement is not the “application” for the purpose of his request to reopen his previously denied hypertension claim as that term is used in 38 U.S.C. § 5110(a). “Application” is not defined in the statute. In the regulations, “claim” and “application” are considered equivalent and are defined broadly to include a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p); see also Rodriguez v. West, 189 F.3d 1351 (Fed. Cir. 1999). Although the representative’s February 1995 statement in support of the Veteran’s psychiatric claim mentioned his hypertension, the document does not ask the Board or the AOJ to award compensation for his hypertension. Nor did the statement suggest that the Veteran’s hypertension was related to military service. After April 1990, the AOJ did not receive any document specifically asking for benefits for the hypertension until April 9, 2010, when the Veteran filed a written statement, which indicated his desire to “apply for service-connected disability for high blood pressure.” In the same statement, the Veteran wrote that he had suffered a heart attack, which the AOJ treated as a separate claim for compensation for any current heart condition which may be related to service. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In August 2010, the AOJ denied service connection for a heart condition and also denied the request to reopen the hypertension claim. But the Veteran initiated a timely appeal of both rulings and, after the Board reopened the hypertension claim in August 2016, both claims remained on appeal until May 2018, when the AOJ granted service connection for hypertension and two heart conditions (left ventricular hypertrophy and supraventricular arrhythmia, also claimed as sinus tachycardia), with an initial effective date of April 9, 2010. There is medical evidence that all three conditions existed for many years before April 9, 2010. But under 38 C.F.R. § 3.400 the appropriate effective date of an award of compensation “will be the date of receipt of the claim or the date entitlement arose whichever is later.” (emphasis added). Because the AOJ received the initial claim for service connection for the heart conditions and the request to reopen the previously denied hypertension claim on April 9, 2010, after he developed the relevant disabilities, the AOJ acted appropriately in assigning the current effective dates. In both his May 2019 notice of disagreement (NOD) and his October 2019 substantive appeal (VA Form 9), the Veteran indicated his desire for effective dates earlier than April 9, 2010 for his hypertension and service-connected heart condition benefits. But he did not explain why he believed that earlier effective dates would be consistent with 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. The AOJ correctly applied these laws when it assigned April 9, 2010 as the effective date for the Veteran’s award of service connection for hypertension, left ventricular hypertrophy and supraventricular arrhythmia. For these reasons, his requests for earlier effective dates are denied. Increased Rating for Hypertension The Veteran has been assigned a 10 rating for hypertension under 38 C.F.R. § 4.104, Diagnostic Code 7101. Under this regulation, a 10 percent evaluation is warranted when diastolic pressure is predominately 100 or more, or when systolic pressure is predominately 160 or more, or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation is warranted when diastolic pressure is predominately 110 or more, or when systolic pressure is predominately 200 or more. A 40 percent rating is authorized when diastolic pressure is predominantly 120 or more, as is a 60 percent rating when diastolic pressure is predominantly 130 or more. The AOJ assigned a zero percent (noncompensable) rating for the Veteran’s hypertension after reviewing a January 2018 report from a nurse practitioner who examined the Veteran and provided information about the nature and severity of his hypertension. The report confirms a diagnosis of hypertension, identifying 1981 as the initial year of diagnosis. According to the examiner, the Veteran required continuous medication for the control of his hypertension. At the time of the examination, this consisted of 25 milligram doses of metoprolol and 40 milligram doses of lisinopril. Blood pressure readings were 128/92, 145/90, and 150/85, with an average blood pressure reading of 141/89. According to the examiner, the Veteran did not have a history of diastolic blood pressure predominantly elevated to 100 or more. The examiner further indicated that the Veteran’s hypertension did not affect his ability to work. Although the complete medical history of the relevant disability is relevant to increased rating claims generally, see Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), the review of an increased rating claim is usually most concerned with the severity of the relevant disability during the relevant appeal period – in this case, April 9, 2010 to the present. But because the Veteran requires continuous mediation for the control of his service-connected hypertension, he will be eligible for an increased 10 percent rating if he is “an individual with a history of diastolic pressure predominantly 100 or more” for the purposes of DC 7101. For this reason, the Board has carefully reviewed all of the numerous blood pressure measurements in the Veteran’s medical records. It appears that the highest blood pressure reading taken during the Veteran’s active duty service was 170/98 in January 1982, which is when tachycardia was first noted his service medical records. The record includes another measurement, in September 1982, when the diastolic pressure was 98, but this time with lower systolic pressure (130). Shortly before his first enlistment in the Army, in May 1972, his blood pressure was 128/78. According to most of the other in-service blood pressure readings, his diastolic pressure was lower than 90. At the time of his separation examination, in March 1983, his blood pressure was 118/94 when sitting, 132/81 when recumbent, and 118/84 when standing. For the sake of brevity, the Board will not report all of the Veteran’s post-service blood pressure measurements. But it will be useful to provide a representative sample of measurements over the years. According to a treatment note from June 1984, his blood pressure was 98/72. Another note, dated November 1986, reported blood pressure of 106/64. According to a May 1987 discharge summary, which describes a psychiatric hospitalization in which the Veteran was connected to a cardiac monitor which detected atrial fibrillation, his blood pressure was 112/80. A note from October 1987 indicates blood pressure of 143/114 –for this Veteran, a rare example of diastolic pressure exceeding 100. In January 1988, his blood pressure was 124/78. A note from May 1988 reported blood pressure of 133/68. According to his initial VA examination report, dated April 1989, the examiner took four blood pressure readings and the Veteran’s diastolic pressure never exceeded 82. In the 1990s, it appears that the Veteran’s highest blood pressure readings were 144/102 in June 1991. But it was more typical for the Veteran’s diastolic pressure to be in the 80s or 90s. There are not many records from the 2000s, but the VA medical records from the most recent decade (2010 to 2019) include dozens of measurements. For the year 2010, it appears that the highest recorded blood pressure measurement was 143/90 in September of that year. Notes from April 2012 indicate blood pressure of 100/60 and 137/83 on separate days. Treatment notes from May 2012 indicate at least five separate blood pressure, with a diastolic pressure no lower than 70 and no higher than 89. In August 2013, the Veteran’s blood pressure was measured at least five times. While none of the August 2013 measurements indicated a diastolic pressure higher than 100, subsequent records from October 2013 indicated a reading of 159/106. According to VA treatment records from 2014, the Veteran had blood pressure measurements on at least fifteen different occasions. On only one day, in October 2014, did his diastolic pressure exceed 100. This measurement (167/110) was apparently a subject of concern and the VA nursing staff checked the Veteran’s blood pressure on other occasions that same day. Those measurements were 164/101, 165/88, and 157/95. These measurements are found in the same document on the electronic claims file with measurements from February 2015 and May of 2015. On both of these occasions, the Veteran’s diastolic pressure was lower than 100. Another electronic document includes reports of at least seven different blood pressure measurements in December 2015. None of these readings indicated a diastolic pressure above 100. In January 2016, the Veteran’s blood pressure was 135/76. Most of the exceptions to the general trend of diastolic pressure below 100 took place in the Spring of 2016 and in December 2016. Treatment records indicate that the Veteran’s diastolic pressure was below 100 for most of February 2016. In that month, the VA nursing staff checked the Veteran’s blood pressure at least eleven times and his diastolic pressure was mostly in the 70s or 80s. On one occasion in February 2016, the Veteran’s blood pressure was 152/102. In March 2016, blood pressure readings were 130/85, 178/107, and 153/96. In April 2016, blood pressure readings were 157/92, 165/114, 170/99, 165/114 again, 163/110, 149/90,149/93, and 137/88. In July 2016, blood pressure was 137/93. There was another significant but temporary increase in the Veteran’s blood pressure in December 2016, when he was admitted to the Emergency Department for polysubstance abuse. Blood pressure readings were 170/92, 77/64, 164/111, 171/106, 174/102, 160/100, 152/94, 150/91, 148/96, 191/121, 143/93, 171/106, 174/102, 157/102, 132/88, 100/72. The last note indicates that, “He is in good spirits and obviously feeling better with medication change/adjustment. . .” The most recent VA treatment records include four blood pressure measurements taken during occasional medical appointments between May 2018 and May 2019. These readings are 125/69, 114/69, 115/74, and 115/78. Having considered the evidence, the Board agrees with the January 2018 examiner that the Veteran is not “an individual with a history of diastolic pressure predominantly 100 or more” for the purposes of DC 7101. That conclusion is consistent with the Veteran’s medical records. While these records include occasionally readings of diastolic pressure of 100 or more, it has been much more common for the Veteran’s diastolic pressure to be below 100. In reaching this conclusion, the Board has considered the two exceptional spikes in the Veteran’s blood pressure, in March and April 2016 and in December 2016. It is significant that, while both these episodes coincided with several readings of diastolic pressure exceeding 100, the Veteran’s diastolic pressure went down after adjustments in medication. In McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016), the Court held that DC 7101 contemplated the effects of medication on the appellant’s symptoms. The Court explained that, “[t]he criteria for compensable evaluations under DC 7101 thus contemplated two factual alternatives. First, a veteran whose blood pressure is currently controlled by medication – i.e., whose blood pressure does not otherwise meet the criteria for a compensable evaluation – but who has a history of diastolic pressure predominantly 100 or more is entitled to receive the minimum compensable evaluation of 10%. Second, a veteran whose blood pressure is currently elevated to varying degrees is entitled to evaluations ranging from 10% to 60%.” Id. at 272 (internal citations omitted). The Veteran’s decades of controlled blood pressure, together with the favorable response to medication changes following relatively brief periods in which diastolic pressure exceeded 100, are inconsistent with a finding that he has a history of diastolic pressure predominantly 100 or more. Under these circumstances, the Veteran is not eligible for an increased 10 percent rating for hypertension under DC 7101. As noted, the Board has reviewed the Veteran’s NOD and substantive appeal. In these documents, he indicated his desire to receive greater compensation for hypertension. But he did not attempt to explain why he is eligible for an increased compensable rating under DC 7101. DC 7101 does not authorize an increased 20 percent compensable rating unless the Veteran has “Diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more . . .” For the reasons above, the record supports the conclusion of the January 2018 examiner that the Veteran’s diastolic blood pressure has predominantly been below 100 and there is no evidence that his systolic pressure has ever reached 200 or more. Accordingly, an initial rating for hypertension higher than 10 percent is not warranted either. Increased Rating for Supraventricular Arrhythmia / Sinus Tachycardia The Veteran’s service-connected supraventricular arrhythmia, also claimed as sinus tachycardia, has been assigned a 10 percent disability rating under 38 C.F.R. § 4.104, DC 7010. Under DC 7010, a 10 percent rating is assigned for supraventricular arrhythmias manifested by permanent atrial fibrillation (lone atrial fibrillation), or one to four episodes per year of paroxysmal atrial fibrillation, or other supraventricular tachycardia documented by ECG or Holter monitor. 38 C.F.R. § 4.104. A 30 percent rating is assigned for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by an electrocardiogram ("ECG") or Holter monitor. An evaluation in excess of 30 percent is not available under Diagnostic Code 7010. The currently assigned ratings are based on an examination report on the Veteran’s heart conditions, dated January 2018. After an in-person examination and review of the medical records, the diagnoses were supraventricular arrhythmia and left ventricular hypertrophy. With respect to supraventricular arrhythmia, the examiner identified 1983 as the time of initial diagnosis. Section V of the examination report (“Arrhythmia”) asked the examiner to identify the type of cardiac arrhythmia. Leaving blank the boxes next to text identifying atrial fibrillation, atrial flutter, supraventricular tachycardia, and other forms of arrhythmia, the examiner marked the box corresponding to “Other cardiac arrhythmia, specify:” Next to this part of the form, the examiner wrote, “Sinus tachycardia.” The January 2018 report described the Veteran’s arrhythmia was intermittent or paroxysmal. According to the examiner, the Veteran’s arrhythmia had been documented by EKG and the Veteran experienced between one and four episodes of arrhythmia in the most recent 12 months. Section X of the report (“Hospitalization”) indicates that sinus tachycardia resulted in the need for the Veteran’s most recent hospitalization in for a heart condition, which occurred in 2015. The Board has reviewed the medical records concerning this hospitalization. According to a May 2015 progress note, the results of the Veteran’s EKG were abnormal. The assessment was sinus tachycardia associated with medicine noncompliance. A subsequent cardiology consultation indicated left ventricle ejection fraction (LVEF) of 53 percent with rest and 56 percent with stress. There was no evidence of ischemia. These records do not indicate how frequently the Veteran experienced episodes of sinus tachycardia in the recent past. The Board has reviewed the other post-service treatment records concerning the Veteran’s heart. Atrial fibrillation was an Axis III diagnosis during the Veteran’s psychiatric hospitalization in May 1987. According to the discharge summary, “Patient was transferred for Psychiatry Service to CCU on 5-11 secondary to new onset atrial fibrillation. He was treated with detoxification regimen and Atenolol. He got along well and spontaneously recovered to normal sinus rhythm 5-12. Repeat ECG reported ‘early repolarization, high QRS voltage - consider LVH. Atrial fibrillation resolved since tracing of 5-11-87.’” The Veteran was hospitalized again in 1992. Treatment records reveal a “borderline” EKG and an Axis III diagnosis of left ventricular hypertrophy. The EKG revealed normal sinus rhythm. In November 1992, the Veteran had yet another psychiatric hospitalization. This time the discharge summary reported a normal EEG and an EKG showing normal sinus rhythm and left ventricular hypertrophy by voltage. The next available piece of medical evidence concerning the heart is a myocardial perfusion rest/stress study, dated March 2010. The results indicate, “Resting EKG showed normal sinus rhythm. Stress EKG was negative. Blood pressure response was physiologic. Patient had no chest pain or arrhythmias.” In September 2012, the Veteran participated in a VA heart conditions examination. According to the examiner’s report, “[the Veteran] denies having arrhythmia, pacemaker, or heart attack. [He] say[s] ‘I have no problems with my heart.’” He told the examiner that he had been taken to a hospital for what he initially thought was a heart attack, but he later learned that, “he had a panic attack and did not have a heart attack.” The examiner reviewed a chest x-ray, EKG, and an electrocardiogram. He indicated that the Veteran did not have a cardiac arrhythmia. After the September 2012 examination, there are no medical records concerning the Veteran’s heart conditions until the 2015 hospitalization. Likewise, there are no treatment records of arrhythmia or other heart problems after 2015. The Board has reviewed the Veteran’s NOD and substantive appeal. The NOD indicates the Veteran’s desire to receive increased compensation for his cardiac arrhythmia but makes no attempt to explain why an increased rating is appropriate under DC 7010 or any other potentially applicable diagnostic code. The substantive appeal makes an argument for a higher rating for “heart disease” based on the left ventricular ejection fraction (LVEF) recorded in March 2010. Because LVEF is contemplated by DC 7020 – the code used by the AOJ to rate the Veteran’s left ventricular hypertrophy – and not by DC 7010, the Board will consider this as an argument for an increased rating for left ventricular hypertrophy. Most significantly, none of the Veteran’s statements undermine the assessment of the January 2018 examination report indicating that his arrhythmia was intermittent with between one and four episodes in the past 12 months. The post-service medical treatment records are consistent with this finding. Arrhythmia or sinus tachycardia has been noted on several occasions since the Veteran’s discharge from active duty. But there is no information from any source suggesting that he experienced more than four episodes of cardiac arrhythmia at any point during the relevant appeal period (April 2010 to the present). The appellant has the burden of proving, at least to an equipoise standard, all of the requirements of a claim for benefits. See 38 U.S.C. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Because the preponderance of the evidence weighs against a finding that the Veteran met the criteria for rating higher than 10 percent for supraventricular arrhythmia or sinus tachycardia at any time during the appeal period, the benefit of the doubt doctrine does not apply, see 38 U.S.C. § 5107(b), and the claim for a higher rating must be denied. REASONS FOR REMAND Increased Rating for Left Ventricular Hypertrophy The AOJ assigned a 30 percent rating for left ventricular hypertrophy pursuant to 38 C.F.R.§ 4.104, DC 7020 (“Cardiomyopathy”). Under these criteria, the disability may be rated based on METs or metabolic equivalents or left ventricular ejection fraction (LVEF). One metabolic equivalent 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.” 38 C.F.R. § 4.104, note 2. The currently assigned rating is appropriate when a workload of greater than 5 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. DC 7020. The regulation authorizes a higher 60 percent rating if the Veteran has experienced more than one episode of acute congestive heart failure in the last year or if a workload of more than 3 but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness or syncope, or if LVEF is between 30 and 50 percent. A 100 percent rating is authorized for chronic congestive heart failure or when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope or when LVEF is less than 30 percent. Id. According to the January 2018 heart conditions examination report, the examiner did not conduct an exercise stress test to assess METs, marking the box next to the following pre-printed text: “Exercise stress testing is not required as part of the Veteran's current treatment plan and this test is not without significant risk”. On the interview-based METs test portion of the report, the examiner indicated that no cardiac symptoms would be present with a workload of 1 to 3 METs. Apparently, the examiner did not attempt to estimate what level of METs would result in the symptoms listed in DC 7020 – i.e., dyspnea, fatigue, angina, dizziness, or syncope. According to the examiner, the METs level provided was not solely due to his diagnosed heart conditions. Yet, when asked to estimate the METs level solely due to the heart conditions listed above, the examiner indicated 1-3 METs. This note suggests that the Veteran’s heart conditions alone limit the Veteran’s effective workload to 1 to 3 METs. But the note indicating that, based on the interview-based METs test, the Veteran would experience “No cardiac symptoms” at this level of activity is confusing, especially in light of the examiner’s subsequent note indicating that service-connected heart conditions had no impact on his ability to work. The examiner added these comments: “Veteran leads a sedentary lifestyle and cannot estimate activity level. Does take multiple (>35 different) that contribute to energy level”. In March 2018, the examiner provided an addendum to the report, suggesting that LVEF would be a better method than interview-based METs for judging the severity of the Veteran’s left ventricular hypertrophy. The addendum suggested that the AOJ should, “disregard current remark comment of ‘[the Veteran’s] current cardiac status is based on his current METs from interview’ and update with ‘Veteran’s LVEF of 56% on 8/2015 is most reflective of Veteran’s current cardiac status.’” In her most recent written brief, the Veteran’s attorney argues that the Board should assign a 100 percent rating based on the examiner’s initial indication that the Veteran’s workload was limited to 1-3 METs due solely to the Veteran’s cardiac disability. The attorney criticized the March 2018 addendum, arguing that, unlike the criteria for rating respiratory disorders, see 38 C.F.R. § 4.96(d)(6), the regulations concerning cardiovascular diseases do include a provision authorizing the examiner to select the testing method which most accurately reflects the severity of the relevant disorder. The problem with this argument is that, as noted, the examiner did not actually make the finding that would justify the assignment of a 100 percent rating based on METs testing – i.e., he did not conclude that the Veteran would experience the relevant symptoms (dyspnea, fatigue, angina, dizziness, or syncope) with a workload of 3 METs or less. Instead, he indicated that there would be “[n]o cardiac symptoms” with this level of activity. However, the attorney is correct to suggest that the examination report is inadequate. If the Veteran would experience the relevant symptoms with a workload of between 3 to 5 METs – a question the examiner left unanswered – then he would be eligible for a rating of 60 percent under DC 7020 even if his LVEF was greater than 50 percent. The Board will remand the increased rating claim for left ventricular hypertrophy with instructions to arrange an adequate examination. On remand, the examiner should clarify whether or not any METs limitations on the Veteran’s activities are the result of his service-connected heart conditions. In Clark v. Wilkie, No. 18-6489, 2019 U.S. App. Vet. LEXIS 1975 (November 7, 2019), the Court recently affirmed a Board decision which held that, notwithstanding the general rule of Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when effects of a service-connected and non-service-connected conditions cannot be distinguished, symptoms should be attributed to the service-connected condition), the combined impact of a service-connected and non-service-connected condition on an METs score can support the use of an alternative way of measuring heart function, such as LVEF. Clark, 2019 U.S. App. Vet. LEXIS 1975, at 8-9. Special Monthly Compensation The Veteran's appeal of the denial of special monthly compensation (SMC) could potentially be affected by the results of a new examination of the Veteran’s heart conditions. Thus, the SMC issue is intertwined with the increased rating issue being remanded. The appropriate remedy when a pending claim is inextricably intertwined with an issue on appeal is to defer adjudication of the claim on appeal pending the adjudication of the inextricably intertwined claim. See Smith v. Gober, 236 F.3d 1370, 1372 (Fed. Cir. 2001); Henderson v. West, 12 Vet. App. 11, 20 (1998). The matters are REMANDED for the following action: 1. Arrange a new examination to determine the nature and severity of the Veteran’s left ventricular hypertrophy. The examiner must be provided access to the Veteran's claims folder, as well as to any files placed in Virtual VA and the Veterans Benefits Management System (VBMS). The examiner should make a laboratory determination of metabolic equivalents by exercise testing unless an exercise stress test cannot be done for medical reasons. If the Veteran cannot complete an exercise stress test for medical reasons, the examiner must explain what those reasons are. Then, and only then, may the examiner estimate the level of activity (expressed in metabolic equivalents and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness or syncope. If the examiner uses an interview with the Veteran, rather than an exercise stress test, to determine metabolic equivalents, the examiner's report must identify the reason why an exercise stress test could not be done. Whether the examiner uses an exercise stress test or an interview to estimate the activity level (expressed in metabolic equivalents) resulting in dyspnea, fatigue, angina, dizziness, or syncope, the examiner should indicate whether any limitations in this activity level are the result of service-connected left ventricular hypertrophy or the results of another condition. IF THE EXAMINER CANNOT DETERMINE WHETHER THE LIMITS IN THE VETERAN’S ACTIVITY LEVEL ARE RELATED TO LEFT VENTRICULAR HYPERTROPHY OR SOME OTHER CONDITION, THE EXAMINER SHOULD CLEARLY SAY SO AND EXPLAIN THE MEDICAL REASONS FOR THAT CONCLUSION. 2. After completing the above and any other development that is reasonable, the claims for an increased rating for left ventricular hypertrophy and for SMC should be readjudicated based on the entirety of the evidence. If either of the benefits remain denied, the Veteran and his representative should be issued a supplemental SOC. An   appropriate period of time should be allowed for response. David Wight Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Nye, 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.