Citation Nr: 20031663 Decision Date: 05/05/20 Archive Date: 05/05/20 DOCKET NO. 14-18 923 DATE: May 5, 2020 ORDER Entitlement to a rating in excess of 60 percent for coronary artery disease (CAD) from July 1, 2016 is dismissed. Entitlement to an initial rating of 30 percent for coronary artery disease (CAD) prior to July 1, 2016 is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. FINDINGS OF FACT 1. In February 2020 correspondence, the Veteran explicitly and unambiguously withdrew the appeal of entitlement to a rating in excess of 60 percent for coronary artery disease (CAD) from July 1, 2016. 2. During the period on appeal, the Veteran’s CAD, status post myocardial infarction with coronary artery bypass graft was characterized as requiring continuous medication, exercise capacity at 5-7 METs with evidence of fatigue upon stress testing, without evidence of congestive heart failure, cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray, and with left ventricular function with an ejection fraction above 50 percent. 3. Resolving all reasonable doubt in favor of the Veteran, the Veteran’s PTSD is etiologically related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the issue of entitlement to a rating in excess of 60 percent for coronary artery disease (CAD) from July 1, 2016 are met. 38 U.S.C. § 7105 (b)(2), (d)(5); 38 C.F.R. §§ 20.202, 20.204. 2. For the period on appeal, the criteria for a disability rating of 30 percent for service-connected CAD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.7, 4.104, Diagnostic Code (DC) 7005. 3. The criteria for entitlement to service connection for posttraumatic stress disorder (PTSD) have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1970 to November 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from December 2011 and March 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to a rating in excess of 60 percent for coronary artery disease (CAD) from July 1, 2016 is dismissed. Under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204. The Veteran, through his representative, withdrew the appeal in February 2020 correspondence. See February 2020 Appellate Brief. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review this issue and it is dismissed. 2. Entitlement to a rating of 60 percent for coronary artery disease (CAD) prior to July 1, 2016 is granted. The Veteran contends he is entitled to an increased initial rating for his service-connected CAD, evaluated at 10 percent from August 31, 2010 to July 1, 2016. A 60 percent disability rating for CAD, effective July 1, 2016, was assigned in an April 2018 decision, creating a staged rating as indicated on the title page. 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran asserts that a 100 percent evaluation is warranted, however, based on the evidence as whole, the Board finds that a uniform evaluation of 30 percent is warranted for the period on appeal. See February 2020 Appellate Brief. In a Joint Motion for Partial Remand, the parties agreed the Board’s denial of an evaluation in excess of 10 percent was in error due to a failure to address favorable evidence. Specifically, in light of cardiac findings at a January 2013 VA examination, estimated at 1-3 METs, the Board’s discussion of evidence of fatigue prior to this examination was inadequate. See April 2019 JMPR. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. The Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s appeal. The Veteran’s CAD is currently rated under Diagnostic Code 7005. Diagnostic Code 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease) and requires documented coronary artery disease. Coronary artery disease) resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when continuous medication is required, is rated 10 percent disabling. Coronary artery disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. Coronary artery disease 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 results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Coronary artery disease resulting in chronic congestive heart failure; or workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. Id. The Board notes there are multiple examinations of the Veteran’s CAD which vary significantly during the appellate period. See May 2011 Examination; January 2013 VA Examination; November 2015 VA Examination. The record also includes cardiac testing in February 2014. See February 2014 Cardiac Imaging. During the appellate period, the Veteran has not manifested acute or chronic congestive heart failure. In May 2011, the Veteran submitted a VA heart examination report that shows he had a capacity for 8 METs without symptoms of dyspnea, fatigue, angina, dizziness, or syncope. Ejection fraction was 69 percent and there was no evidence of cardiac hypertrophy or dilatation on electrocardiogram. In January 2013, VA examination showed that he had a METs level of 1-3 with decreased endurance, fatigue, and weakness daily after lunch. The Veteran’s ejection fraction was not provided, but there was no evidence of cardiac hypertrophy or dilatation on electrocardiogram. The examiner noted that the Lexiscan stress test with METs was the appropriate measure of his cardiac function. Private treatment records indicate that June 2013 testing showed LVEF was 58 percent and tissue Doppler indices were consistent with impaired relaxation with thickening of mitral and tricuspid valve leaflets. In February 2014, nuclear stress testing showed the Veteran’s left ventricular dysfunction with ejection fraction was 54 percent. A November 2015 VA examination report indicates that the examiner found the February 2014 and January 2015 testing showing LVEF to be 66 percent to be the most accurate measure of cardiac function. See November 2015 VA Examination. This examination did not contain exercise stress testing. In July 2016, the Veteran’s private physician completed a Disability Benefits Questionnaire (DBQ). Testing showed the Veteran’s left ventricular dysfunction with ejection fraction was 42 percent, warranting a 60 percent evaluation. See April 2018 Decision. The Veteran was noted to have no symptoms during the stress testing and there was no cardiac dilation or hypertrophy. The July 2016 examiner noted the Veteran’s CAD would not impact his ability to work. Upon review, the Board finds that an initial 30 percent evaluation is warranted. Although the Veteran has manifested varying results from exercise testing and ejection fraction measures, the Veteran’s ejection fraction was 69, 54, 58, and 66 percent prior to July 1, 2016, but 42 percent on this date. He also had varying exercise test results during this period, including a capacity for 8 METs without symptoms of dyspnea, fatigue, angina, dizziness, or syncope in May 2011 and no symptoms during stress testing in July 2016. While he was found to manifest 1-3 METs of capacity with fatigue limiting his endurance in January 2013, the Board finds this is not indicative of his CAD impairment throughout the period on appeal or an accurate measure of his limitation of exercise capacity from CAD. As noted above, he was found to have no symptoms on stress testing in July 2016 and the examiner found the Veteran would have no impact from his CAD on his ability to work. The Board has considered the assignment of a 60 percent evaluation, however, there is a lack of evidence showing that the Veteran’s CAD symptoms manifested 50 percent or less LVEF or 3-5 METs of exercise capacity, based on the evidence as a whole, prior to July 1, 2016. In sum, the Veteran’s CAD impairment is most accurately reflected by symptoms of exercise capacity for approximately 5-7 METs with fatigue. Therefore, the Board finds he meets the criteria for 30 percent evaluation for CAD, but not the 60 percent criteria. Thus, resolving reasonable doubt in the Veteran’s favor, his CAD disability more nearly approximates the impairment reflected by the 30 percent evaluation for the period prior to July 1, 2016. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for PTSD is granted. The Veteran contends that he currently has PTSD that is directly related to the traumatic events he experienced during active duty service; specifically, he relates his symptoms to his combat experiences while assigned to an artillery unit in the Republic of Vietnam. See December 2015 Statement. Following the denial of this issue in April 2018, the parties to the JMPR also agreed that the Board overlooked a contention from the Veteran that a March 2016 VA examination that weighed against the claim was inadequate, rendering the reasons and bases for a denial service connection inadequate as well. See April 2019 JMPR. The Board was directed to consider and respond to the Veteran’s March 2018 argument the VA examination was inadequate. See March 2018 Informal Hearing Presentation. Upon review, the Board agrees with the Veteran that the March 2016 VA examiner did not provide an adequate opinion; the examiner appears to have applied an incorrect standard and does not provide clear rationale in support of their opinion. See March 2016 VA Examination. Since the April 2018 denial, additional evidence has been submitted which supports the Veteran’s claim and the Board finds service connection is warranted. To establish service connection for PTSD, the record must contain the following: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). In response, the Veteran has submitted an examination report and opinion that finds he meets the criteria for PTSD and that his PTSD is related to his combat experiences in service. See February 2020 Examination Report. In regard to in-service stressors, the Board finds his reports of combat experiences consistent with the circumstances of his service and he is credible as to his reports. In regard to the presence of PTSD and nexus, as noted above, the record includes findings that the Veteran has a current diagnosis of PTSD, as shown by the February 2020 opinion from M.C. M.D. Further, the February 2020 opinion finds he has PTSD with dissociative symptoms with delayed expression and that he has experienced these symptoms since active duty. The examiner provided rationale and citation to the record in support of their opinion. Based on the above, the Board finds the February 2020 report is highly probative. Resolving all reasonable doubt in favor of the Veteran, service connection for the Veteran’s PTSD is warranted; and the claim is granted. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990); 38 U.S.C. § 5107 and 38 C.F.R. § 3.102. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Trickey 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.