Citation Nr: 20042314 Decision Date: 06/22/20 Archive Date: 06/22/20 DOCKET NO. 09-44 384 DATE: June 22, 2020 ORDER Service connection for a right ankle disability other than calcaneofibular ligament strain, degenerative arthritis, and resolved Achilles tendonitis is denied. An initial rating higher than 10 percent for non-obstructive coronary artery disease prior to September 20, 2010 is denied. An initial rating higher than 30 percent for non-obstructive coronary artery disease from September 20, 2010 is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran had a right ankle disability other than calcaneofibular ligament strain, degenerative arthritis, and resolved Achilles tendonitis at any time during or approximate to the pendency of the claim. 2. Prior to September 20, 2010, non-obstructive coronary artery disease was not manifested by a metabolic equivalent (METs) level of 7 or less, or evidence of cardiac hypertrophy or dilatation. 3. From September 20, 2010, non-obstructive coronary artery disease was not manifested by a METs level of 5 or less, a left ventricular ejection fraction of 50 percent or less, or congestive heart failure. CONCLUSIONS OF LAW 1. The criteria for service connection for a right ankle disability other than calcaneofibular ligament strain, degenerative arthritis, and resolved Achilles tendonitis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an initial rating higher than 10 percent for non-obstructive coronary artery disease prior to September 20, 2010 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.104, Diagnostic Code (DC) 7005. 3. The criteria for an initial rating higher than 30 percent for non-obstructive coronary artery disease from September 20, 2010 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.104, DC 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Army from August 1972 to May 1984. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2009 and June 2012 rating decisions. It was previously remanded for additional development in October 2016 and December 2018. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to direct service connection requires evidence of three elements: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Right ankle disability other than calcaneofibular ligament strain, degenerative arthritis, and resolved Achilles tendonitis The Veteran initially sought service connection for bilateral ankle disabilities. He has since been service-connected for Achilles tendonitis of the left foot, as well as calcaneofibular ligament strain, degenerative arthritis, and resolved Achilles tendonitis of the right foot. Because the claim for a right ankle disability was broadly interpreted, the question remains whether there are any other right ankle disabilities which may warrant service connection. The Board finds there are none. Private treatment records from August 2009 and March 2014 show a diagnosis of Achilles tendonitis. A June 2011 VA examination diagnosed degenerative changes and resolved Achilles tendonitis. An additional November 2017 VA examination diagnosed an “LCL” sprain, later clarified as a calcaneofibular ligament strain. All these diagnoses are presently service-connected, and a review of the remaining treatment records does not show any other conditions of the right ankle during or approximate to the appeal period. Therefore, service connection for any additional right ankle disabilities is not appropriate. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran was granted service connection for coronary artery disease effective from April 29, 2008 and assigned a 10 percent rating under 38 C.F.R. § 4.104, DC 7005. From September 20, 2010, he was assigned a 30 percent rating. For rating diseases of the heart, one MET 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. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, 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. 38 C.F.R. § 4.104, Note 2. Under DC 7005, a 10 percent rating is assigned when a 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. A 30 percent rating is assigned when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned when there is 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 results in dyspnea, fatigue, angina, dizziness, or syncope, or; when there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Coronary artery disease prior to September 20, 2010 An initial rating higher than 10 percent is not warranted during this period. Private treatment records from January 2008 document a left ventricular ejection fraction of 60 to 65 percent. A December 2008 VA examination also found an ejection fraction greater than 50 percent, along with normal-sized heart, no history of congestive heart disease, and a METs level of greater than 8. A comparison between these findings and the above criteria shows that a rating higher than 10 percent is not warranted. Coronary artery disease from September 20, 2010 The Veteran’s coronary artery disease was increased to 30 percent based on a September 20, 2010 echocardiogram which showed heart dilatation. However, an even higher 60 percent rating is not appropriate. An August 2012 VA examination also documented cardiac hypertrophy but showed a left ventricular ejection fraction of 55 to 60 percent and a METs level of greater than 7. There were also no episodes of congestive heart failure in the last two years. An additional VA examination in November 2016 showed similar findings. The Veteran had an ejection fraction of 50 to 55 percent, a METs level of greater than 5, and no episodes of congestive heart failure. A comparison between these findings and the above criteria shows that the current 30 percent rating is appropriate. The remainder of the Veteran’s VA and private treatment records do not document any congestive heart failure, and do not otherwise show an ejection fraction of 50 percent or less or a METs level of 5 or less. Therefore, the schedular criteria for the 60 percent rating have not been met. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shamil Patel, 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.