Citation Nr: 20044501 Decision Date: 07/02/20 Archive Date: 07/02/20 DOCKET NO. 19-01 051 DATE: July 2, 2020 REMANDED Entitlement to a rating in excess of 60 percent for ischemic heart disease (IHD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1954 to October 1959 and from December 1959 to February 1974. The case is on appeal from a November 2015 rating decision of the Regional Office (RO). The Veteran provided testimony at a May 2020 Virtual Board of Veterans’ Appeals (Board) Hearing, conducted by the undersigned Veterans Law Judge. As a threshold matter, the Board notes that the Veteran has raised the issue of entitlement to an effective date earlier than August 31, 2010 for the grant of a 60 percent rating for service connected IHD. However, the RO has yet to adjudicate the issue of entitlement to an earlier effective date in the first instance. As such, the issue is referred to the RO for appropriate action. 38 C.F.R. § 19.9 (b). 1. Entitlement to a rating in excess of 60 percent, and earlier than August 31, 2010, for ischemic heart disease (IHD) is remanded. The Veteran testified at a May 2020 Virtual Board Hearing that his IHD disability has worsened since his last VA examination. The Veteran reported that he now uses continuous oxygen, he is limited in his ability, and he has been hospitalized several times. The Veteran’s representative indicated that he would submit new evidence in support of his contentions. To date, this evidence has not been associated with the Veteran’s claims file. On remand, the Veteran and his representative will be given an opportunity to submit such evidence in support of the Veteran’s increased rating claim. The Veteran’s IHD is currently evaluated at a 60 percent rating under Diagnostic Code (DC) 7005. See 38 C.F.R. § 4.104. Under DC 7005, a 60 percent rating requires 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, which results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. A 100 percent rating requires documented coronary artery disease (CAD) 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 (LVEF) of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. At his August 2018 VA examination, the Veteran’s IHD disability showed 1-3 METs (supporting a 100 percent rating under DC 7005). However, complicating this matter, the examiner indicated that his nonservice-connected lung disease, chronic obstructive pulmonary disease (COPD), significantly contributes to his poor METs, and the estimated METs level due solely to his heart condition was 3-5 METs (supporting a 60 percent rating under DC 7005). Indeed, the evidence of record suggests the severity of the Veteran’s condition, to include his continuous use of oxygen, is attributed to his non-service-connected COPD and not his service-connected IHD. However, in light of the Veteran’s testimony and in order to afford him further opportunity to substantiate his contention that his disability has worsened since the last examination, the Board finds a new VA examination is warranted. On remand, the examiner is directed to clearly discern the effects of each disability (the IHD versus the COPD) where possible and explain where such distinction is not possible. See Mittleider v. West, 11 Vet.App. 181 (1998) (holding that when a claimant has both service-connected and nonservice-connected disabilities, the Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability). 2. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Considering the Veteran’s remanded issue of an increased rating for IDH, resolution of this issue may affect the outcome of his TDIU claim, and the Board finds that this claim is inextricably intertwined. Therefore, the Board will defer adjudication of the TDIU claim until after the development necessary for the assigned evaluation for the IHD claim and clarity is obtained as to the effects of the IHD versus his non-service-connected COPD. The matters are REMANDED for the following action: 1. Provide the Veteran an opportunity to identify any outstanding medical treatment records relevant to his claimed disability. After obtaining necessary authorization from the Veteran, all outstanding records should be obtained, to include all updated VA medical treatment records and private treatment records from the Veteran’s physician (Dr. M. Krueger). 2. After obtaining any outstanding records, to the extent possible, schedule the Veteran for a new VA examination by an appropriate medical examiner to determine the current severity of his service connected IHD disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must address "the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops" and this must be based on exercise testing, unless such "cannot be done for medical reasons." If the examiner determines that such testing cannot be done for medical reasons, the examiner must include the underlying reasons for this conclusion. The examiner must then provide "an estimation 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." See 38 C.F.R. § 4.104, note (2). The examiner is further directed to discern, to the extent possible, the specific effects stemming from the Veteran’s IHD versus his non-service-connected COPD where possible. If such distinction is not possible, it should be so stated. (Continued on the next page)   3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Warren 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.