Citation Nr: 20068569 Decision Date: 10/22/20 Archive Date: 10/22/20 DOCKET NO. 15-05 285 DATE: October 22, 2020 ORDER The appeal of the issue of entitlement to service connection for a sleep disorder is dismissed. Entitlement to an effective date earlier than January 20, 2015 for the grant of service connection for erectile dysfunction (ED) is denied. Entitlement to an effective date earlier than January 20, 2015 for the grant of special monthly compensation (SMC) based on loss of use of a creative organ is denied. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD) greater than 30 percent prior to March 4, 2019, and greater than 50 percent from that date, is denied. Entitlement to a higher 30 percent rating for atherosclerotic heart disease during the period prior to March 5, 2019 is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a higher disability rating for atherosclerotic heart disease, greater than 60 percent from March 5, 2019 is denied. FINDINGS OF FACT 1. On February 20, 2020, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant, through his authorized representative, that a withdrawal of the appeal for service connection for a sleep disorder is requested. 2. No formal or informal claim for service connection for ED was received from the Veteran prior to June 13, 2011. 3. No formal or informal claim for service connection for prostate cancer was received from the Veteran prior to January 20, 2015. 4. In a June 2015 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for prostate cancer effective January 20, 2015. 5. In a March 2016 rating decision, the AOJ granted service connection for ED as secondary to service-connected prostate cancer, and SMC based on loss of use of a creative organ; an earlier effective date of January 20, 2015 was granted in an August 2018 rating decision. 6. Entitlement to service connection for ED arose at a June 5, 2015 VA examination. 7. During the period prior to March 4, 2019, the severity, frequency, and duration of the Veteran’s PTSD symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 8. During the period from March 4, 2019, the severity, frequency, and duration of the Veteran’s PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 9. During the period prior to March 5, 2019, the Veteran’s atherosclerotic heart disease shows evidence of cardiac hypertrophy on echocardiogram. Metabolic equivalent (MET) testing shows the Veteran did not develop dyspnea, fatigue, angina, dizziness, or syncope at a workload of 5 METs or less, and there was no evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent or more than one episode of active congestive heart failure in the past year. 10. During the period from March 5, 2019, the Veteran’s arteriosclerotic heart disease did not result in episodes of acute congestive heart failure in the past year. MET testing shows the Veteran develops dyspnea and dizziness at a workload of greater than 3 but not greater than 5 METs. MET testing shows the Veteran did not develop these symptoms at a workload of 3 METs or less, and the evidence did not show chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for service connection for a sleep disorder by the appellant (or his authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria are not met for an effective date earlier than January 20, 2015 for the grant of service connection for ED. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.1, 3.400. 3. The criteria are not met for an effective date earlier than January 20, 2015 for the grant of SMC based on loss of use of a creative organ. 38 U.S.C. §§ 1114 (k), 5107, 5110; 38 C.F.R. §§ 3.350 (a)(1), 3.400. 4. During the period prior to March 4, 2019, the criteria for a disability rating in excess of 30 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 5. During the period from March 4, 2019, the criteria for a disability rating in excess of 50 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 6. During the period prior to March 5, 2019, the criteria for a higher 30 percent rating for atherosclerotic heart disease are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. 7. During the period from March 5, 2019, the criteria for a rating greater than 60 percent for atherosclerotic heart disease are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1967 to July 1971. This case comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the AOJ dated in September 2010, December 2010, May 2013, and March 2016. The Board previously remanded this case to the AOJ in May 2018 and January 2020, for additional development. In a June 2020 rating decision, the AOJ granted a higher 60 percent rating for atherosclerotic heart disease, effective March 5, 2019, a higher 50 percent rating for PTSD, effective March 4, 2019, and SMC at the housebound rate from March 5, 2019. The case was subsequently returned to the Board. 1. Service connection for a sleep disorder In May 2018, the Board remanded the issue of service connection for a sleep disorder to the AOJ for additional development. In February 2020, VA received correspondence from the Veteran’s representative in which he withdrew his appeal as to this issue. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his authorized representative. Id. In the present case, the appellant, through his authorized representative, has withdrawn his appeal as to this issue and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal as to this issue, and it is dismissed. Earlier Effective Dates 2. Earlier effective date for service connection for ED 3. Earlier effective date for SMC based on loss of use of creative organ These matters come to the Board on appeal from a March 2016 rating decision that granted entitlement to service connection for ED as secondary to service-connected prostate cancer, and granted SMC based on loss of use of a creative organ; the Veteran appealed for an earlier effective date. During the pendency of the appeal, an earlier effective date of January 20, 2015 was granted, as this was the date of receipt of his original claim of service connection for prostate cancer. In this case, SMC was awarded based on the grant of service connection for ED. SMC is payable at a specified rate if a veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C. § 1114 (k); 38 C.F.R. § 3.350 (a)(1). The Veteran and his representative contend that an earlier effective date prior to January 20, 2015 should be granted for the award of service connection for ED and for SMC based on loss of use of a creative organ. In June 2013, the Veteran’s representative asserted that the Veteran’s ED was secondary to service-connected PTSD. The Veteran’s representative now contends that an earlier effective date of May 10, 2010 should be granted for ED and SMC, and that he filed a claim for ED on that date. The representative asserts that the Veteran has always maintained that his ED is related to a service-connected disability. See June 2016 letter from the Veteran’s representative. In January 2020, the Board remanded these claims to the AOJ for a VA medical opinion as to whether the Veteran’s ED was caused or aggravated by service-connected PTSD. In the remand, the Board stated that the Veteran filed a claim for service connection for ED in June 2011, and that the Veteran continuously pursued this claim. A VA medical opinion was obtained in March 2020, and the appeal was returned to the Board. Initially, the Board notes that the Veteran is not entitled to an earlier effective date under the regulations applicable to Nehmer class members. As prostate cancer is a covered herbicide disease, the Veteran is generally considered a Nehmer class member. See 38 C.F.R. § 3.816 (b)(1)(2). However, an earlier effective date for service connection for ED as a residual of prostate cancer is not available to the Veteran in this case under the Nehmer provisions because there was no claim pending (or denied) for service connection for prostate cancer residuals prior to the January 20, 2015 claim. The effective date for an award of service connection for claims received within one year after separation from service shall be the day following separation from service, or date entitlement arose; otherwise, the effective date shall be the date of receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110 (b)(1); 38 C.F.R. §§ 3.400 (b)(2). Prior to March 24, 2015, a claim was defined as 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) (2014). A claimant’s identification of the benefit sought does not require technical precision. Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009) (citing Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007)). Rather, “[a] claimant may satisfy this requirement by referring to a body part or system that is disabled or by describing symptoms of the disability.” Brokowski, 23 Vet. App. at 86-87. The scope of a claim includes any disability that reasonably may be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). On January 27, 2009, VA received the Veteran's original claim of service connection for PTSD. He did not claim service connection for ED or prostate cancer. Service connection was granted for PTSD in an April 2010 rating decision. An informal claim of service connection for ED was received from the Veteran on June 13, 2011. He claimed service connection for ED on a direct basis, “and also possibly secondary to PTSD or my service-connected Heart Condition.” In a May 2013 rating decision, the AOJ denied service connection for ED, and the Veteran perfected an appeal of that decision. The AOJ subsequently granted entitlement to secondary service connection for ED as due to prostate cancer, and SMC based on loss of use of a creative organ in a March 2016 rating decision, and the instant appeal ensued. Although the Veteran's representative contends that the Veteran submitted a claim of service connection for ED on May 10, 2010, a review of the Veteran's VA Form 21-4138 received on that date shows that he did not claim service connection for ED. Instead, he claimed service connection for ischemic heart disease, bilateral hearing loss, and tinnitus, and an increased rating for PTSD. While VA must interpret a claimant’s submissions broadly, VA is not required to conjure up issues not raised by the claimant. The elements for any claim formal or (before March 24, 2015) informal, are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing.” See Shea v. Wilkie, 926 F.3d 1362, 1367 (Fed. Cir. 2019). The mere presence of a disability does not establish an intent on the part of a Veteran to seek service connection for that condition. See KL v. Brown, 5 Vet. App. 205, 208 (1993); Crawford v. Brown, 5 Vet. App. 33, 35 (1995). The Board finds that the Veteran's May 10, 2010 VA Form 21-4138 is not a claim of service connection for ED, or for SMC based on loss of use of a creative organ, as the claims listed on that form do not reasonably encompass a claim of service connection for ED, and because the Veteran did not identify ED or any symptoms of ED in this document. The Board finds that there is no formal or informal claim of service connection for ED or SMC based on loss of use of a creative organ prior to June 13, 2011. To the extent the medical evidence of record reflects a diagnosis of ED prior to his June 13, 2011 claim, governing law provides that treatment records by themselves do not constitute informal claims when service connection has not yet been established for a condition. 38 C.F.R. §§ 3.157 (2014); Sears v. Principi, 16 Vet. App. 244 (2002); see also Pacheco v. Gibson, 27 Vet. App. 21 (2014). Medical records standing alone are not sufficient to constitute an informal claim because such “evidence does not establish an intent on the part of the veteran to seek... service connection.” Brannon v. West, 12 Vet. App. 32, 35 (1998). The Board finds that the Veteran’s original claim of service connection for ED was received on June 13, 2011, many years after his separation from service. Thus, the effective date may be no earlier than the date of receipt of the claim. 38 U.S.C. § 5110 (b)(1); 38 C.F.R. §§ 3.400 (b)(2). The Veteran’s original claim for service connection for prostate cancer was received on January 20, 2015. Next, it must be determined when entitlement to service connection for ED arose. The term “date entitlement arose” is not defined in the current statute or regulation. The United States Court of Appeals for Veterans Claims (Court) has interpreted it as the date when the claimant met the requirements for the benefits sought. This is determined on a “facts found” basis. See 38 U.S.C. § 5110 (a); see also McGrath v. Gober, 14 Vet. App. 28, 35 (2000) (in the context of a service connection claim, the Board must determine when the service-connected disability manifested itself under all of the facts found). Although medical records reflect prior treatment for ED (see June 2007 private medical records), it was first linked to service-connected prostate cancer at a June 5, 2015 VA examination. The June 2015 VA examiner opined that the etiology of the Veteran’s ED was prostate cancer/ brachy-therapy. In this case, service connection was granted for ED as secondary to service-connected prostate cancer, and the Board finds that entitlement to service connection for ED arose at the June 5, 2015 VA examination that first provided an adequate medical opinion linking ED to service-connected prostate cancer. There is no competent evidence linking ED to service, and no competent evidence prior to June 5, 2015 showing that ED is secondary to any service-connected disability. Instead, the preponderance of the probative evidence prior to that date shows that the Veteran’s ED is due to non-service-connected central hypogonadism. See September 2012 VA endocrinology consult, showing that the Veteran was screened for hypogonadism with symptoms of ED. The diagnostic assessment was central hypogonadism. He was noted to have low testosterone with an inappropriately normal LH/FSH (luteinizing hormone/ follicle-stimulating hormone). Androgel (testosterone gel) was prescribed in September 2012. Subsequent medical records reflect treatment for hypogonadism and ED. A March 2020 VA examiner opined that it is less likely than not that the Veteran's ED is proximately due to or the result of service-connected PTSD. The rationale was that a September 2012 VA medical record indicated that the Veteran's ED was due to low testosterone, and his LH was also low, and he was diagnosed with central hypogonadism. The examiner also opined that ED was not at least as likely as not aggravated beyond its natural progression by a service-connected condition. The rationale was that while prostate cancer VA examinations showed ED without relief from medication, VA medical records reflect Sildenafil as a current/active medication, which is not consistent with any worsening of the condition, and therefore no aggravation by the Veteran's PTSD is shown. While the Veteran believes his ED is secondary to service-connected PTSD or heart disease, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, which demonstrates that his ED is related to non-service-connected central hypogonadism and service-connected prostate cancer. The Board finds that the probative evidence does not show that entitlement to service connection for ED arose prior to June 5, 2015. In this case, SMC was awarded based on a finding that the Veteran’s service-connected ED constituted loss of use of a creative organ, and therefore the effective date for this benefit may be no earlier than the effective date of service connection for ED. The Board finds there is no basis for an effective date earlier than January 20, 2015 for the award of service connection for ED and SMC based on loss of use of a creative organ. The effective date of service connection on a secondary basis is based on the date of claim or date entitlement to the secondary disability arose. 38 C.F.R. § 3.400; Ross v. Peake, 21 Vet. App. 528, 531 (2008); Ellington v. Peake, 531 F.3d 1364 (Fed. Cir. 2008); Roper v. Nicholson, 20 Vet. App. 173, 181 (2006). Thus, governing law and regulation provide that the proper effective date in this case may be no earlier than the date entitlement arose. Consequently, the earliest possible effective date he may receive is January 20, 2015. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The appeal is denied. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. When it is not possible to separate the effects of the service-connected disability from a non-service-connected disability, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). In general, the degree of impairment resulting from a disability is a factual determination and the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any initial rating/increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 4. Entitlement to an increased rating for PTSD This matter comes to the Board on appeal from a September 2010 rating decision that granted a higher 30 percent rating for PTSD, effective May 10, 2010. The AOJ has rated PTSD as 30 percent disabling from May 10, 2010, and as 50 percent from March 4, 2019, under Diagnostic Code 9411. The Veteran contends that an increased rating should be granted for PTSD as it is more disabling than currently evaluated. See correspondence from the Veteran and his representative dated in June 2011, February 2015, and July 2020. In June 2011, the Veteran and his representative contended that his alcohol abuse co-existed with his PTSD, that he was socially isolated, had mild to moderate PTSD symptoms at least three times per week, and had irritability, difficulty sleeping, intrusive recollection of events, and a July 2010 VA outpatient treatment record showed that he had depressed mood, past fleeting suicidal ideation, and impaired memory. In February 2015, the Veteran's representative stated that the Veteran had received VA treatment for PTSD from 2010 to 2011, and in 2013, but no longer received treatment for PTSD because it caused disruption in his mental status after the appointments. In July 2020, the Veteran's his representative contended that an increased 70 percent rating should be assigned for PTSD, because his condition was described as severe in his medical records, and because in 2013 he reported having difficulty with maintaining close relationships, avoidance of things that reminded him of his combat experiences, a low mood, and low energy. The representative noted that the Veteran reported thinking about suicide with a weapon in his hand, and that the symptom of suicidal ideation is contemplated in a 70 percent rating. See July 2020 letter from the Veteran’s representative. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Prior to March 4, 2019 The issue during this period is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 30 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. VA and private treatment records, the May 2010 VA examination, and the Veteran’s lay statements show that during the period prior to March 4, 2019, the Veteran’s PTSD disorder was manifested by symptoms associated with a 30 percent rating (anxiety, depressed mood, chronic sleep impairment, and mild memory loss), and symptoms associated with a 50 percent rating (impaired judgment). He also had symptoms that are not listed with a specific rating, such as irritability, intrusive recollection of events, nightmares, hypervigilance, exaggerated startle response, and survivor guilt. VA outpatient treatment records and the VA examination report also reflect diagnoses of major depressive disorder, dysthymia, and alcohol abuse. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 30 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. The Veteran reported that these symptoms were not present daily, but occurred at least three times per week, and were of mild to moderate severity. Further, irritability, intrusive recollection of events, hypervigilance, exaggerated startle response and nightmares are similar to anxiety, depressed mood, suspiciousness, and chronic sleep impairment which are contemplated by the assigned 30 percent rating. The Board notes that the Veteran expressed suicidal ideation in July 2010, which is contemplated by the 70 percent criteria and is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 70 percent or 100 percent disability ratings. In July 2010, the Veteran reported experiencing fleeting suicidal ideation, and about six months ago he got his gun out, but then decided that “this is stupid, I’ll get through this.” The examiner stated that the Veteran had passive suicidal ideation without a plan, and contracted for safety. He denied suicidal ideation in existing treatment records, and during the May 2010 VA examination. The Board also finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 30 percent rating. The Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but was generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. At the May 2010 VA examination, the Veteran stated that he enjoyed his work trading vehicles into auctions, and was considered a trusted employee. The examiner stated that his PTSD symptoms were not affecting his employment. He told the examiner that being employed kept him occupied. Mental status examinations in VA and private treatment records and the May 2010 VA examination indicate that the Veteran was alert and oriented, cooperative and reasonable, had good personal hygiene and grooming, normal posture and psychomotor movements, established good rapport, spontaneous speech with normal rate, volume and tone, mildly anxious mood, appropriate affect, thought processes were logical, coherent and goal-oriented, cognitive functions were adequate, there were no deficiencies of cognition or memory, concentration and attention were mildly impaired, insight was good, and judgment was fair because of his continued use of alcohol. In July 2010, the examiner stated that the Veteran's insight was limited, and judgment was good. In April 2013, his mood was euthymic, thought process was normal, and judgment and insight were good. Records reflect that during this period, he had a good relationship with his wife of many years, his adult children, and a friend. Depression screens were generally negative during this period, and he declined mental health treatment from 2014 to 2018. While the Veteran did experience symptoms contemplated by a 50 percent rating, to include impaired judgment, the evidence overall during this period does not demonstrate the level of impairment associated with a 50 percent rating. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 30 percent rating. Treatment records contain reports that the Veteran was generally performing well at work. An April 2013 mental health note reflects that he had worked for his current company for 8 years, and transported vehicles to auctions. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 50 percent rating during the period prior to March 4, 2019. The criteria for a 50 percent or higher rating are not met and the appeal must be denied. Period from March 4, 2019 The issue in this period of the appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran’s symptoms do not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran’s symptoms more closely approximate the symptoms associated with a 50 percent rating, and result in a level of impairment that most closely approximates the level of impairment associated with a 50 percent rating. VA and private treatment records, the March 4, 2019 VA examination, and the Veteran’s lay statements show that the Veteran’s PTSD was manifested by symptoms associated with a 30 percent rating (anxiety, suspiciousness, panic attacks that occur weekly or less often, depressed mood, chronic sleep impairment), symptoms associated with a 50 percent rating (disturbances in motivation and mood, impairment of short and long-term memory), and symptoms associated with a 70 percent rating (suicidal ideation). He also had symptoms that are not listed with a specific rating, such as anger, hypervigilance, feelings of detachment from others, exaggerated startle response, flashbacks, guilt, and intrusive thoughts. In February 2020, the Veteran asserted that his mental health symptoms included anger, anxiety, chronic sleep problems, depression, emotional numbing, flashbacks, guilt, heavy use of alcohol, intrusive thoughts, isolation, lack of emotions, memory loss, neglect of personal hygiene, neglects family, no friends, panic attacks, problems getting along with people, suicidal feelings/thoughts, and inability to share feelings. He also stated that he was not working. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. The Veteran reported that these symptoms were not present daily. Further, anger, irritability, intrusive recollection of events, hypervigilance, exaggerated startle response and nightmares are similar to anxiety, depressed mood, suspiciousness, and chronic sleep impairment flattened affect, panic attacks more than once a week, impairment of short and long-term memory impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, which are contemplated by the assigned 50 percent rating. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records, and during the March 2019 VA examination. The Board also finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 50 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity. Mental status examinations in VA and private treatment records and the May 2019 VA examination indicate that the Veteran was alert and oriented, highly cooperative, and pleasant. The VA examiner opined that the Veteran’s presenting PTSD symptoms and depression diagnosis negatively impacted his ability to perform occupational tasks, and due to mental health challenges, his ability to carry out and complete tasks successfully was highly impaired. He continuously experienced mood dysregulation and depressive symptoms that led to feelings of sadness, tearfulness, loss of pleasure in activities and isolation from others that significantly impacted his interpersonal relationships. Further, he experienced trauma symptoms to include nightmares, intrusive thoughts, poor concentration, sleep disturbance, and avoidance of distressing memories. These presenting symptoms impacted his ability to establish and maintain relationships and carry out occupational tasks. Records reflect that during this period, he had a good relationship with his wife of many years and his adult children. While the Veteran did experience symptoms contemplated by a 70 percent rating, occasional suicidal ideation, the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. Further, while the March 2019 VA examination reflects that the Veteran reported that he stopped working due to being hostile with coworkers, he has previously reported that he stopped working due to other medical problems, including prostate cancer residuals. See his March 2016 letter. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 70 percent rating during the period from March 4, 2019. The criteria for a 70 percent or higher rating are not met and the appeal must be denied. 5. Entitlement to a higher rating for heart disease This matter comes to the Board on appeal from a December 2010 rating decision that granted service connection and a 10 percent rating for atherosclerotic heart disease, effective January 27, 2009. In a June 2020 rating decision, the AOJ granted a higher 60 percent rating for atherosclerotic heart disease, effective March 5, 2019. The Veteran and his representative contend that his atherosclerotic heart disease is more disabling than currently evaluated. In February 2015, the Veteran’s representative contended that a higher 30 percent rating should be assigned under Diagnostic Code 7005 as he reported shortness of breath, dizziness and fatigue. In July 2020, the representative asserted that the Veteran did not receive any testing at the original VA examination, and the examiner did not provide a rationale for the finding that his METS was 10. The examiner noted that he had shortness of breath, which would indicate a higher evaluation, and he was noted to be taking medication. The Veteran's service-connected atherosclerotic heart disease has been rated as 10 percent disabling prior to March 5, 2019, and as 60 percent disabling from that date, under Diagnostic Code 7005. Arteriosclerotic heart disease is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005, for arteriosclerotic heart disease (coronary artery disease). Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where a 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 dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for 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. A 100 percent rating is warranted for 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. One metabolic equivalent (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. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, 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. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase “30 to 50 percent” means 30 percent through 50 percent. Id. at 380. For the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. Period prior to March 5, 2019 During the period prior to March 5, 2019, the Board finds that the rating criteria for a higher 30 percent rating under Diagnostic Code 7005 are more nearly approximated, as a July 2010 VA echocardiogram showed mild concentric left ventricular hypertrophy. 38 C.F.R. §§ 4.3, 4.7; See also April 2011 letter from a private cardiologist, Dr. Y., in which he noted that echocardiograms in March 2008 and April 2011 showed moderate left ventricular hypertrophy. The Veteran is competent to report his readily observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, records on file show that some of his symptoms have been related to other medical problems and medications. Treatment records show that a symptom of service-connected PTSD is chronic sleep impairment and fatigue, and in a March 2016 letter, the Veteran reported he had dizziness from Tamsulosin. A higher 60 percent rating is not warranted unless there is 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. Considering all relevant evidence of record, the Board finds an even higher 60 percent rating is not warranted during this period, as the evidence does not show that the Veteran had 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. Rather, treatment records and a June 2010 VA examination indicated a clinical METS of 10 and left ventricular ejection fraction of 68 percent in October 2009 (see October 2009 letter from a private cardiologist, Dr. Y.), 60 percent in July 2010 (see July 2010 VA echocardiogram) and 70 percent in April 2011 (see April 2011 letter from Dr. Y.). Dr. Y. stated that the findings may suggest he had hypertrophic cardiomyopathy or that his left ventricular function is slightly hyperdynamic due to dehydration. The June 2010 VA examiner stated that a cardiac catheterization showed he did not have valvular heart disease. In December 2011 and August 2012, Dr. Y. diagnosed increased LVOT gradient, and stated that this may be related to his volume status at the time of his April 2011 echocardiogram. There were no other signs or suggestions consistent with hypertrophic cardiomyopathy, and he had no significant cardiac symptoms. In December 2011 and August 2012, he denied chest pain and shortness of breath. In August 2012 he reported occasional dizziness. The Board finds that these medical records are highly probative and outweigh the Veteran's statements as to the severity of his atherosclerotic heart disease. Although the Veteran's representative asserted in January 2016 that the Veteran’s cardiologist opined that he should be rated 100 percent disabled due to his heart condition alone, such a statement is not found in the medical records. Accordingly, the Board concludes that the Veteran’s atherosclerotic heart disease arteriosclerotic heart disease is manifested by no worse than workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, and evidence of cardiac hypertrophy on echocardiogram throughout the appeal period. These findings correspond to the criteria for a 30 percent rating under DC 7005. Thus, the Board concludes that the Veteran’s atherosclerotic heart disease more nearly approximated the criteria for a higher 30 percent rating during the period prior to March 5, 2019, but did not meet the criteria corresponding to a higher 60 percent rating during this period. A higher 30 percent rating is granted prior to March 5, 2019. Period from March 5, 2019 On VA examination on March 5, 2019, the Veteran reported symptoms of dizziness and dyspnea on exertion, solely due to atherosclerotic heart disease with activities consistent with METs level 3-5. The impact of the heart condition on the ability to work is reported as symptoms of dizziness and dyspnea on exertion with activities such as brisk walking, light yard work, weeding or mowing the lawn with a power mower. The examiner opined that the Veteran should be able to perform the following in a normal 8 hour workday: occasional, less than a third of the workday, sedentary work involving sitting most of the time, but may involve walking or standing for brief periods of time, with walking and standing being required only occasionally and all other sedentary criteria being met. Interview-based METs testing on day of exam showed greater than 3-5 METs. This METs level has been found to be consistent with activities such as light yard work (weeding), mowing lawn (power mower), and brisk walking (4 mph). Although the Veteran contends that a higher rating is warranted, he has not presented evidence of 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. Considering all relevant evidence of record, the Board finds that the Veteran did not have any episode of acute congestive heart failure in the past year, and there is no evidence of left ventricular dysfunction with an ejection fraction ranging from 30 percent to 50 percent. He had symptoms of dizziness and dyspnea on exertion, due solely due to atherosclerotic heart disease with activities consistent with METs level 3-5. Accordingly, the Board concludes that the Veteran’s atherosclerotic heart disease arteriosclerotic heart disease findings during the period from March 5, 2019 correspond to the criteria for a 60 percent rating under DC 7005. A higher 100 percent rating is not warranted unless there is 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. Congestive heart failure is not shown, his symptoms appear at greater than 3 METs. Thus, the Board concludes that the Veteran’s atherosclerotic heart disease does not meet the criteria corresponding to a higher 100 percent rating during the period from March 5, 2019. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. L. Wasser, 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.