Citation Nr: 21000529 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 16-38 931 DATE: January 5, 2021 ORDER Entitlement to an initial rating in excess of 30 percent for coronary artery disease (CAD), status post coronary artery bypass graft, is denied. FINDING OF FACT The Veteran’s CAD is manifested by cardiac dilation. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for CAD have not been met. U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.7, 4.15, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1964 to February 1968. In October 2019, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In November 2019, this appeal was remanded for further development. Increased Rating: CAD Legal Principles and Regulations Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Analysis In August 2012, the Veteran filed a claim for entitlement to service connection for CAD. In a January 2014 rating decision, service connection for CAD was granted at 10 percent under DC 7005. In February 2012, the Veteran filed a timely notice of disagreement (NOD) appealing the initial rating. In a November 2019 Board decision, the Board increased the Veteran’s initial rating for CAD to 30 percent for the entire period on appeal. Subsequently, in a July 2020 rating decision, the RO implemented the 30-perent rating effective August 7, 2012, the date of the original claim. Given that the Veteran filed an appeal to the initial rating decision, the Veteran is appealing the original assignment of disability evaluation following the award of service connection for CAD. In such a case, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Diagnostic Code (DC) 7005 provides that a 30-percent evaluation is assigned for workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60-percent evaluation is warranted where there is more than one episode of acute congestive heart failure in the past year; or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100-percent evaluation is warranted with chronic congestive heart failure; or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction (LVEF) of less than 30 percent. In the present case, the Veteran contends that his heart disability warrants a rating higher than the current assigned rating. A review of the evidence of record reveals the following. In a January 2014 VA examination report for heart conditions, upon cardiac functional assessment, the VA examiner noted that the Veteran’s LVEF is 60 to 65 percent. The METs results were greater than 3 METs but less than 5 METs. The VA examiner opined that the objective fraction (LVEF) is a more accurate reflection of the Veteran’s cardiac condition versus METs testing. Th VA examiner explained that LVEF is not subjectively influenced by other non-cardiac factors, which include age and lifestyle. Specifically, the VA examiner explained that the LVEF represents the proportion of blood that the left ventricle ejects with each beat; thus, that the LVEF more accurately represents the function of the heart muscle. Conversely, METs testing describes the exercise capacity of the entire organ, and therefore, is influenced by other co-morbid conditions. As such the VA examiner opined that a more reliable and accurate indication of the Veteran’s heart condition is the LVEF. In a March 2014 private medical report, the examiner noted that the Veteran has significant CAD. The examiner noted that the Veteran’s cardiac condition is stable at this time. However, the examiner noted that the Veteran has significant chest discomfort. In a May 2014 VA examination report for heart conditions, upon cardiac functional assessment, the VA examiner noted that although METs testing was not completed as it is not based on the Veteran’s treatment plan and cannot be completed without significant risk, based on the Veteran’s responses, the VA examiner estimated a METs level greater than 3 METs but less than 5 METs. The VA examiner noted LVEF is 60 to 65 percent. In agreement with the January 2014 VA examination report, the VA examiner likewise noted that the METs results are not an accurate reflection of the Veteran’s heart condition because the METs results includes the Veteran’s other comorbidities. The VA examiner noted that is more accurate as LVEF represents the functionality of the heart without the influence of other non-cardiac conditions. In an September 2019 echocardiogram report, the results of the examination reveal that the Veteran’s left ventricular size and systolic function is normal. The ejection fraction estimate is 60 to 65 percent. The left atrium is moderately dilated, and the right atrium is mildly dilated. In a November 2019 VA examination report for heart conditions, the Veteran reported occasional fatigue. Upon examination, the VA examiner noted no evidence of cardiac hypertrophy or cardiac dilation. Upon cardiac functional assessment, the VA examiner noted that the Veteran denies experiencing symptoms attributable to a cardiac condition with any level of physical activity. In a December 2019 VA examination report for heart conditions, the VA examiner noted no evidence of cardiac hypertrophy. However, the VA examiner noted cardiac dilation as reflected in the September 2019 echocardiogram. Upon cardiac functional assessment, the VA examiner noted that although METs testing was not completed as it is not based on the Veteran’s treatment plan and cannot be completed without significant risk, based on the Veteran’s responses, the VA examiner estimated a METs level greater than 3 METs but less than 5 METs. The VA examiner noted LVEF is 60 to 65 percent. Consistent with the prior VA examination reports, the VA examiner noted that the limitation of METs level is due to multiple medical conditions including the heart conditions. The VA examiner explained that the Veteran has multiple non-cardiac co-morbidities affecting his METs, to include hypothyroidism, residuals of neck cancer, deconditioning, etc. The VA examiner noted that since the Veteran’s LVEF is within normal limits, it is more likely than not that none of the functional deficit can be attributed to this heart condition, in other words, the decrement in METs cannot be attributed to his heart condition. Upon review of the evidence of record, the Board finds that the Veteran’s CAD more nearly approximates the current assigned rating of 30 percent. Specifically, the Adult Echocardiogram Report, dated September 30, 2019, reflects that the Veteran’s atrium is dilated. Given such, the criteria for a 30-percent rating has been met. A higher rating of 60 percent is not warranted. The Board acknowledges that most of the VA examination reports note that the Veteran’s METs level reflects a workload of greater than 3 METs but not greater than 5 METs. However, as explained by the VA examiners, the limitation of METs level is due to multiple medical conditions including the heart conditions. The VA examiners explained that the Veteran has multiple non-cardiac co-morbidities affecting his METs, to include hypothyroidism, residuals of neck cancer, deconditioning, etc. As such, the VA examiners of record agree that the LVEF is a more accurate representation of the Veteran’s cardiac function. Thus, when examining the Veteran’s LVEF, it has consistently been noted as 60 to 65 percent. In fact, the December 2019 VA examiner noted the Veteran’s LVEF is within normal limits. Consequently, because the Veteran’s LVEF is greater than 30 to 50 percent, the criteria for a 60 percent rating are not met. Furthermore, a 60 percent is not warranted as there is no evidence of congestive heart failure throughout the period on appeal. Additionally, a 100 percent rating is not warranted as there is no evidence of chronic congestive heart failure; nor is the LVEF less than 30 percent. The Board acknowledges the Veteran’s assertion in September 2020 statement that he is taking medicine with these disabilities. However, the Veteran has not explained the significance of taking of medicine. Nonetheless, factoring this into his disability picture does not equate to a higher rating as it is not part of the ratting criteria for his disability. In sum, for the reasons discussed above, a rating in excess of 30 percent for the Veteran’s service-connected CAD is not warranted. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt doctrine is not applicable, and his claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Abdelbary, Associate 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.