Citation Nr: 21001958 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-02 370 DATE: January 12, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for coronary artery disease, previously rated as radiation fibrosis with superior vena cava syndrome status-post vascular stenting, is denied. FINDING OF FACT Throughout the appeal period, the Veteran’s coronary artery disease has been manifested by left ventricular dysfunction with an ejection fraction (LVEF) of 67 percent and interview-based metabolic equivalent (METs) of 7 to 10, resulting in dyspnea, fatigue, angina, and dizziness, and continuous medication. CONCLUSION OF LAW The criteria for entitlement to an initial rating in excess of 10 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1968 to June 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. A hearing transcript has been associated with the record. This case was previously before the Board in March 2019, when it was remanded for further development. Specifically, the RO was instructed to obtain the Veteran’s updated VA treatment records and to perform a VA examination to determine the current nature and severity of the Veteran’s disability. Updated VA treatment records have been associated with the record and a VA examination was conducted in August 2020. Therefore, the Board determines that there has been substantial compliance with its previous remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). An August 2020 rating decision changed the diagnosis for the service connected disability from radiation fibrosis with superior vena cava syndrome status-post vascular stenting to coronary artery disease. The assigned rating was unchanged. 1. Coronary Artery Disease The Veteran asserts that his hear disability is worse than currently rated. Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Evaluation of a service-connected disability requires a review of a veteran’s medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Veteran’s coronary artery disease has been evaluated as 10 percent disabling, effective December 28, 2011, under Diagnostic Code 7005. Under Diagnostic Code 7005 (arteriosclerotic heart disease/coronary artery disease), a 10 percent rating is assigned for a workload of greater than 7 METs but not greater than 10 METs which results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent rating is assigned for 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 dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating contemplates 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; LVEF of less than 30 percent to 50 percent. A 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure; or, workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or, there is LVEF of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. One MET (metabolic equivalent) is defined as 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 evaluation, and a laboratory determination 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). The Veteran underwent an examination in February 2014. See Artery and Vein Conditions Disability Benefits Questionnaire (DBQ), February 26, 2014. The examiner stated that the Veteran experienced superior vena cava syndrome. The Veteran was noted to take anticoagulants and to have undergone stent placement. The Veteran underwent an examination in July 2020. See Heart Conditions DBQ, July 28, 2020. The examiner stated that the Veteran experienced coronary artery disease and radiation fibrosis with superior vena cava syndrome status-post vascular stenting. The examiner stated that the coronary artery disease was caused by hyperlipidemia, radiation changes to the anterior chest wall with radiation necrosis were caused by the radiation treatment the Veteran received for lung cancer, and radiation fibrosis with superior vena cava syndrome status-post vascular stenting were caused by lung cancer. The examiner noted that the Veteran used four different medications for coronary artery disease, hyperlipidemia, chest-wall necrosis and pain, and hypertension. There was no evidence of a myocardial infraction, congestive heart failure, cardiac arrhythmia, heart valve condition, infectious cardiac conditions, or pericardial adhesions. The examiner stated that the Veteran did undergo heart surgery, as radiation fibrotic changes caused compression to the vena cava and caused vena cava syndrome, which required stent placement. Upon physical examination, the Veteran’s heart rate was 68, rhythm was regular, the heart sounded normal, there was no jugular-venous distension, the auscultation of the lungs was clear, peripheral pulses were normal, there was no peripheral edema, and blood pressure was 122/67. There was no evidence of cardiac hypertrophy or dilatation. A 2012 echocardiogram showed LVEF of 67 percent, normal wall motion, and normal wall thickness. Interview-based METs test indicated dyspnea and dizziness at 3 to 5 METs. The Veteran did not have an exercise stress test. The examiner related that the estimated METs level due solely to the cardiac condition was 7 to 10, and the reported METs level of 3 to 5 was due to other co-morbid conditions such as chronic pain syndrome, chest-wall rib pain, and lung cancer status post thoracotomy right lung. The examiner opined that the Veteran’s heart condition did not have an impact on his ability to work. VA treatment records show ongoing diagnoses of heart disorders. No stress test results are present in the records. See VA treatment records. The Veteran’s private treatment records show that ejection fraction was noted at 67 percent and his EKG was normal. See Iowa Heart Center, August 5, 2013. At another visit, the ejection fraction was noted to be 67 percent. See Iowa Heart Center, July 5, 2012. An echo showed LVEF of 67 percent and normal diastolic function. See Medical Oncology and Hematology Associates, February 10, 2014. No stress test results are present in the records. After review of the pertinent evidence of record discussed above, the Board finds the most probative evidence of record shows the Veteran’s service-connected coronary artery disease has been manifested by LVEF of 67 percent and interview-based METs of 7 to 10, resulting in dyspnea, fatigue, angina, and dizziness, and continuous medication. The Veteran’s coronary artery disease has not been manifested by at least workload of greater than 5 METs but not greater than 7 METs, evidence of cardiac hypertrophy or dilatation, or LVEF of 50 percent or less. In fact, as discussed above, the Veteran demonstrated, at worst, a workload of 7-10 METs and LVEF of 67 percent. Moreover, there were no documented findings of cardiac hypertrophy or dilatation nor congestive heart failure. As a result, an initial rating in excess of 10 percent for service-connected coronary artery disease must be denied. The Board considers the Veteran’s reported history of symptomatology related to the service-connected coronary artery disease. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through the senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for a higher rating for his coronary artery disease have been met. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, competent evidence concerning the nature and extent of the Veteran’s disability has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran’s subjective reported symptomatology. The Board has considered whether a staged rating under Hart, supra, is appropriate for the Veteran’s service-connected coronary artery disease; however, the Board finds that his symptomatology has demonstrated impairment that is consistent throughout the appeal. Therefore, assigning a staged rating for such disability is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-7 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating due to individual unemployability (TDIU) is part of a rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this case, the record does not reflect, and the Veteran does not allege, that he is unemployable due to his coronary artery disease. Therefore, the Board finds that a TDIU is not raised by the Veteran or reasonably raised by the record in connection with his increased rating claim decided herein and, consequently, no further consideration of such is necessary at this time. (Continued on the next page)   Accordingly, the Board finds that a preponderance of the evidence is against an initial rating in excess of 10 percent for coronary artery disease, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lech, 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.