Citation Nr: 21002124 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 15-07 939 DATE: January 12, 2021 ORDER Entitlement to a rating in excess of 30 percent for the period from March 10, 2011 to October 8, 2013 for ischemic heart disease (IHD) is denied. FINDING OF FACT For the entire period on appeal, the evidence of record demonstrates that the Veteran’s IHD manifested in, at worst, evidence of cardiac dilation on an echocardiogram, with a workload of greater than 5 METs but no greater than 7 METs resulting in dyspnea, fatigue, and dizziness. CONCLUSION OF LAW The criteria for an increased rating for IHD for the period from March 10, 2011 to October 8, 2013 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.100, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1965 to July 1968. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In April 2018, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. This case has a lengthy procedural history that has been outlined in detail in previous Board decisions that are incorporated herein by reference. Addressing the most relevant procedural history, the claim was most recently previously before the Board in July of 2020. At that time, it was remanded for additional development, to specifically include obtaining an addendum opinion from a VA examiner. The claim has now been returned to the Board for appellate review. Entitlement to a rating in excess of 30 percent for the period from March 10, 2011 to October 8, 2013 for IHD is denied. As an initial matter, the Board notes that this issue has previously been framed as entitlement to an effective date prior to October 8, 2013 for the assignment of a 100 percent disability rating for IHD. However, based on the evidence of record, the issue on appeal is better characterized as entitlement to a rating in excess of 30 percent for the period from March 10, 2011 and October 8, 2013. Specifically, the Veteran believes the 100 percent rating he has been assigned from October 8, 2013 through the present should be assigned from May 4, 2011, the date of a VA heart examination. The Veteran has contended that symptoms he experienced between May 4, 2011 and October 8, 2013, such as dizziness and fatigue, were the same as those reported to a VA clinician at his October 8, 2013 examination upon which his 100 percent rating was initially granted and his rating should therefore be higher during this period. See e.g. May 2014 Correspondence; April 2018 Board Hearing Transcript. However, the Board notes that the Veteran’s 30 percent rating was subsequently assigned an earlier date of March 10, 2011 and, therefore, the Board has considered this date in reviewing whether a higher rating is warranted. See February 2013 Rating Decision. Unfortunately, after a thorough review of the evidence of record in this case, both lay and medical, the Board concludes that a rating in excess of 30 percent is not warranted for the Veteran’s IHD for the period from March 10, 2011 to October 8, 2013. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (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. The Veteran’s IHD is rated under 38 C.F.R. § 4.104, Diagnostic Code 7005 for evaluating coronary artery disease. Pursuant to Diagnostic Code 7005, a workload of greater than 7 Metabolic Equivalent (METs) but no greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or CAD requiring continuous medication, warrants a 10 percent rating. A workload of greater than 5 METs but no greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilation on an electrocardiogram, echocardiogram, or x-ray warrants a 30 percent rating. More than one episode of acute congestive heart failure in the past year, a workload greater than 3 METs but no greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with a left ventricular ejection fraction (LVEF) of 30 to 50 percent, warrants a 60 percent rating. A 100 percent rating is warranted for chronic congestive heart failure, a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or a left ventricular dysfunction with a LVEF of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. Turning to the evidence of record relevant to the period on appeal, private treatment records note a diagnosis of coronary artery disease with a LVEF of 60 to 65 percent in March 2011. These private records also reveal that following a review of the Veteran’s cardiovascular system, he denied chest pain, dyspnea, orthopnea, syncope, palpitations, blood clots, edema, and paroxysmal nocturnal dyspnea. He reported that, “he feels well, without any cardiac symptoms”. An echocardiogram performed on March 10, 2011 revealed a LVEF of 66 percent. The examiner diagnosed myocardial infarction, inferior wall; coronary artery spasm; and dissection intima circumflex coronary artery. The Veteran’s aortic root size was noted to be borderline dilated. While the examiner concluded that there were “no regional wall motion abnormalities” and a normal left atrium, VA afforded the Veteran the benefit of the doubt in deeming his borderline dilated aortic root to be “considered equivalent to cardiac dilation” in order to increase his rating to 30 percent from this date. See February 2013 Rating Decision. A March 2011 VA primary care provider patient letter from a few days later regarding test results indicates that the Veteran was informed that, “[t]he echocardiogram or soundwave test of the heart is essentially normal. If you did indeed have an episode consistent with heart damage, it was not sufficient to cause the entire wall resectionable not functioning properly.” At a May 2011 VA examination, the examiner objectively noted that the Veteran’s treatment plan includes taking continuous medication for this condition. His METs score was recorded as greater than 5 but not greater than 7 METs with reported symptoms of dyspnea. The examiner noted a history of myocardial infarction but did not report congestive heart failure. After a follow-up, a March 2013 VA patient letter regarding test results indicates that the Veteran was informed that, “the 24 hour Holter or heart monitor was most remarkable for being unremarkable. You did have a few extra beats but nothing significant (runs, frequency.) Further, no symptoms were indicated by you in the diary”. A later March 2013 cardiology outside medical record note in his VA treatment records indicates that the Veteran, “denies any cardiac symptoms”. An August 2013 VA note states that the Veteran was, “clinically without evidence of decompensation of atherosclerotic heart disease”. Further, while the Veteran had, “known coronary artery disease and history both appear wall microinfarction” it was stated that he also, “smokes about one pack of cigarettes a day”, “does not have any cardiac symptoms” and “today’s examination did not reveal any evidence of heart failure. No bruit was heard over the large arteries. No evidence of abdominal aortic aneurysm ECG revealed normal sinus rhythm with first-degree AV block and right bundle branch block”. As stated above, VA has assigned an effective date of March 10, 2011 for the Veteran’s 30 percent rating, the date that it became reasonably ascertainable that a higher evaluation for this condition was warranted. However, the Board acknowledges the Veteran’s assertions that his symptoms warrant a higher rating for this period. The Board also acknowledges that the Veteran previously asserted his belief that his May 2011 VA examination was inadequate. In this regard, a retrospective medical opinion was authored by a VA examiner in July of 2020 in order to comply with the Board’s most recent remand and address the then-severity of the Veteran’s IHD condition. After a review of the Veteran’s claims file and the relevant medical literature, the July 2020 VA examiner explicitly acknowledged the Veteran’s lay contention that symptoms experienced between May 4, 2011 and October 8, 2013, such as dizziness and fatigue, were the same as those reported to a VA clinician at his October 8, 2013 examination. However, the VA examiner also referred to multiple incidents of documentation in treatment records that, “the Veteran had been smoking [multiple] packs of cigarettes per day” which as “re-confirmed by CAPRI problem list Tobacco Use Disorder cause[d] Chronic obstructive pulmonary disease (COPD) condition”. He stated that, “based on medical literature COPD is caused by cigarette smoking”, a condition which “reduces airflow into the lungs, making breathing difficult and labored presenting as dyspnea and fatigue” and was “consistent [with] the Veteran’s symptoms of dyspnea and fatigue” during the asserted period. Further, the Veteran’s symptoms during this period were “related to cigarette smoking/copd condition; consistent” and were “not related, not incurred, not due, nor aggravated by service connected condition of IHD”. Based on this, the VA examiner concluded that, “it is my retrospective opinion that a cardiac Met > 5-7 was wrongly granted on May 4, 2011” and “it is my retrospective medical opinion that a cardiac Met > 1-3 was also wrongly granted by VA clinician on October 8, 2013” as “the Veteran experienced No cardiac symptoms with any level of physical activity related to IHD condition [during this period]”. This evaluation was based on a review of the Veteran’s complete history and reported symptoms. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This examiner reviewed the claims file and provided opinions that were sufficiently clear and had well-reasoned rationales. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The Board relies on this well-supported opinion in finding that the Veteran’s asserted symptoms such as dizziness and fatigue for the period prior to October 8, 2013 were unrelated to his service-connected IHD. Most importantly, the whole of the evidence of record from the relevant time period, as outlined in detail above, does not support the Veteran’s assertion that his IHD condition was worse than the 30 percent currently assigned from March 10, 2011 to October 8, 2013. Although the VA examinations and treatment notes from this period demonstrate ongoing documentation related to the Veteran’s IHD condition, none of the records present with conclusive data indicative of a more severe manifestation of the Veteran’s condition than the rating already assigned. In directly addressing the Veteran’s assertions, the Board finds that there is no evidence to support an evaluation of 100 percent for service-connected IHD. The records show that the Veteran’s condition was mostly stable during the time period. While the evidence does show that the Veteran had complaints of dizziness and fatigue during this period and had periods of required continuous medication, test results completed showed that his heart was generally stable without acute congestive changes. The evidence does not show that the Veteran developed chronic congestive failure during this time, nor is it indicative of a workload of 3 METs or a left ventricular dysfunction with a LVEF of less than 30 percent. A 60 percent rating is also not warranted as the evidence does not demonstrate a workload between 3 METs and 5 METs nor left ventricular dysfunction with a LVEF of 30 to 50 percent. Significantly, the Veteran himself denied having any cardiac symptoms whatsoever on several occasions throughout the period on appeal. Of note, the thorough rationale and explanation provided by the July 2020 VA examiner (which is not rebutted by any medical evidence in the record) indicates that even the Veteran’s current 30 percent rating for the period at issue in this case and the 100 percent rating that followed should not have been granted. While it is not a Board policy to develop cases in order to reduce or deny ratings and the current evaluations and dates are therefore being preserved, it should not be overlooked that the Veteran’s current 30 percent rating is, in actuality, likely a higher evaluation than what is actually warranted for this period. The preponderance of the evidence is against the 100 percent evaluation asserted by the Veteran and is in fact against a higher rating whatsoever for the Veteran’s IHD for the period from March 10, 2011 to October 8, 2013. In addition, while the Veteran’s contentions regarding the severity of his condition during that time have been explicitly acknowledged and considered, the Board finds that the weight of the objective evidence of record does not support his assertions. Further, while the Veteran is competent to report on matters observed within his respective personal knowledge, he has not been shown to possess the highly specialized knowledge and training necessary to render an opinion as to the severity of cardiac conditions. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In this regard, the severity of the Veteran’s IHD condition is not a matter capable of lay observation and requires medical expertise to determine. The rating criteria require both documentation of this objective measure of heart-related findings and that such findings fall within a pre-established range in order to warrant a certain rating. Therefore, while the Veteran’s assertions have been afforded some probative value, this low probative weight is outweighed by the highly probative medical evidence of record. (Continued on the next page)   Based on the foregoing discussion, the evidence of record showed no distinct periods of time during the appeal period when the Veteran’s service-connected IHD condition varied to such an extent that further staged ratings would be warranted. See Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent for the period from March 10, 2011 and October 8, 2013 for IHD and the doctrine of reasonable doubt is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Smith, 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.