Citation Nr: 21003337 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 16-16 927 DATE: January 21, 2021 ORDER Entitlement to an initial disability rating in excess of 60 percent for coronary artery disease (CAD), status post myocardial infarction is denied. REMANDED Entitlement to a compensable disability rating for shell fragment wound, left upper arm is remanded. FINDING OF FACT The Veteran’s CAD, status post myocardial infarction has not involved chronic congestive heart failure; workload of 3 METs or less; or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSION OF LAW The criteria for a rating in excess of 60 percent for CAD, status post myocardial infarction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from June 1967 to June 1970 and is a Purple Heart recipient. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from a December 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The Veteran provided testimony at a March 2019 hearing before the undersigned Veterans Law Judge in Washington, D.C. A transcript of the hearing is associated with the claims folder. The claims were previously remanded in July 2019 for additional development. In an October 2020 rating decision, the Veteran’s service-connected coronary artery disease status post myocardial infarction was assigned a 60 percent effective January 20, 2011. However, since this increase did not constitute a full grant of the benefit sought, the higher evaluation issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Entitlement to an initial disability rating in excess of 60 percent for coronary artery disease, status post myocardial infarction Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran’s entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations, to the extent they are sufficient to warrant changes in the evaluations assignable under the applicable rating criteria. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). As is the case here, in initial-rating cases, where the appeal stems from a rating decision granting service connection with respect to the initial evaluation assigned the disability at issue, VA assess the level of disability from the effective date of service connection. Fenderson, 12 Vet. App. at 125; 38 U.S.C. § 5110; 38 C.F.R. § 3.400. “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 required for that rating. Otherwise, the lower rating will be assigned.” 38 C.F.R. § 4.7. The Veteran’s coronary artery disease is rated under Diagnostic Code 7005, which compensates for arteriosclerotic heart disease, also known as coronary artery disease. Under the applicable rating criteria, a 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs (Metabolic Equivalent of Task) 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. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005. A 100 percent rating is assigned 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. Id. The Veteran was afforded a VA examination in October 2012. At that time, the examiner noted his history of ischemic heart disease with myocardial infarction and history of multiple heart surgeries, to include an implanted cardiac pacemaker. His coronary artery disease was treated with medication. An interview-based stress test revealed METs levels greater than 3-5, resulting in dyspnea and fatigue, consistent with activities such as light yard work, mowing the lawn, and brisk walking (4 mph). Echocardiogram showed evidence of cardiac hypertrophy. On echocardiogram, his left ventricular ejection fraction was 54 percent. He did not have congestive heart failure. More recently, the Veteran was afforded a VA examination in October 2019.At that time, the examiner noted his history of a heart attack with a history of heart surgeries, to include an implanted cardiac pacemaker. His coronary artery disease was treated with medication. Heart rate was 76 with regular rhythm. Heart sounds were normal. Peripheral pulses were normal. He did not have any peripheral edema. Echocardiogram did not show evidence of cardiac hypertrophy but showed conduction abnormality. An interview-based stress test revealed METs levels greater than 5-7, resulting in intermittent chest heaviness with rest and activity and shortness of breath with walking up to two blocks, consistent with activities such walking 1 flight of stairs, golfing, mowing lawn, and heavy yard work. An exercise-based stress test was not required as part of the Veteran’s current treatment plan and was not without significant risk. On echocardiogram, his left ventricular ejection fraction was 40 percent. He did not have congestive heart failure. The October 2019 VA examiner also noted that the Veteran has valvular heart disease. However, according to an October 2020 addendum, it was noted that the diagnosed trace mitral and tricuspid regurgitation are not considered clinically significant and are unrelated to the Veteran’s coronary artery disease, status post myocardial infarction. In this case, the Board finds that a total schedular rating is not warranted for the Veteran’s ischemic heart disease. Left ventricular ejection fraction has recently been shown to be 40 percent and his prior METS level was reported to be greater that 3 to 5, which is consistent with a 60 percent rating. He has not shown chronic congestive heart failure, he does not have a METs level of 3 or less, and he has not shown left ventricular ejection fraction of 30 percent or less at any time. Therefore, the schedular criteria for a rating in excess of 60 percent have not been met based on the available evidence. The Veteran has not sought any additional cardiac testing short of basic follow-up care; he has not asserted that his cardiac condition has worsened since his most recent VA examination. The Board has carefully reviewed the Veteran’s available VA and private treatment records but finds no further evidence warranting an increase the Veteran’s rating for coronary artery disease. In sum, the Board finds that the Veteran’s coronary artery disease has resulted in left ventricular ejection fraction no less than 40 percent and METs greater than 3-5, resulting in dyspnea and fatigue; he does not have congestive heart failure. Therefore, the Veteran does not meet the criteria for a rating in excess of 60 percent for coronary artery disease, and the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a compensable disability rating for shell fragment wound, left upper arm is remanded. Following the Board’s July 2019 remand, the Veteran was afforded scar examinations in September 2019, October 2019, and July 2020. However, the Board finds the examiner only addressed the Veteran’s forearm and calf scars and did not discuss the service-connected left upper arm scar. See October 2012 VA scars examination report. On remand, the AOJ should afford the Veteran a new VA examination to determine the current manifestations and severity of his service-connected shell fragment wound, left upper arm. The matter is REMANDED for the following action: Arrange for the Veteran to undergo a VA examination to determine the current severity of his service-connected shell fragment wound, left upper arm. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place.   Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Williams, 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.