Citation Nr: 21004602 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 12-29 142 DATE: January 27, 2021 ORDER A rating higher than 10 percent for coronary artery disease (CAD) from October 9, 1998 to October 17, 2008 is denied. FINDING OF FACT From October 9, 1998 to October 17, 2008, the Veteran’s CAD was not manifested by congestive heart failure; by a workload of 7 METs or less; by cardiac hypertrophy or dilatation on electrocardiogram or echocardiogram, or X-ray; or by left ventricular dysfunction with an ejection fraction of 50 percent or less. CONCLUSION OF LAW The criteria for a rating higher than 10 percent for CAD from October 9, 1998 to October 17, 2008 are not satisfied . 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1968 to January 1970. He died in October 2008. The appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter for further development in April 2015 and June 2019. The appellant testified at a hearing before the undersigned Veterans Law Judge in February 2015. A transcript of the hearing is of record. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected disabilities in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Coronary Artery Disease A. Rating Criteria The Veteran’s service-connected CAD has been rated under Diagnostic Code (DC) 7005, which pertains to arteriosclerotic heart disease (coronary artery disease). 38 C.F.R. § 4.104. When evaluating disabilities of the cardiovascular system under diagnostic codes 7000-7007, 7011, and 7015-7020, it must be ascertained in all cases whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X-ray) is present and whether or not there is a need for continuous medication. 38 C.F.R. § 4.104. METs testing is also required in all cases except: (1) when there is a medical contraindication; (2) when the left ventricular ejection fraction has been measured and is 50% or less; (3) when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; (4) when a 100% evaluation can be assigned on another basis. Id. If left ventricular ejection fraction (LVEF) testing is not of record, the cardiovascular disability must be rated based on the alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran’s cardiovascular disability. Id. One MET (metabolic equivalent) 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. 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. Note (2). Diagnostic Code 7005 provides for the following ratings for documented coronary artery disease resulting in the manifestations corresponding to each rating: A 10 percent evaluation is assigned when a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when continuous medication or a pacemaker is required. A 30 percent evaluation is assigned under DC 7015 when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is assigned under DC 7015 when there is more than one episode of acute congestive heart failure in the past year; or when 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 percent to 50 percent. A 100 percent evaluation is assigned under DC 7015 for chronic congestive heart failure; or when there is a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of less than 30 percent.   B. Analysis The Veteran’s treatment records show that from October 9, 1998 to October 17, 2008, his CAD was not manifested by congestive heart failure, by a workload of 7 METs or less, by cardiac hypertrophy or dilatation on electrocardiogram or echocardiogram, or X-ray, or by left ventricular dysfunction with an ejection fraction of 50 percent or less. By way of background, and prior to the period under review, the private treatment records show that in September 1996 the Veteran was hospitalized for cardiac symptoms, including chest and arm pain. He was found to have had a past myocardial infarction on electrocardiogram (EKG) of unknown age, and coronary artery disease. He underwent coronary artery bypass surgery that same month. Service connection for the Veteran’s CAD has been in effect since October 9, 1998. A November 1998 private cardiology treatment record reflects that the Veteran was doing what he could to “continue in good health.” There were no specific cardiovascular problems. An exercise stress test was interpreted as normal. There was no chest pain, and the Veteran achieved a 100 percent predicted maximum heart rate, with a workload of 10 METs. A few days later, a November 1998 private treatment record notes that the Veteran recently had a stress test, and did “very well on that without any problems.” A November 1999 private cardiology treatment record reflects that examination revealed a regular heart rate and rhythm. No murmurs or gallops were noted. The treating cardiologist stated that since the Veteran was “doing so well,” there was no need for him to be seen periodically by cardiology. A September 2003 VA examination report reflects that the Veteran stated he had experienced no chest pains since his September 1996 coronary bypass surgery. He could walk up to a mile without difficulties. No abnormalities were noted on examination. An ejection fraction of 60 percent was estimated based on an echocardiogram (ECG). The ECG showed a normal right heart, normal valves, and no pericardial effusion. A November 2004 psychiatric examination report reflects that the Veteran was self-employed doing lawn maintenance, which was seasonal in nature. He did all the work himself. A March 2008 VA treatment record reflects that the Veteran’s CAD was stable, and that he had no chest pain. In June 2008, an Adenoscan Cardiolite test was performed at a private facility. The scan was interpreted as normal, with normal left ventricular systolic function. The measured ejection fraction was 60 percent. An exercise stress test report states that the Veteran exercised “according to the adenosine [sic]” for a little over seven minutes, achieving a work level of maximum METS of 1.0. The report states that the exercise test was stopped due to the Adenoscan being complete. Notably, the “Interpretation” section and “Conclusions” section were left blank, and the area for the physician to sign was also left blank. As will be explained below, the generation of this exercise stress test report was not based on an actual exercise stress test, but instead based on the Adenoscan Cardiolite test, which is not an exercise test. A July 2008 private cardiology treatment record from the same facility that conducted the June 2008 Adenoscan Cardiolite test states that a cardiac examination showed a regular rate and rhythm, with no appreciable murmurs, rubs, or gallops. In an April 2012 VA opinion, the examiner reviewed the June 2008 exercise stress test report showing a METs level of 1.0, and found that this report did not in fact represent the results of an exercise stress test. The examiner explained that an Adenoscan Cardiolite test is not an exercise test, but that the report was provided on a summary sheet titled “Exercise Stress Test Report.” It appeared that the report was “machine-generated” using the wrong software that employed input data for a chemical (i.e. adenosine) rather an exercise stress test. This explained why the METs level was reported as “1.00,” which would be an “absurd entry to make.” In this regard, the examiner stated that a METs level of 1.00 corresponds to total rest, and therefore implies the inability to generate any physical movement whatsoever. Since the test was almost certainly a chemical stress test, the value entered for “minutes exercised” would either have not been entered, or entered as zero. The software would then have provided a result of 1.00, since that would be the least possible result and would likely be the software’s default value. The examiner observed that the statement in the report that the “patient exercised . . . for 7:08 minutes,” probably was generated based on the test start and stop times (i.e. the start and stop time of the scan). The Board here notes that, as mentioned above, the report states that the test was stopped when the scan was complete, which is in keeping with the examiner’s observation. The examiner added that there was no other evidence indicating that the Veteran exercised for this test, and therefore no way of estimating exercise-based METs based on that report. Indeed, the Board here notes that, as shown above, the actual report of the Adenoscan Cardiolite states that the scan was interpreted as normal. In a January 2019 VA medical opinion, the examiner stated that an estimate of the Veteran’s METs level could not be provided based on the available evidence in the claims file without resort to mere speculation. The examiner explained that the Veteran was not available to be examined (he passed away in October 2008), the appellant had not provided sufficient information, and the Veteran’s past medical records did not contain enough subjective data to make a non-speculative estimation of METs. The examiner stated that in the absence of a reliable METs determination, the ejection fraction of the left ventricle would be the most medically accurate means of determining the Veteran’s heart function. The examiner noted in this regard that the Veteran’s ejection fraction had been estimated as 60 percent in 2003, and determined to be 60 percent in June 2008 based on the chemical stress test. Thus, the Veteran’s left ventricular ejection fraction was normal seven years and then twelve years after his September 1996 coronary bypass surgery. The examiner further stated that the Veteran’s systolic function was also found to be normal. Thus, the examiner concluded that the left ventricular ejection fraction was the most accurate medical data on which to rate the Veteran’s heart disability. The January 2019 examiner also considered the appellant’s statements. In this regard, she stated that after his heart surgery, the Veteran was “easily tired, did not exercise in the same way . . . and . . . seemed to take a nap every day.” The examiner found that this statement did not provide a “direct correlation” to the Veteran’s heart function, as the Veteran’s fatigue could be due to other factors. The examiner also noted that the Veteran had a lawn moving business after his heart surgery. Although he used a riding lawn mower, the examiner observed that this type of work would not just involve sitting, as the Veteran would have to sweep, string trimming on the mower, pick up sticks and objects before mowing, etc. The examiner noted that this would be a good occupation for someone with stable or near normal cardiac functional status. The examiner added that a review of the Veteran’s private treatment records did not show that he had any reported subjective cardiac symptoms during the period under review, which was in keeping with the objective data pertaining to cardiac function found in the echocardiogram studies. The Board finds that the VA medical opinions are probative, as they represent the conclusions of medical professionals based on review of the Veteran’s medical history, and are supported by thorough explanations. Based on the Veteran’s treatment records and the VA medical opinions, the Board finds that the criteria for a rating higher than 10 percent for the Veteran’s CAD are not satisfied for the period from October 9, 1998 to October 17, 2008. These show that the Veteran did not have a workload of 7 METs or less, notwithstanding the statement in the June 2008 exercise stress test report that his METs level was 1.0. The April 2012 VA medical opinion adequately explains that this value was not based on an exercise test, but was automatically generated by the computer software used to create the report for a chemical stress test based on a scan (i.e. the Adenoscan Cardiolite scan). As shown above, that scan itself was interpreted as normal. The January 2019 VA examiner adequately explained that based on the available evidence, the Veteran’s left ventricular ejection fraction was the best way of evaluating his heart function. That examiner found that the ejection fraction of 60 percent was normal. The examiner also found that review of the treatment records showed that the Veteran did not have apparent symptoms of heart problems, explaining that his fatigue could be attributed to other factors. The treatment records themselves do not show findings or complaints of cardiac symptoms during the period under review. Finally, they do not show that the Veteran had congestive heart failure, or findings of cardiac hypertrophy or dilatation on EKG, ECG, or X-ray. Accordingly, the criteria for a rating higher than 10 percent under DC 7005 for the Veteran’s CAD were not met for the period from October 9, 1998 to October 17, 2008. See 38 C.F.R. § 4.104. As the Veteran had a history of a myocardial infarction and coronary bypass surgery, DC’s 7006 (myocardial infarction) and 7017 (coronary bypass surgery) would also be applicable. See id. Because the myocardial infarction and coronary bypass surgery occurred more than three months prior to the period under review, 100 percent ratings may not be assigned for the three-month period following the myocardial infarction or hospital admission for the bypass surgery under these DC’s. See id. The rating criteria under DC’s 7006 and 7017 are otherwise identical to the criteria under DC 7005. As discussed above, the criteria for a rating higher than 10 percent are not met for the period under review. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rutkin, 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.