Citation Nr: 21004989 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 15-04 065 DATE: January 28, 2021 REMANDED Entitlement to a higher initial rating for service-connected coronary artery disease (CAD) status-post myocardial infarction, in excess of 10 percent prior to August 27, 2019 and 30 percent thereafter is remanded. Entitlement to a higher initial rating for service-connected supraventricular arrhythmias, in excess of zero percent prior to August 27, 2019 and 10 percent thereafter is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1962 to September 1966. Service in Republic of Vietnam is indicated by the record. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which awarded service connection for coronary artery disease status-post myocardial infarction and assigned an initial 10 percent rating, effective November 17, 2010. The Board remanded this matter in December 2017. While the matter was in remand status, in a September 2019 rating decision, the RO recharacterized the Veteran's CAD disability as CAD status-post myocardial infarction; mitral valve regurgitation, and increased the assigned rating to 30 percent from August 27, 2019. The RO also assigned a separate 10 percent evaluation for supraventricular arrhythmia from August 27, 2019. According to the RO, supraventricular arrythmia had previously been combined with the Veteran’s service-connected CAD. Although higher ratings were granted, the claims remain in appellate status, as the maximum schedular ratings were not assigned for throughout the appeal period. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The claims on appeal were again remanded by the Board in November 2019. A supplemental statement of the case (SSOC) was issued in October 2020. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. 1. Entitlement to an initial rating for service-connected CAD status-post myocardial infarction, in excess of 10 percent prior to August 27, 2019 and 30 percent thereafter, is remanded. 2. Entitlement to a higher initial rating for service-connected supraventricular arrhythmias, in excess of zero percent prior to August 27, 2019 and 10 percent thereafter, is remanded. The claims on appeal were remanded by the Board in November 2019 in order to obtain an updated VA examination. The examiner was instructed to conduct METs testing and document symptoms experienced upon diagnostic testing unless there is a medical contraindication for such testing, the left ventricular ejection fraction has been measured and is 50 percent or less, chronic congestive heart failure is present, or there has been more than one episode of congestive heart failure within the past year. The remand instructions specifically indicated, if exercise testing cannot be accomplished, the examiner must include an explanation for why this is so. Upon remand, the Veteran was afforded a VA examination in December 2019, which was did not provide the information needed to determine current evaluation of service-connected CAD and supraventricular arrhythmia. He was afforded another VA examination in October 2020 at which time the examiner assessed the service-connected heart disability. However, as noted in the January 2021 Written Brief Presentation, the examiner did not conduct METs testing, but rather cited exercise stress testing performed in 2018. Significantly, the VA examiner failed to provide an explanation as to why exercise stress testing was not performed contemporaneous to the October 2020 VA examination. In addition, the Veteran’s representative has challenged the qualifications of the October 2020 VA examiner. See the Written Brief Presentation dated January 2021. There is no indication in the VA examination report that the October 2020 VA examiner, who identified herself as a nurse practitioner specializing in general and family medicine, was qualified to assess the nature and severity of cardiac disabilities. See Francway v. Wilkie, 2018-2156 (Fed Cir. July 23, 2019) (holding that once a challenge is raised, the presumption of competency is rebutted, and VA must satisfy its burden of persuasion as to the examiner's qualifications and respond to the challenge by providing information about the qualifications of a medical examiner to the veteran). Accordingly, given the concerns addressed above, the claims on appeal must be remanded in order to obtain a new VA examination as to the cardiac disabilities rendered by a qualified physician. Prior to arranging for the Veteran to undergo further VA examination, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain all pertinent, outstanding records. 3. Entitlement to a TDIU is remanded. Regarding the claim for a TDIU, the Board observes that the claim is intertwined with the pending higher initial rating claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). As such, the matter of entitlement to a TDIU must also be remanded. The matters are REMANDED for the following action: 1. Obtain all outstanding records of VA evaluation and/or treatment. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file 2. The Veteran should be afforded a VA examination with an appropriately qualified physician to determine the extent of his service-connected CAD and supraventricular arrhythmias. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the examination. The examination should be conducted in accordance with the current disability benefits questionnaire. All necessary tests and studies should be conducted and the results of any such testing and studies should be included in the examination report. In particular, the examiner must conduct METs testing and document symptoms experienced upon diagnostic testing unless there is a medical contraindication for such testing, the left ventricular ejection fraction has been measured and is 50 percent or less, or chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year. If exercise testing cannot be accomplished to determine the METs level at which dyspnea, fatigue, angina, dizziness, or syncope develops, the examiner must include an explanation for why this is so. In addition, the examiner should address the impact of the service-connected CAD and supraventricular arrhythmias upon the Veteran’s industrial activities, including his ability to obtain and maintain substantially gainful employment. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. K. Buckley, 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.