Citation Nr: 21061937 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 17-37 173 DATE: October 5, 2021 ORDER An increase rating from July 7, 2015 to June 9, 2016 of 60 percent, but no higher, for coronary artery disease with Prinzmetal's angina (CAD) is granted. An increased rating in excess of 30 percent disabling for CAD from June 10, 2016 onward is denied. FINDINGS OF FACT 1. From July 7, 2015 to June 9, 2016, the evidence is in relative equipoise that the Veteran's Metabolic equivalent (MET) testing shows the Veteran develops dyspnea and angina at a workload of 4.6 METs. MET testing shows the Veteran did not develop these symptoms at a workload of 3 METs or less, and the evidence did not show chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. 2. From June 10, 2016 onward, MET testing shows the Veteran develops dyspnea and angina at a workload of greater than 5-7 METs. MET testing shows the Veteran did not develop these symptoms at a workload of 5 METs or less, and there was no evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent or more than one episode of active congestive heart failure in the past year. CONCLUSIONS OF LAW 1. The criteria for a rating of 60 percent, but no higher, from July 7, 2015 to June 9, 2016 for CAD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. 2. The criteria for a rating in excess of 30 percent for CAD from June 10, 2016 onward are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from September 1967 to May 1970 with service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran currently has two active cases on appeal, an increased rating for coronary artery disease with Prinzmetal's angina (CAD) and service connection for tinnitus. The appeal for service connection for tinnitus was the subject of a hearing before a different Veteran's Law Judge. Accordingly, the current decision is only with respect to the initial rating that granted service connection for CAD. The Veteran is advised that he will receive a separate decision for his claim of service connection for tinnitus. Increased Rating 1. An increase rating from July 7, 2015 to June 9, 2016 of 60 percent, but no higher, for CAD is granted. 2. An increased rating in excess of 30 percent disabling for CAD from June 10, 2016 onward is denied. The Veteran contends that the VA did not give the appropriate weight to the Veteran's three evaluations prior to July 7, 2015, and from July 7, 2015 through June 10, 2016. The Veteran points to (1) a March 2015 disability and benefits questionnaire (DBQ) wherein the Veteran achieved 4.6 METs, (2) a September 2015 compensation and pension examination (C&P examination), which also reported 4.6 METs, and (3) a letter from his primary provider that his METs ranged between 3-5 METs. See Extension Request received 3/26/2019 at page 1. As for the Veteran's claim for an increase in excess of 30 percent from June 10, 2016 for CAD, the Veteran contends that his current medical records should be considered for that claim. Id. Increased Rating Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, in determining the present level of disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 510 (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 rating during the course of the appeal, the assignment of staged ratings would be necessary. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Analysis Arteriosclerotic heart disease is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005, for arteriosclerotic heart disease (coronary artery disease). Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where 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 dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for 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 results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted 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. One MET 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. 38 C.F.R. § 4.104, Note (2). 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. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. For the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. An increase rating from July 7, 2015 to June 9, 2016 of 60 percent, but no higher, for CAD is granted. The Veteran was diagnosed with CAD in March 2015. An echocardiogram showed left ventricular ejection fraction (LVEF) at 50 to 55 percent. On an exercise stress test, the Veteran achieved 4.6 METs. See Medical Treatment Record received 7/07/2015 at page 6; see also C&P Exam received 9/28/2015 at page 6. The Veteran was first provided a Compensation and Pension examination in September 2015. The VA examiner diagnosed the Veteran with Coronary spasm, including Prinzmetal's angina and Angina Claa CCS III. See C&P Exam received 9/28/2015 at page 2. The VA examiner used the aforementioned private diagnostic test results in the disability benefits questionnaire (DBQ) and did not conduct additional diagnostic examinations. The Veteran also submitted a private DBQ which also used the aforementioned March 2015 result of 4.6 METs and 55 LVEF. See VA 21-0960A-1 Ischemic Heart Disease Disability Benefits Questionnaire at page 1. The Veteran submitted a private exercise stress test in December 2015, wherein he achieved 7.5 METs and had an LVEF of 60 percent, which the provider's conclusion reflects most "normal" findings, to include wall motion of the left ventricle, exercise capacity, and left ventricular ejection fraction. See Medical Treatment Record received 12/29/2015 at page 3. Subsequently, the Veteran's VA provider submitted a letter stating that the test was abnormal "because it shows 2 mm of inferolateral ST depression at peak and into recovery positive for ischemia." See Capri received 4/21/2016 at page 1. The VA provider, Dr. A.A., stated that since the Veteran gets short of breath easily, e.g. unable to walk more than 50-100 feet without shortness of breath, and unable to go up and down stairs, his activity level is between 3-5 METs. Id. An April 2016 VA examination, however used the December 2015 test results although it noted abnormality with the finding of ischemia since this was not shown in the images, but ischemia was shown based on the results. Accordingly, the April 2016 VA examiner opined that the 7.5 METs was most indicative of the Veteran's exercise capacity. See C&P Exam received 4/20/2016 at page 8. The Board finds that reasonable doubt should be resolved in favor of the Veteran that his level of disability from the date of claim, July 7, 2015, to June 10, 2016 meets the 60 percent rating criteria. 38 C.F.R. § 4.3. Additionally, the Board finds that the December 2015 results were unreliable due to the internal inconsistency noted by the VA provider, Dr. A.A.. Accordingly, given the Veteran's symptoms at the time, e.g., inability to walk up a flight of stairs and walk more than 50-100 feet without shortness of breath, and his March 2015 treatment results of 4.6 METs as well as his VA provider's estimation of a workload between 3-5 METs, the Board finds a 60 percent rating under DC 7005 is warranted. A higher 100 percent rating is not warranted unless there is 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. Rather, as described above, the Veteran's providers and VA examinations have shown LVEF of 50 to 55 percent and 4.6 METs with no showing of congestive heart failure. See C&P Exam received 4/20/2016 at page 4; see also C&P Exam received 9/28/2015 at page 4. Thus, the Board concludes that the Veteran's arteriosclerotic heart disease did not meet the criteria corresponding to a higher 100 percent rating. An increased rating in excess of 30 percent disabling for coronary artery disease with Prinzmetal's angina (CAD) from June 10, 2016 onward is denied. The Veteran contends that his CAD should be rated in excess of 30 percent from June 10, 2016 onward. See Extension Request received 3/26/2019 at page 1. A review of the Veteran's records shows that on June 10, 2016 the Veteran had an echocardiogram which showed an ejection fraction of 55-60 percent. See Capri received 8/13/2020 at page 6. In January 2017, the Veteran achieved 7 METs with an exercise time of six minutes per a VA cardiology diagnostic study note. See Capri received 2/06/2019 at page 304. In October 2017, the Veteran had an ejection fraction of 55 percent, in February 2018 he had achieved 5.8 METs with an ejection fraction of 60 percent. See Capri received 8/13/2020 at page 6; see also Capri received 2/06/2019 at page 163. After the Boards March 2020 remand, the Veteran received a new VA examination because of his complaints of worsening symptoms. See BVA Decision received 3/12/2020 at page 6. On the January 2021, the Veteran's disabilities of CAD and Coronary spasm were confirmed, and there was no new diagnosis. The Veteran reported chest pain on occasion but stated that he was very active and trying to increase his exercise tolerance. See C&P Exam received 1/23/2021 at page 2. An exercise test was not performed due to the Veteran's balance condition, and the examiner did an interview based METs test. The examiner endorsed symptoms during activity such as dyspnea, angina, and chest tightness. The Veteran's interview-based results were greater than 5-7 METs. Given the aforementioned, the Board finds that the preponderance of the evidence weighs against a finding of greater than 30 percent disabling for the Veteran's CAD from June 2016 onward. First, the objective tests referenced above show that the Veteran had an ejection fraction greater than 50 percent and METs consistently greater than 5 from January 2016 onward. The Board also finds that the January 2021 VA examination is probative as to the Veteran's current level of disability and that the examiner specifically referenced the Veteran's complaints of chest tightness and symptoms of dyspnea and angina, which are contemplated by the 30 percent rating assigned for this period. Accordingly, a rating in excess of 30 percent from June 10, 2016 onward is denied. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Dixon, 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.