Citation Nr: 21062301 Decision Date: 10/07/21 Archive Date: 10/06/21 DOCKET NO. 17-37 625 DATE: October 7, 2021 REMANDED Entitlement to an increased rating in excess of 60 percent for hypertension with atherosclerotic coronary artery disease, to include entitlement to separate compensable ratings, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Navy from May 1963 to October 1985. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision. The June 2013 rating decision denied the Veteran's increased rating claim for his service-connected hypertension with atherosclerotic coronary artery disease. During the pendency of the Veteran's appeal of this decision, a June 2017 rating decision awarded an increased rating of 60 percent effective from the Veteran's date of claim on March 20, 2012. As the assigned evaluation was less than the maximum available rating, the issue remained on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In decisions dated in July 2019 and May 2021, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. 1. Entitlement to an increased rating in excess of 60 percent for hypertension with atherosclerotic coronary artery disease, to include entitlement to separate compensable ratings, is remanded. 2. Entitlement to a TDIU is remanded. The Veteran's hypertension with atherosclerotic coronary artery disease disability is currently assigned a 60 percent disability rating under 38 C.F.R. § 4.104, Diagnostic Code 7005. Under Diagnostic Code 7005, the next higher 100 percent rating is appropriate for chronic congestive heart failure, or; a workload of 3 metabolic equivalents (METs) or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. For rating diseases of the heart, 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. In the May 2021 remand, the Board directed the AOJ to schedule the Veteran for a VA examination to evaluate his heart disability. The remand instruction noted that all indicated tests and studies, including echocardiographic and METs testing, should be accomplished. The instruction added that if METs testing was medically contraindicated, the examiner should so state and provide a METs estimate. In response to the remand, a VA examiner completed Disability Benefits Questionnaires (DBQs) for heart conditions and hypertension in May 2021. Although the DBQ for heart conditions indicates that only an interview-based METs test was conducted, the examiner did not provide a response to a question in the report requesting for the examiner to provide a reason if an exercise stress test was not performed. As such, it is unclear from the examination report whether the interview-based estimate of the Veteran's METs level is an appropriate measure of the Veteran's METs consistent with Note 2 of 38 C.F.R. § 4.104. Based on the foregoing, the Board finds that the May 2021 VA examination does not provide adequate information necessary to rate the Veteran's disability under the relevant criteria found in Diagnostic Code 7005. Consequently, the AOJ should obtain an addendum opinion on remand regarding this unanswered question from the May 2021 VA examination report. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board's May 2021 remand instruction also requested for the examiner to provide an opinion as to whether it is at least as likely as not that the Veteran is unable to secure or follow a substantially gainful occupation due to the effects of his cardiovascular disability and other service-connected disabilities. In addition, a June 2012 VA examination previously reported that the Veteran retired in 1999 after working as a letter carrier and supervisor, and an August 2014 VA examiner opined that his heart disability did impact his ability to work. The Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel of that claim for an increased rating is whether TDIU is warranted. Rice v. Shinseki, 22 Vet. App. 447 (2009). Accordingly, the Board has assumed jurisdiction over the issue. As the Veteran has not yet completed a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, the AOJ should request that he do so upon remand. The TDIU issue is also inextricably intertwined with the increased rating claim for the Veteran's heart disability remanded herein. See Harris v. Derwinski, 1 Vet. App, 180 (1991). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his hypertension with atherosclerotic coronary artery disease. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding, relevant VA medical records, to include records dated since May 2021. 2. Provide the Veteran with a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) and ask him to complete and return this form. 3. After completing the preceding development in paragraphs 1 and 2, obtain an addendum opinion from the VA examiner who completed the May 2021 Disability Benefits Questionnaire for heart conditions. The claims file must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. (a) The May 2021 VA examiner should clarify whether there was a medical reason for why the Veteran's METs level was not determined by a laboratory determination of the METs level through exercise testing at the May 2021 VA examination. If there was a medical reason, the examiner must specifically provide the reason as to why it was not possible or not medically recommended for the Veteran to undergo the METs exercise test. (b) If the May 2021 VA examiner reports a non-medical reason(s) why a METs exercise test was not administered on the Veteran, the examiner must explain in detail the non-medical reason(s), and then review the claims file and perform the METs exercise test on the Veteran. (c) If the May 2021 VA examiner is unavailable, the AOJ should schedule the Veteran for an in-person VA examination with another examiner to perform a METs exercise test on the Veteran, unless the examiner finds that a METs exercise test cannot be performed for a medical reason. In the case where the examiner finds that a METs exercise test cannot be performed for a medical reason, the examiner must specifically provide the reason(s) as to why it is not possible or not medically recommended for the Veteran to undergo the METs exercise test. The examiner should then estimate 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. 4. Then, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to a TDIU. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.