Citation Nr: 21068690 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 17-37 921 DATE: November 12, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for ischemic heart disease (IHD), status post coronary bypass surgery (CABG) with residual scar prior to April 17, 2018 is denied. Entitlement to a rating of 30 percent for IHD, status post CABG with residual scar beginning April 17, 2018 is granted. REMANDED Entitlement to service connection for cold injury sequela peripheral sensory neuropathy of the bilateral lower extremities with feet pain and numbness is remanded. Entitlement to service connection for bilateral upper extremity peripheral neuropathy/carpal tunnel syndrome (CTS) is remanded. Entitlement to service connection for an anxiety disorder and eligibility for benefits for the period from August 22, 2013 to March 1, 2018 is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to September 19, 2018 is remanded. FINDING OF FACT Prior to April 17, 2018, the Veteran had a workload of greater than 7 METs but not greater than 10 METs; beginning April 17, 2018, the Veteran had a workload of greater than 5 METs but not greater than 7 METs resulting in fatigue and dizziness consistent with a 30 percent evaluation under Diagnostic Code (DC) 7005. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for IHD, status post CABG with residual scar prior to April 17, 2018 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.104, DC 7005 (2020). 2. Beginning April 17, 2018, the criteria for a rating of 30 percent for IHD, status post CABG with residual scar have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.104, DC 7005 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1964 to May 1967, to include service in Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal from April 2014, August 2014, and September 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that in a prior remand the issue of entitlement to service connection for an anxiety disorder was found to no longer be on appeal due to the grant of service connection for MDD. However, the Veteran initially requested service connection for the acquired psychiatric disorder of anxiety on August 22, 2013 and his grant of service connection for MDD was granted effective March 2, 2018. Normally, where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Here, however, the Board finds that the full benefits sought on appeal were not granted as a claim for service connection for an anxiety disorder remains pending as well as the issue of the Veteran's eligibility for benefits for the period from August 22, 2013 to March 1, 2018. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities 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. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Pertinent regulations also provide that it is not necessary for all of the individual criteria to be present as set forth in the Rating Schedule, but that findings sufficient to identify the disability and level of impairment be considered. 38 C.F.R. § 4.21. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 1. Entitlement to an initial rating in excess of 10 percent for IHD, status post CABG with residual scar prior to May 2, 2014, and a rating in excess of 10 percent beginning September 1, 2014 and thereafter. The Veteran was initially granted service connection for IHD in an August 2014 rating decision, effective August 22, 2012, evaluated at 10 percent. From May 2, 2014 to August 31, 2014 the Veteran was granted a 100 percent evaluation following a hospital admission for a CABG. Beginning on September 1, 2014, the Veteran was again rated at 10 percent due to requiring continuous medication for his IHD, and for a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, dizziness, or syncope. The Veteran's IHD is rated under DC 7005, under which the next higher rating of 30 percent requires workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. A review of the records confirms that the Veteran did not meet this criterion until April 17, 2018, wherein at a VA examination it was estimated that his workload was greater than 5 METs but not greater than 7 METs and resulted in fatigue and dizziness. While the record contains several private treatment records for the Veteran's IHD, these records do not contain METs estimates, or evidence of hypertrophy or dilation as required by DC 7005. The Veteran was first given a VA examination for his IHD in July 2014. Here, the examiner diagnosed coronary artery disease (CAD) and noted an implanted cardiac pacemaker. The examiner found the Veteran underwent several angioplasties in 2006, 2010, and 2012, and finally a CABG and pacemaker implantation in 2014. The examiner noted no evidence of cardiac hypertrophy or cardiac dilatation. Following an interview-based METs test the examiner estimated a >7-10 METs workload resulting in fatigue. The Board notes this finding is consistent with a 10 percent rating under DC 7005. The Veteran was given another VA examination for his IHD in December 2014. Here, the examiner again noted no cardiac hypertrophy or cardiac dilatation and, in an interview-based METs test estimated a >7-10 METs workload resulting in fatigue. The Board notes that this finding is consistent with a 10 percent rating under DC 7005 as well. Private treatment records show that in November 2017 the Veteran was admitted with 90% asymptomatic right carotid stenosis. An angioplasty was performed. The Veteran subsequently requested service connection for this condition as well as a temporary 100% evaluation, both of which were denied. In May 2018 he was given another VA examination for his heart conditions. Here, the examiner noted that the Veteran reported feeling more fatigued than previously, but no cardiac hypertrophy or cardiac dilatation was found. However, based on an interview-based METs test dated April 17, 2018, the examiner estimated a >5-7 METs workload resulting in fatigue and dizziness. The examiner confirmed that this METs level limitation was due solely to the Veteran's service-connected heart conditions. Additional treatment records show no worsening of the Veteran's IHD. Moreover, the record contains no additional METs estimates or any findings that would support a finding of the next higher rating under 7005, such as a workload of >3-5 METs or left ventricular dysfunction with an ejection fraction of 30 to 50%. Accordingly, a 30 percent evaluation, but no more, is warranted under DC 7005 for the Veteran's IHD status post CABG with residual scar beginning April 17, 2018. REASONS FOR REMAND 1. Entitlement to service connection for cold injury sequela peripheral sensory neuropathy of the bilateral lower extremities with feet pain and numbness is remanded. 2. Entitlement to service connection for bilateral upper extremity peripheral neuropathy/CTS is remanded. The Board previously remanded these claims in June 2020 to obtain VA examinations for the Veteran's various conditions of the bilateral extremities. A review of the records shows that the Veteran has indicated that he does not want to attend any in-person examinations due to the ongoing COVID-19 pandemic and his compromised health. Thus, an opinion based on a review of the records was obtained in July 2021. In said opinion, the examiner was asked to state whether it was at least as likely as not that any current neurological disorder of the Veteran's bilateral limbs is related to his military service, including his conceded exposure to herbicide agents. In response, the examiner wrote "Upper extremity: No; Lower extremity: Yes." As rationale for his opinion, he wrote "The etiologies of the upper extremity neuropathy (carpal tunnel and cervical radiculopathy) are not established to be caused by herbicide agents in the medical literature." In addressing the Veteran's complaints of pain in his extremities during his active service, the examiner simply wrote "Unrelated." As rationale he provided "The complains [sic] of pain documented in the extremities during service are nonspecific to peripheral neuropathy, and are at least as likely as not related to a specific musculoskeletal pathology." The Board finds these opinions to be inadequate, as the examiner did not provide an adequate rationale for his opinions, and there are internally inconsistent findings. Accordingly, remand for an addendum opinion is necessary. Moreover, the Board notes that the Veteran was subsequently diagnosed with and service connected for Parkinson's disease. Therefore, on remand the examiner should also provide an opinion as to whether the Veteran's bilateral upper and lower extremity neurological conditions were precursors for or were in any way related to his Parkinson's disease. 3. Entitlement to service connection for an anxiety disorder and eligibility for benefits for the period from August 22, 2013 to March 1, 2018 is remanded. The Veteran first requested service connection for an acquired psychiatric condition, anxiety, in August 2013. The Veteran provided several theories of entitlement including that his anxiety was due to combat-related stress from events in Vietnam. In a September 2014 rating decision, the RO denied service connection finding no evidence that the Veteran's anxiety was related to his active service. The Veteran continued to appeal this issue and in December 2014 contended that his anxiety was secondary to his service connected IHD. The Board notes that this theory of entitlement was never reviewed by the RO. Instead, in May 2017 a statement of the case (SOC) was issued finding only that the Veteran's anxiety was not due to combat-related stress or service related. The Veteran appealed this issue up to the Board. Subsequently, in March 2018, the Veteran filed another application requesting service connection for depression secondary to his CAD. The Veteran was given a VA examination in April 2018, wherein the examiner opined that his anxiety was part of his MDD diagnosis and that "MDD is at least as likely as not due to his CAD and adjustment issues to his physical limitations." Thus, the RO issued a May 2018 rating decision granting service connection for MDD, effective March 2, 2018, the date of the Veteran's most recent application. No review or separate discussion of the Veteran's pending claim for anxiety was made, despite the Veteran's contention that his anxiety was secondary to his IHD and the VA examiner's opinion that the Veteran's anxiety was part of his MDD diagnosis. Accordingly, remand is warranted to obtain an addendum opinion regarding the relationship between the Veteran's anxiety and MDD, and to obtain an opinion regarding whether the Veteran's anxiety is secondary to his service connected IHD. 4. Entitlement to a TDIU prior to September 19, 2018 is remanded. The issue of entitlement to an earlier affective date for the grant of a TDIU is inextricably intertwined with the other issues on remand. Accordingly, this issue must be remanded as well. The matters are REMANDED for the following action: 1. Update the electronic file with any new VA treatment records and private treatment records. 2. Obtain an addendum opinion based on a review of the records only regarding the Veteran's bilateral upper and lower extremity neurological conditions. The examiner should identify all neurological disorders from August 2013 to present, including peripheral neuropathy and CTS. The examiner should then answer the follow questions: (a.) Is it at least as likely as not (50 percent probability of greater) that any of the Veteran's neurological disorders of the bilateral upper and/or lower extremities are related to his active military service, including herbicide exposure? (b.) Is it at least as likely as not (50 percent probability of greater) that any of the Veteran's neurological disorders of the bilateral upper and/or lower extremities were caused or aggravated by his service-connected Parkinson's disease? In formulating an opinion, the examiner should specifically consider and address the Veteran's complaints of pain in his extremities during his active service. A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Obtain an addendum opinion based on a review of the records only regarding the Veteran's psychiatric conditions. Specifically, the examiner should provide an opinion as to the relationship between the Veteran's service connected MDD and his anxiety disorder. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's anxiety disorder was caused or aggravated by his service connected IHD status post CABG with residual scar. A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Ruiz, 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.