Citation Nr: 21069157
Decision Date: 11/17/21	Archive Date: 11/17/21

DOCKET NO. 20-03 373
DATE: November 17, 2021

REMANDED

Entitlement to an evaluation in excess of 30 percent for coronary artery disease (CAD), status post coronary artery bypass graft (CABG) with scar and atherosclerosis, is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the U.S. Army from November 1966 to October 1968.  

This matter comes before the Board of Veteran's Appeals (Board) on appeal from a December 2018 rating decision by the Regional Office (RO). 

Entitlement to an evaluation in excess of 30 percent for CAD, status post CABG with scar and atherosclerosis

The Veteran's CAD, status post CABG with scar and atherosclerosis, is currently assigned a 30 percent rating, effective June 14, 2012.  The Veteran seeks an increased rating.  See Form 21-526, October 2018.

The Veteran was last afforded a VA examination in November 2018.  Recent VA treatment records show stress testing was performed in March 2019.  See CAPRI, received December 2019 at p.15.

At the July 2021 Board hearing, the Veteran testified that his symptoms, including shortness of breath and fatigue with exertion, had worsened in the last eight months. 

Because the Veteran reports a worsening of symptoms, the Board finds the claim should be remanded to obtain a new VA examination to address the current severity of his service-connected CAD.

In addition, on remand, all of the Veteran's more recent VA treatment records dated since January 2020 should be associated with the claims file.

The matters are REMANDED for the following action:

1.  Associate with the claims file all of the Veteran's recent VA treatment records dated since January 2020.

2.  After the above development has been completed, schedule a new VA examination to address the current severity of the Veteran's service-connected coronary artery disease, status post CABG with scar and atherosclerosis.  The claims folder should be made available to the examiner and pertinent documents therein should be reviewed by the examiner.  All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail  stress testing must be performed if not medically contraindicated.  The examiner must explain why any of these clinical tests are not appropriate or could not be performed.  A complete rationale for any opinions expressed should be provided.

Ask the VA examiner to complete a scars VA examination form with regard to the Veteran's scar associated with his CAD and history of CABG.

The examiner should also address the effect of the Veteran's coronary artery disease, status post CABG with scar and atherosclerosis, on his occupational functioning and activities of daily living.

 

 

J.W. FRANCIS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Juliano, 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.