Citation Nr: 21070336 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 17-65 379 DATE: November 23, 2021 ORDER A disability rating greater than 60 percent for the service-connected coronary artery disease, status post myocardial infarction and stent placement (CAD) is denied. FINDING OF FACT The Veteran's CAD has not been manifested by chronic congestive heart failure; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction less than 30 percent. CONCLUSION OF LAW The criteria for a disability rating greater than 60 percent for the service-connected CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION In a March 2021 decision, the Board of Veterans' Appeals (Board) restored a 60 percent rating for the service-connected CAD effective August 1, 2014 and remanded the claim for a rating greater than 60 percent for CAD for further development. The record reflects substantial compliance with the remand requests. Dyment v. West, 13 Vet. App. 141 (1999). Increased RatingCAD Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. With a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture 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. The appeal for an increased rating for CAD stems from a February 2013 rating decision that proposed to reduce the evaluation of the disability from 60 percent to 30 percent. On a VA Form 9 for another claim then on appeal received later that month, the Veteran indicated that his CAD was getting worse. Thus, the appeal of the propriety of this rating reduction also included a claim for an increased rating for the disability. Although the Veteran had perfected an appeal of the claim for a total disability rating based on individual unemployability (TDIU), his representative (in December 2015) requested a withdrawal of that appeal, and, in a December 2015 decision, the Board dismissed that issue. Thus, any claim for an increased rating for the service-connected CAD associated with the appeal of the claim for a TDIU was also dismissed. The Veteran's CAD has been assigned a 60 percent rating under Diagnostic Code 7006-7005. 38 C.F.R. § 4.104. His disability has been evaluated as residuals under Diagnostic Code 7005, which is specific for CAD. 38 C.F.R. § 4.27. Under Diagnostic Code 7005, more than one episode of acute congestive heart failure in the past year; or workload greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent warrants a 60 percent rating. A 100 percent requires evidence of chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. [A 100 percent rating under Diagnostic Code 7006, for myocardial infarction, requires the same rating criteria as that of the 100 percent rating under Diagnostic Code 7005. 38 C.F.R. § 4.104.] Effective December 10, 2017, VA amended the regulations pertaining to the evaluation of disabilities of the endocrine system, which included an amendment to Diagnostic Code 7008 for hyperthyroid heart disease. 82 Fed. Reg. 50804 (Nov. 2, 2017). However, as there is no evidence that the Veteran has hyperthyroid heart disease, that amendment has no effect on the current appeal. At an October 2012 VA examination, the Veteran reported a history of three heart stent placement surgeries between 2002 and 2003 and symptoms of chest pain but denied any hospitalizations for a heart condition since 2003. The examiner noted that the Veteran did not have congestive heart failure. The Veteran described dyspnea (shortness of breath), fatigue, angina (chest pain), dizziness and syncope (fainting) during activity. The examiner estimated the Veteran's workload at 1 to 3 METs and noted that the Veteran had chronic obstructive pulmonary disease (COPD) but could not comment on its effect on METs level without speculating. In a January 2013 addendum, another VA examiner noted that a January 2013 echocardiogram revealed an ejection fraction of 55 to 60 percent. The examiner further noted that a December 2012 VA treatment record shows that the Veteran denied any cardiac symptoms since 2003 and that, when he was last seen by cardiology in 2009, he only complained of knee pain. The examiner then stated that the low estimated METs is due to noncardiac conditions of COPD and osteoarthritis of the knees. The examiner further stated that in this case the ejection fraction is a more accurate indicator of cardiac function. The examiner noted that it is not possible to state without resorting to speculation the exact percentage of METs due solely to the cardiac condition. The examiner concluded that the Veteran's CAD would have no effect on physical or sedentary employment. In a December 2015 disability benefits questionnaire, a private physician noted a history of a myocardial infarction with three stent placements in 2003 and another stent placement in 2004. The physician initially indicated that the Veteran does not have congestive heart failure but then noted that he has chronic congestive heart failure with episodes of acute congestive heart failure in the past year (with the most recent one in November 2015) but that reportedly went untreated. The physician noted that the Veteran was unable to tolerate an exercise tolerance test (ETT) in April 2013 and that an echocardiogram showed an ejection fraction of 67 percent in October 2015. The physician noted symptoms of dyspnea, fatigue and chest pain and estimated the Veteran's workload at 1 to 3 METs. The physician indicated that the interview-based METs test was more accurate that the ETT test. The physician noted that the Veteran had other noncardiac conditions and estimated that 80 percent of the METs level was solely due to CAD but noted that it is not possible to estimate accurately that percentage. At an April 2016 VA examination, the Veteran reported a history of three heart stent placement surgeries from 2002 to 2003 (with no hospitalizations for heart problems since then). He reported that he had been told that he had had a small heart attack, or myocardial infarction, but the examiner observed that recent diagnostic testing does not show any evidence of a former heart attack. The examiner noted that the Veteran has not had a myocardial infarction and does not have congestive heart failureand that he has had multiple cardiac evaluations that were negative for any evidence of ischemia, including a November 2004 ETT with a METs level of 10.4, January 2007 ETT with a METs level of 9.9, and an October 2009 nuclear stress test with an ejection fraction of 70 percent. He reported dyspnea and fatigue during activity, but the examiner estimated his workload at greater than 5 to 7 METs. The examiner explained that the ETT more accurately reflects the Veteran's current cardiac functional level; the limitation in METs level is due to multiple medical conditions including the heart condition, and it is not possible to estimate accurately the percentage of METs limitation related to each medical condition. The examiner concluded that the Veteran's heart condition could limit his ability to perform heavy exertional occupations but not more sedentary and light duty occupationsand that he is limited in his ability to perform physical activities due to multiple underlying medical conditions, including significant arthritis in his knees, history of smoking for many years, deconditioning, and history of CAD. At a September 2021 VA examination, the Veteran reported symptoms of occasional chest pain. He denied any recent hospitalizations for the treatment of any heart condition. The examiner noted that the Veteran does not have congestive heart failure and that his current ejection fraction was 50 percent. The Veteran reported fatigue during activity. The examiner estimated his workload at greater than 3 to 5 METs. The examiner explained that he has multiple conditions, the effects of which cannot be distinguished. The examiner explained that the left ventricular ejection fraction is a more accurate measure of the heart's ability in this case and that this Veteran's heart condition does not impact his ability to work. In a separate medical opinion, the examiner stated that the Veteran has multiple other conditions that can be contributing to his symptoms and that he has the ability to function in an occupational environment but with limitation of strenuous activity. While the Board has considered, and appreciates, the Veteran's cardiac symptoms, his CAD has not been manifested by chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. None of the medical evidence of record, including the three VA examinations, shows that he has chronic congestive heart failure. Although his private physician indicated that he has chronic congestive heart failure, that notation may have been based on the history provided by the Veteran, who also reported that he was not treated for any episodes of congestive heart failure. Importantly, the private physician's indication that the Veteran has chronic congestive heart failure is outweighed by the other medical evidence of record. Hayes v. Brown, 9 Vet. App. 67 (1996). None of the medical evidence of record, including the private examination and three VA examinations, shows that the Veteran has left ventricular dysfunction with an ejection fraction of less than 30 percent. All ejection fractions of record have been greater than 30 percent. Thus, a higher 100 percent rating based on congestive heart failure or ejection fraction is not warranted. As noted by the private physician and three VA examiners, the Veteran has other disabilities affecting his ability to function, and the effects of those disabilities cannot be separated from that of his CAD. While the private physician indicated that the interview-based METs test was more accurate that the ETT, that was based on the Veteran's inability to tolerate an ETT in April 2013. While the April 2016 VA examiner indicated that the ETT more accurately reflects the Veteran's cardiac functional level, the examiner cited to ETTs prior to the appeal period, and as such that opinion is of little probative value. Hayes, 9 Vet. App. 67. In any event, both the January 2013 and September 2021 VA examiners indicated that the left ventricular ejection fraction is a more accurate measure of the cardiac function in this case. The Board finds that the opinions of the two VA examiners outweighs that of the sole private physician. Hayes, 9 Vet. App. 67. As noted above, all of the ejection fractions during the appeal period have been greater than 30 percent and do not meet the criteria for a higher 100 percent rating. Moreover, even considering the Veteran's noncardiac disorders, the most recent two VA examiners estimated his workload at greater than 3 METs (with the earliest examiner's estimated METs being attributed to COPD). While the private physician estimated the workload at 1 to 3 METs, the physician further estimated that only 80 percent of that limitation was due to CAD, which would raise the upper limit of that estimate to greater than 3 METs. In any event, the Board finds that the estimates of the two most recent VA examinerswhich placed the workload at greater than 3 METsoutweighs that of the sole private physician. Id. All VA examiners have indicated that the Veteran's CAD would have little to no effect on any sedentary employment. Accordingly, the Board concludes that a 100 percent rating for the service-connected CAD, based on METs, is not warranted. The Board acknowledges that a lay person is competent to give evidence about observable symptoms such as chest pain, shortness of breath, fatigue, dizziness and fainting. Layno v. Brown, 6 Vet. App. 465 (1994). However, the objective evidence of record, along with the Veteran's own report of his limitations due to his heart disability, does not support a higher 100 percent rating. (CONTINUED ON NEXT PAGE) Accordingly, the Board concludes that a disability rating greater than 60 percent for the service-connected CAD is not warranted. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. W. Kim, 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.