Citation Nr: 21072001 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-01 260 DATE: December 2, 2021 ORDER Entitlement to a rating in excess of 10 percent for coronary artery disease (CAD), old myocardial infraction claimed as hearting disease angina (mini heart attack), from October 17, 2013, to April 24, 2015, is denied. Entitlement to a rating in excess of 10 percent for CAD, old myocardial infraction claimed as hearting disease angina (mini heart attack), from August 1, 2015, to the present is denied. FINDINGS OF FACTS 1. From October 17, 2013 to April 24, 2015, the Veteran's service-connected CAD did not manifest 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 dilatation on electrocardiogram, echocardiogram, or X-ray. 2. From August 1, 2015 to the present, the Veteran's service-connected CAD did not manifest 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 dilatation on electrocardiogram, echocardiogram, or X-ray. CONCLUSIONS OF LAW 1. The criteria for entitlement a rating in excess of 10 percent for CAD from October 17, 2013, to April 24, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005-7006. 2. The criteria for entitlement a rating in excess of 10 percent for CAD from August 1, 2015, to the present have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7006. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army 1968 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). The Board issued a remand in July 2021 instructing the RO to obtain outstanding treatment records from May 2020 to July 2021 and obtain an addendum opinion to determine if the August 2015 and November 2015 echocardiogram more nearly approximated the Veteran's CAD at that time. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The RO obtained outstanding treatment record and an August 2021 medical opinion. The Board finds the RO substantially Procedural History In the August 2016 rating decision, the Veteran was awarded service connection for CAD with a 10 percent disability rating effective March 15, 2016, under 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005. After subsequent adjudication, the effective date of service connection was changed to October 17, 2013. See May 2020 Rating Decision. A temporary 100 percent evaluation was assigned April 25, 2015, to July 31, 2015, because the Veteran experienced a myocardial infarction on April 25, 2015. The 10 percent disability resumed on August 1, 2015 and is the current disability rating assigned. The DC was changed to 7006 on August 1, 2015. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is 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, 4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). Under DC 7005 and 7006, a 10 percent rating is warranted when the evidence shows documented CAD and 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 for 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 dilatation 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 maximum 100 percent rating is warranted when the evidence shows chronic congestive heart failure (CHF); 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. Under DC 7006, a maximum 100 percent rating is also warranted during and for three months following myocardial infarction, documented by laboratory test. 1. Entitlement a rating in excess of 10 percent for CAD from October 17, 2013, to April 24, 2015. Generally, the Veteran contends that he is entitled to a higher initial disability rating because the severity of his condition was greater than assessed. See generally, September 2016 Notice of Disagreement (NOD) (Veteran wrote that 15 percent was warranted); September 2016 Statement; January 2017 NOD (Veteran wrote that 20 percent warranted); April 2017 Statement. Pursuant to DC 7005, the evidence of record did not demonstrate 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 dilatation on electrocardiogram, echocardiogram, or X-ray from October 17, 2013 to April 24, 2015. See e.g., May 2013 Emergency Department Note (denied fever, chills, sweats, change in appetite or weight, fatigue); August 2013 Emergency Department Note (chest clear to auscultation; cardiac: regular rhythm, no murmur, no gallop); September 2014 Columbia VAMC Urology Note (arterial calcifications, including coronary arterial; a non-aneurysmal abdominal aorta; mild dilatation, 1.7 cm, of the right common iliac artery; no pathologically enlarged lymph nodes); October 2014 Columbia VAMC Primary Care Note (reported no chest pain, dysphagia, or dizziness); May 2015 Palmetto-Heart Record (diagnosis of CAD); June 2015 Palmetto Admission Record (denied chest discomfort since 2006, diagnosis of non-ST evaluation myocardial infarction). The Board acknowledges the Veteran's contention that his symptoms of CAD increased in severity. A layperson is competent to report observable symptomatology which comes to him via his senses. See Barr v. Nicholson, 21 Vet. App. 303, 308 (U.S. 2007). However, the medical evidence of record does not support the increase for a rating disability. Although the Veteran did not undergo formal testing to measure his LVEF or METS, the Board considered the medical treatment records from October 13, 2013 to April 24, 2015. The records show that the Veteran's condition was mostly stable during the period. He denied having symptoms associated with a 30 percent rating such as fatigue and dizziness. Therefore, the Board finds that the claim for an increased rating during this period is not warranted. There is no doubt to resolve. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement a rating in excess of 10 percent for CAD from August 1, 2015 to the present. Generally, the Veteran contends that he entitled to a higher rating for his service-connected CAD because his symptoms have increased in severity. The Board finds that entitlement to a rating in excess of 10 percent for CAD is not warranted. The evidence of record does not show that the Veteran's CAD manifested 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 dilatation on electrocardiogram, echocardiogram, or X-ray. See e.g., March 2016 VA Cardiology Consult (CAD controlled on asa; veteran denied chest pain, dizziness, palpitation, and shortness of breath; RCA was nondominant with 70 percent tubular proximal stenosis); October 2016 Urology Note (no complaint of chest pain or discomfort); March 2017 Nurse Practitioner Note (denied dizziness, chest pain, and shortness of breath; normal heart rhythm, no gallops, murmurs or rubs); May 2017 Nurse Practitioner Note (denied dizziness, chest pain, and shortness of breath); July 2017 Oncology Note (regular rate and rhythm, no murmurs); The Veteran's private treatment records show that an echocardiogram was conducted in April 2015 that revealed dilatation of the right atrial cavity, right ventricular cavity, and aortic root, and an estimated left ventricular ejection fraction (LVEF) of 45 percent. A VA cardiac examination was conducted in November 2015. The examiner indicated that the Veteran's CAD requires continuous medication. He found no evidence of congestive heart failure, cardiac hypertrophy, or cardiac dilatation. He stated that both EKG and echocardiogram test results were clinically normal and that the Veteran had a LVEF of 55 percent. The examiner conducted an interview based metabolic equivalent (MET) test and indicated that the Veteran experiences fatigue with more than 7 to 10 METs. Because of the discrepancies regarding the severity of the Veteran's CAD between the private April 2015 echocardiogram results (indicating cardiac dilatation and estimated LVEF of 45 percent) and the November 2015 echocardiogram findings (indicating no evidence of cardiac dilatation and a LVEF of 55 percent), the Board remanded this issue for a new VA examination in its April 2019 decision. Specifically, the Board directed the examiner to explain the reason for the apparent discrepancies regarding the Veteran's CAD symptoms and to opine as to which symptoms are most representative of his level of cardiac functioning. A new VA cardiac examination was conducted in September 2019. The examiner noted that the Veteran continues to require medication to control his CAD. He found no evidence of congestive heart failure. The examination report indicated that an echocardiogram was performed and revealed no evidence of cardiac hypertrophy or cardiac dilatation. The Veteran's LVEF was between 55 and 65 percent. During his interview based METs test, the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. In explaining the apparent discrepancy between the April 2015 and November 2015 echocardiogram results, the examiner stated that findings between examinations can vary based on the locations and providers conducting the examinations. He indicated that updated echocardiogram results provide current findings. The Board also found this medical opinion inadequate because the examiner did not provide an opinion as to whether the results of the April 2015 or November 2015 echocardiogram better approximated the Veteran's disability level throughout the rating period on appeal. While he indicated that the echocardiogram conducted in conjunction with the September 2019 examination represents the current level of the Veteran's CAD disability, he did not indicate whether those findings apply retrospectively. He also gave a brief explanation as to why the April and November 2015 echocardiogram results may be different, but he did not state whether one finding is more reliable than the other. Therefore, remand was required to obtain an additional opinion to determine the accuracy and reliability of the findings. A new opinion was obtained in July 2021. The examiner wrote that it was more likely that the echocardiogram done in November 2015 is more appropriate. As it more closely approximates the more recent Oct 2019 echocardiogram with lack of cardiac dilation and an ejection fraction of 55 to 60%. An addendum opinion was obtained in September 2021. The examiner wrote that the difference is likely due to the reliability of the person performing the test. When tests are performed in medicine, there will be some variance among those performing the tests which is likely this case. As the November 2015 test most closely reflects the more recent exam, it is likely more reliable. (Continued on the next page) Based on the foregoing, the Board finds that there is no evidence to support an evaluation of 30 percent or higher for the Veteran's service-connected CAD. While the evidence does show that the Veteran was hospitalized for a myocardial infarction in April 2015, the evidence shows that his symptoms remained stable from August 1, 2015 to the present. The Veteran consistently denied symptoms chest pain, dizziness, and fatigue. The Board notes that the Veteran has already been assigned a 100 percent rating for the period from April 25 to August 1, 2015. Furthermore, the one echocardiogram that was completed in November 2015 revealed LVEF of 55 percent, which is more closely aligned with a 30 percent rating under the schedular criteria. Additionally, there is no evidence showing stress tests with a workload of 7 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. Accordingly, a rating in excess of 10 percent for CAD from August 1, 2015 is denied. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Harris, Attorney Advisor 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.