Citation Nr: 21072183 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 16-49 932A DATE: December 2, 2021 ORDER Entitlement to a disability rating in excess of 30 percent for coronary artery disease (CAD) prior to January 30, 2017 is denied. Entitlement to a 60 percent disability rating for CAD from January 30, 2017 to March 4, 2021 is granted. Entitlement to a disability rating in excess of 60 percent for CAD from March 4, 2021 is denied. FINDINGS OF FACT 1. For the period prior to January 30, 2017, the Veteran's CAD was manifested by a workload of greater than five METs but not greater than seven METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, with no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 2. For the period from January 30, 2017 to March 4, 2021, the Veteran's CAD was manifested by a workload of greater than three METs but not greater than five METs resulting in dyspnea, angina, and dizziness. There has been no showing of chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. 3. For the period since March 4, 2021, the Veteran's CAD is not manifested by a workload of 3 METs or less, left ventricular dysfunction with an ejection fraction of 30 percent or less, or chronic congestive heart failure. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 30 percent disability rating for CAD prior to January 30, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for entitlement to a 60 percent disability rating for CAD from January 30, 2017 to March 4, 2021 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.104, Diagnostic Code (DC) 7005. 3. The criteria for entitlement to a disability rating in excess of 60 percent for CAD from March 4, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.104, DC 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty from August 1968 to March 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). By way of history, the Veteran filed a claim for service connection for CAD in January 2011. A rating decision dated June 2014 granted service connection for CAD, assigning a 10 percent disability rating, effective August 31, 2010. In March 2015, the Veteran filed a claim for an increased disability rating, resulting in the April 2015 rating decision on appeal. Subsequently, the Veteran appealed the claim to the Board. The Board issued a decision in January 2019, which was appealed to the United States Court of Appeals for Veterans Claims (Court) and vacated in August 2020. Subsequently, the claims returned to the Board in January 2021, at which time the Board remanded the claims to the Agency of Original Jurisdiction (AOJ) for further evidentiary development. During the pendency of the appeal and following the directed development, the AOJ issued a June 2021 rating decision increasing the Veteran's disability rating for CAD to 60 percent, effective March 4, 2021. The specific stages on appeal presently before the Board are discussed in detail below. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. In this case, staged ratings are in effect. Specifically, from the grant of service connection in August 2010, the Veteran is in receipt of a 30 percent rating. During the course of the appeal, an additional stage was created. A 60 percent disability rating is in effect from March 4, 2021. Both stages are before the Board on appeal. Arteriosclerotic heart disease is rated pursuant to 38 C.F.R. § 4.104, DC 7005, for arteriosclerotic heart disease (coronary artery disease or CAD). Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when continuous medication is required. A 30 percent rating is warranted where 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 dilation 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 100 percent rating is warranted for chronic congestive heart failure; 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. One metabolic equivalent (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. See 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. 1. Entitlement to a disability rating in excess of 30 percent for CAD prior to January 30, 2017 is denied. 2. Entitlement to a 60 percent disability rating for CAD from January 30, 2017 to March 4, 2021 is granted. 3. Entitlement to a disability rating in excess of 60 percent for CAD from March 4, 2021 is denied. As background, the Veteran was granted service connection for CAD in a June 2014 rating decision and assigned a 10 percent disability rating, effective August 31, 2010. The Veteran subsequently filed a notice of disagreement (NOD) with the assigned disability rating and appealed this claim to the Board. During the pendency of the appeal, the disability rating for the Veteran's CAD was increased to 30 percent, effective December 16, 2011. Thereafter, a June 2021 rating decision increased the Veteran's disability rating further to 60 percent disabling, effective March 4, 2021, further discussed below. The Veteran's CAD is currently rated 30 percent disabling prior to March 4, 2021 under DC 7005. The Veteran contends he is entitled to a higher rating. Evidence relevant to the entire period on appeal includes VA examinations and accompanying reports, private heart evaluations, VA treatment records, and private treatment records. Prior to January 30, 2017 The Veteran underwent a VA examination for heart conditions in November 2012. The Veteran described feelings of his chest tightening and pain. The VA examiner indicated that the Veteran has not had congestive heart failure (CHF). An echocardiogram was performed, and the Veteran's left ventricular ejection fraction (LVEF) was 60 percent. An interview based METs test was performed, and the Veteran endorsed dyspnea and angina. The Veteran's METs level was greater than seven to 10 METs. The Veteran underwent an additional VA examination in May 2014. The VA examiner found that the Veteran had not had a myocardial infarction nor congestive heart failure. Physical exam found regular heart rhythm and normal heart sounds, no jugular-venous distension, clear auscultation, normal peripheral pulses, and trace peripheral edema in both the right and left lower extremities. An echocardiogram was performed, and the Veteran's LVEF was 60 to 65 percent. An exercise stress test from November 16, 2012 reflected that the Veteran's METs level was 8.3. The Veteran also completed an interview based METs test, which reflected the METs level of greater than 7 to 10 METs. The Veteran endorsed dyspnea during the interview based METs test as well. In support of his claim for an increased rating, the Veteran submitted a heart conditions disability benefits questionnaire (DBQ) in March 2015. However, only two pages of the DBQ were submitted by the Veteran. Missing pages included the tests and data relevant for VA rating purposes. As such, the March 2015 private DBQ will not be considered when determining the proper rating for the Veteran's service-connected CAD prior to January 2017. Based on the foregoing, a preponderance of the evidence reflects that, prior to January 30, 2017, a rating higher than 30 percent is not warranted for CAD. Prior to January 30, 2017, the Board finds that an initial rating in excess of 30 percent is not warranted for the Veteran's CAD. Under Diagnostic Code 7005, a 30 percent rating is warranted if the workload greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. Here, the Veteran's CAD was demonstrated by symptoms of dyspnea and angina, and, at worst, demonstrated a METs level of 7 to 10. As such, prior to January 30, 2017, the Veteran's CAD symptoms more closely approximated the 30 percent rating already assigned and a higher rating is not warranted. From January 30, 2017 to March 4, 2021 The Veteran underwent a VA examination in January 2017. During the January 2017 VA examination the Veteran reported increasing fatigability and dizziness. The VA examiner indicated that the Veteran did not have myocardial infarction nor CHF. Physical exam found regular heart rhythm and normal heart sounds, no jugular-venous distension, clear auscultation, diminished peripheral pulses, and no peripheral edema. The VA examiner used the findings from the May 2014 echocardiogram, which reflected that the Veteran had an LVEF of 60 to 65 percent. Interview based METs testing was performed, and the Veteran endorsed dyspnea, fatigue, angina, and dizziness. The Veteran's METs level was found to be three to five METs. The VA examiner indicated that the interview based METs testing most accurately reflected the Veteran's current cardiac function level. Based on the foregoing, the preponderance of the evidence reflects that from January 30, 2017 a 60 percent, but no higher, rating is warranted for the Veteran's CAD. From January 30, 2017, the Board finds that a 60 percent, but no higher, rating is warranted for the Veteran's CAD. Under Diagnostic Code 7005, a 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; workload of greater than three METs but not greater than five METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or for LVEF of 30 to 50 percent. Here, on January 30, 2017 VA examination, during an interview-based METs test, the Veteran had a workload of three to five METs resulting in symptoms of dyspnea, fatigue, angina, and dizziness. As the Veteran demonstrated the requisite METs level and associated symptoms, the criteria for a 60 percent rating under Diagnostic Code 7005 have been met as of January 30, 2017. However, a total rating (100 percent) is not warranted as there is no competent evidence that the Veteran's CAD has been demonstrated by chronic congestive heart failure, or a workload of 3 METs or less results, or LVEF of less than 30 percent. During the January 2017 VA examination, there was no evidence of chronic congestive heart failure, METs levels were three to five, and an echocardiogram showed a LVEF of 60 to 65 percent. These findings are consistent with December 2018 private opinion which concluded that the METs score of three to five, and symptoms of dizziness, dyspnea on exertion (DOE), and chest pain, reflected by the January 2017 VA examination, are more likely than not based solely on the Veteran's heart function.. Therefore, the Board finds that the preponderance of the evidence supports the grant of a 60 percent, but no higher, rating for CAD, effective January 30, 2017. Prior to this date, a rating in excess of 10 percent is denied. In evaluating the claim, all reasonable doubt has been resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. From March 4, 2021 The Veteran was granted a 60 percent evaluation for CAD effective March 4, 2021. He contends his disability symptoms following that date warrant a higher evaluation. Therefore, the question for the Board is whether the evidence demonstrates a rating in excess of 60 percent is warranted after March 4, 2021. The Veteran was provided an in-person VA examination in March 2021. The Veteran reported during the examination that his heart condition has remained unchanged since his last VA examination; that he has had no subsequent heart procedures, no myocardial infarctions, and ho hospitalizations. The VA examiner noted that continuous medication is required for the control of the Veteran's heart condition. The VA examiner denied that the Veteran has congestive heart failure. Physical exam found regular heart rhythm and normal heart sounds, no jugular-venous distension, clear auscultation of the lungs, diminished peripheral pulses, and no peripheral edema. The Veteran's blood pressure reading was 138/80. An EKG was performed during the examination with normal results. Interview based METs testing was performed during the examination, and the Veteran endorsed fatigue and angina. The Veteran's METs level was found to be three to five METs. An addendum to the March 2021 VA examination was obtained in June 2021 addressing whether the Veteran has a comorbid condition, separate from CAD, which would affect the METs level. The June 2021 VA examiner stated "there is no evidence of a comorbid condition impacting the Veteran's METs level. Records note no history of a cerebrovascular event or stroke. Regardless, the opinion rendered was that the METS level of three to five at that time was related to his cardiovascular condition, including CAD. Review of the available cardiac records reflect no comorbid condition affecting the Veteran's METs level." The Board concludes that the Veteran's CAD is not manifested by chronic congestive heart failure, or a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or a left ventricular dysfunction with an ejection fraction of less than 30 percent. These findings correspond to the criteria for a 100 percent rating under DC 7005. The medical evidence does not show chronic congestive heart failure at any point during the appeal period. Records reveal a workload of three to five METs resulting in dyspnea, fatigue, angina, dizziness. Thus, the Board concludes that the Veteran's arteriosclerotic heart disease did not meet the criteria corresponding to a higher 100 percent rating. The Veteran is competent to report his readily observable symptoms, however he is not shown to be competent to provide a medical opinion on his condition. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Opinions of the VA examiners and the probative VA and private treatment record are given significant probative value and weight. As there is no contrary medical evidence favoring a total disability rating for CAD, the preponderance of the evidence is against an evaluation in excess of 60 percent. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to an increased rating for CAD is not warranted after March 4, 2021. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). C. Casey Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. M. Lowman, 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.