Citation Nr: 21072761 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 15-45 485 DATE: December 6, 2021 ORDER Entitlement to an initial rating for coronary artery disease (CAD) status post coronary artery bypass graft (CABG) in excess of 10 percent from October 1, 2012 to August 18, 2013 is denied. Entitlement to a 60 percent rating, but no higher, for CAD status post CABG from August 19, 2013 to October 30, 2019 is granted. Entitlement to a rating in excess of 10 percent for CAD status post CABG from October 31, 2019 is denied. FINDING OF FACT 1. From October 1, 2012 to August 18, 2013, the evidence does not show that the Veteran had chronic congestive heart failure, more than one episode of acute congestive heart failure in the past year, a workload of 7 metabolic equivalent (METs) or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, evidence of cardiac hypertrophy or dilatation, or left ventricular dysfunction with an ejection fraction (LVEF) of 50 percent or less. 2. From August 19, 2013 to October 30, 2019, the evidence shows the Veteran had LVEF of 48 percent. The evidence does not show he had chronic congestive heart failure, a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or LVEF of less than 30 percent. 3. From October 31, 2019, the evidence does not show that the Veteran had congestive heart failure, more than one episode of acute congestive heart failure in the past year, LVEF of 50 percent or less, or cardiac hypertrophy or dilatation. CONCLUSION OF LAW 1. The criteria for an initial rating in excess of 10 percent for CAD status post CABG in excess of 10 percent from October 1, 2012 to August 18, 2013 have not been met. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104 Diagnostic Code (DC) 7005. 2. The criteria for a 60 percent rating, but no higher, for CAD status post CABG from August 19, 2013 to October 30, 2019 have been met. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104 DC 7005. 3. The criteria for a rating in excess of 10 percent for CAD status post CABG from October 31, 2019 have not been met. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104 DC 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from January 1968 to December 1970, from December 2003 to April 2005, and from October 2005 to February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). A hearing was held in February 2019 with the undersigned Veterans Law Judge. The transcript of the hearing is included in the record. The Board remanded this matter in May 2019 as the Veteran asserted worsening of his CAD. An October 2019 VA examination (VAX) was provided in compliance with the remand instructions. Thus, this matter is ripe for adjudication. INCREASED RATING Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. The evaluation of the same disability under several DCs, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran's CAD has been rated under DC 7005, which provides ratings for arteriosclerotic heart disease (ASHD). ASHD includes 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; continuous medication 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. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. See Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. Entitlement to an initial rating for CAD status post CABG in excess of 10 percent from October 1, 2012 to August 18, 2013 is denied. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's IHD/CAD disability. VA treatment records show that the Veteran underwent a coronary artery bypass in June 2012, which is prior to the date of service connection. However, in relation to that surgery, and the symptomatology that had existed, a 100 percent rating was assigned from September 6, 2012, to October 1, 2012. A 10 percent rating was assigned thereafter. The Veteran was afforded a VAX in August 2013. The VA examiner determined that there was no congestive heart failure, no hypertrophy, and no dilatation. Reference was made to a July 2013 echocardiogram showing that the Veteran's left ventricular function was normal with an ejection fraction from 55 to 60 percent. His METS was 10. The remaining medical records for this period do not include any pertinent findings pertaining to the Veteran's heart disability. Consideration has been given to the Veteran's assertion that he warrants a higher rating. However, outside the argument that a higher rating is warranted, the evidence presented does not suggest that the symptomatology of his heart disability meets the schedular requirements for a rating greater than 10 percent. The existing medical evidence outweighs his lay assertion. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran's claim for an increased initial rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Entitlement to a 60 percent rating, but no higher, for CAD status post CABG from August 19, 2013 to October 30, 2019 is granted. After careful review of the evidence of record, the Board finds that a 60 percent rating, but no higher, is warranted from August 19, 2013 to October 30, 2019 for the Veteran's IHD/CAD disability. VA treatment records show that on August 19, 2013, the Veteran had a LVEF of 48 percent. The imaging showed a large area of ischemia in the right coronary artery territory. The Board affords these treatment records substantial probative weight. Indeed, as it will be discussed in more detail below, the LVEF or EF has been determined to be the best indicator of the Veteran's heart disability. A rating in excess of 60 percent is not warranted as the Veteran's IHD/CAD disability. There is no evidence that the Veteran experienced chronic congestive heart failure or LVEF of less than 30 percent. The evidence is not suggestive that his heart symptomatology meets the schedular requirements for a rating in excess of 60 percent. The existing medical evidence outweighs any lay assertion. In sum, and after affording all doubt in his favor, the evidence shows a disability rating of 60 percent is warranted for the Veteran's IHD/CAD disability. His claim for an increased rating is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Entitlement to a rating in excess of 10 percent for CAD status post CABG from October 31, 2019 is denied. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's IHD/CAD disability. The Veteran was afforded a VAX on October 31, 2019. The VA examiner determined that there was no congestive heart failure, no hypertrophy, and no dilatation. His LVEF was 55 to 60 percent. Although, he experienced fatigue and dyspnea at a workload of greater than 3 METs, but not greater than 5 METs. The VA examiner determined that his METs test was limited due to multiple medical conditions and it was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. Crucially, as the Veteran's "METS testing is limited by many factors", the examiner opined that "the EF (ejection fraction) is the better indicator of heart manifestations of IHD alone." The remaining medical records for this period do not include any pertinent findings pertaining to the Veteran's heart disability. The VAX and medical records do not support a higher rating for his IHD/CAD disability. The evidence does not show that the Veteran had chronic congestive heart failure, more than one episode of acute congestive heart failure in the past year, evidence of cardiac hypertrophy or dilatation, or LVEF of 50 percent or less. Consideration has been given to the Veteran's assertion that he warrants a higher rating. However, outside the argument that a higher rating is warranted the evidence presented does not suggest that the symptomatology of his IHD/CAD disability alone meets the schedular requirements for a rating greater than 10 percent. The existing medical evidence outweighs his lay assertion. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran's claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Smith, 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.