Citation Nr: 21074342 Decision Date: 12/15/21 Archive Date: 12/14/21 DOCKET NO. 19-18 350 DATE: December 15, 2021 ORDER Entitlement to an initial rating in excess of 30 percent for the period from May 8, 2002 to April 22, 2015 for ischemic heart disease, to include coronary artery disease (CAD) is denied. From April 23, 2015 forward, a rating of 60 percent for ischemic heart disease, to include CAD, is granted. FINDINGS OF FACT 1. For the period of May 8, 2002, to April 22, 2015, the Veteran's ischemic heart disease, to include CAD, manifested with an ejection fraction of greater than 60 percent, and a METs level of greater than 7 but less than 10. 2. Resolving all reasonable doubt in his favor, since April 23, 2015, the Veteran's ischemic heart disease, to include CAD, manifested with an ejection fraction of 50 percent. CONCLUSIONS OF LAW 1. For the period of May 8, 2002, to April 22, 2015, the criteria for entitlement to an initial rating of 30 percent for ischemic heart disease, to include CAD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. 2. Since April 23, 2015, the criteria for entitlement to a rating of 60 percent for ischemic heart disease, to include CAD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Air Force from March 1964 to November 1968. The Board notes that in March 2020 the Veteran informed the Board that he no longer wished to be represented by any veterans' service organization, and preferred to represent himself, and his revocation of representation was acknowledged in a January 2021 letter from the Board. See March 2020 Correspondence; see January 2021 Status Letter. Thus, the Veteran is currently self-represented in this case. 38 C.F.R. § 14.631(f)(1). The Veteran had a Board hearing in April 2021 before the undersigned, and a hearing transcript will be associated with the record upon its completion. See April 2021 VA 27-0820 Report of General Information. In May and September 2021, the Board remanded this matter to the RO for additional development. Increased Rating By way of background, the Veteran's claim of entitlement to service connection for CAD (previously claimed as a heart condition (Nehmer decision) was granted in an August 2017 rating decision, and evaluated as 30 percent disabling effective August 19, 2015. See August 2017 Rating Decision-Narrative. In May 2021, the Board granted the Veteran an earlier effective date of May 8, 2002 for the award of service connection for ischemic heart disease, to include CAD, and assigned a rating of 60 percent for this disability, effective June 15, 2015. Therefore, the remaining issue before the Board is entitlement to an initial rating in excess of 30 percent for the period from May 8, 2002 to June 14, 2015 for ischemic heart disease, to include CAD, pursuant to Diagnostic Code 7005. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. § 4.1 (2020). Under Diagnostic Code 7005, a 30 percent rating is warranted for arteriosclerotic heart disease (CAD) resulting in a workload of greater than 5 METs but not greater than 7 METs resulting 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 CAD resulting in more than one episode of acute congestive heart failure in the past year, or; a workload of 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. A 100 percent rating is warranted for CAD resulting in 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. For rating diseases of the heart, one MET (metabolic equivalent) 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. 38 C.F.R. § 4.104, Note 2. The Veteran was first examined by VA in June 2008 and again in September 2008 to determine the nature and etiology of any diagnosed heart disabilities. However, those examinations do not include any objective testing, to include ejection fraction of METs testing so as to ascertain the severity of this disability pursuant to Diagnostic Code 7005. See June 2008 and September 2008 VA Examinations. A September 2008 private echograph of the left ventricle was normal in size and left ventricular contractility was normal with an estimated ejection fraction of 65 percent. It also showed apparent evidence of mild concentric left ventricular hypertrophy. During an April 2011 VA Ischemic Heart Disease Disability Benefits Questionnaire (DBQ), it was found the Veteran had a METs level of more than 7 but less than 10. The March 2011 echocardiogram showed left ventricular ejection fraction of 62 percent. No other physical abnormalities were noted. Thereafter, a June 2015 VA Heart Conditions DBQ noted that an April 23, 2015 echogardiogram showed ejection fraction of 50 to 55 percent. See June 2015 VA Heart Conditions DBQ. As was noted in the prior May 2021 Board decision, during that examination the METs level was found to be greater than 5 but less than 7. In May 2021, the Board then remanded this initial period on appeal (from May 8, 2002 to June 14, 2015), requesting an examination and retrospective opinion regarding the severity of the CAD. On examination, the August 2021 examiner noted an echocardiogram performed in July 2017 showed a left ventricular ejection fraction of 57 percent. An interview-based METs test performed in August 2021 showed a METs level of greater than 5 but less than 7, with dyspnea and fatigue. However, the VA examiner did not provide the requested retrospective opinion for the period from May 8, 2002 to June 14, 2015, and provided objective findings only for the period dated since June 14, 2015. A September 2021 VA addendum opinion was obtained. After a review of the claims file, the examiner stated that there was no indication of congestive heart failure or a work load equal to or less than 5 METs from the period May 8, 2002 to June 14, 2015. Also of record are VA and private treatment records dated throughout the current period on appeal, from May 8, 2002 to June 14, 2015. Specifically, private treatment records dated in August and September 2001 show diagnoses of cardiovascular disease of CAD. A September 2001 echocardiogram showed normal left ventricular dimensions and systolic function based on calculated ejection fraction of 75 percent. The estimated left ventricle (LV) ejection fraction was found to be 65 to 70 percent. Additionally, a calculated ejection fraction of 65 precent was noted for the impression of inferior ischemia. Similarly, a December 2001 echocardiogram showed an ejection fraction of 75 percent, and stress test imaging showed inferior wall ischemia, with an ejection fraction of 68 percent. Left ventricular ejection fraction was noted to be 74 percent. Here, the Board finds a rating of 60 percent is warranted from the April 23, 2015 echogardiogram, which showed an ejection fraction window of 50 to 55 percent. See June 2015 VA Heart Conditions DBQ. The next higher rating of 100 percent is not warranted from April 23, 2015 to June 14, 2015 as the evidence does not show a 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. See 38 C.F.R. § 4.104, Diagnostic Code 7005; see also June 2015 VA Heart Conditions DBQ. For the period of May 8, 2002 to April 23, 2015, the Board finds an initial rating in excess of 30 percent is not warranted. Specifically, the Veteran's ejection fraction was found to be, at worst, 62 percent. See again April 2011 VA Ischemic Heart Disease DBQ. This VA examination also found a METs level of more than 7 but less than 10. Id. Moreover, the September 2021 VA addendum opinion examiner specifically noted there was no indication of congestive heart failure or a work load equal to or less than 5 METs from the period May 8, 2002 to June 14, 2015. The Board is aware that the Veteran believes that the examination he was provided by the VA in April 2011 was inadequate to diagnose ischemic heart disease, (based on a doctor telling him that an ultrasound would not catch blockages). See April 2017 Congressional; see September 2018 NOD; see April 2011 VA Examination Ischemic Heart Disease. The Board, however, notes that there is no evidence that the Veteran was intentionally sent for the wrong examination. Further, as the question before the Board is one of severity, not etiology, any argument concerning the diagnosis of the heart disability is not factored in to the matter at hand. Accordingly, the Board finds that there is at least an equipoise of the evidence that the ejection fraction was 50 percent, as indicated by the April 23, 2015 echocardiogram, reported in the VA examination of June 15, 2015, showing an ejection fraction of 50 to 55 percent. Therefore, a 60 percent rating is warranted from the date of the echocardiogram, April 23, 2015. However, the preponderance of the evidence is against a rating higher than 30 percent for the period of May 8, 2002 to April 23, 2015, or in excess of 60 percent thereafter. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berry, 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.