Citation Nr: 21005721 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 181201-1048 DATE: February 2, 2021 ORDER Entitlement to a disability rating in excess of 30 percent for ischemic heart disease for the period from February 11, 2015 to August 1, 2018, with the exception of the period from May 31, 2017 to July 31, 2017, is denied. Entitlement to a temporary total rating for coronary artery disease from May 31, 2017 to July 31, 2017 is granted, subject to regulations governing payment of monetary benefits. FINDING OF FACT 1. Throughout the appeal period, with the exception of the period from May 31, 2017 to July 31, 2017, the Veteran’s heart condition was manifested by dyspnea and fatigue at a workload of 5-7 METs with some reports of dizziness. 2. On May 31, 2017, the Veteran underwent surgery to implant a pacemaker. CONCLUSION OF LAW 1. The criteria for entitlement to a disability rating in excess of 30 percent for ischemic heart disease for the period from February 11, 2015 to August 15, 2018, with the exception of the period from May 31, 2017 to July 31, 2017, were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.7, 4.10, 4.104, Diagnostic Codes (DCs) 7005, 7010, 7011, 7015. 2. The criteria for a temporary total (100 percent) rating for CAD based on implantation of a pacemaker from May 31, 2017 to July 31, 2017 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, DC 7018. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1967 to November 1969, including service in the Republic of Vietnam. The Veteran is the recipient of the Purple Heart Medal. The Board of Veterans’ Appeals (Board) notes that the Rapid Appeals Modernization Program (RAMP) rating decision on appeal was issued in August 2018, in response to the Veteran’s request to opt into the test program through a Supplemental Claim. In November 2018, the Veteran elected the modernized review system, selecting the Hearing Lane for Board review. 38 C.F.R. § 19.2 (d). The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2019. The matter on appeal comes before the Board from an August 2020 order by the United States Court of Appeals for Veterans Claims (CAVC) granting a Joint Motion for Partial Remand (JMPR), which set aside a September 2019 denial by the Board, and remanded the issue on appeal. 1. Entitlement to an increased rating for ischemic heart disease from February 11, 2015 to August 1, 2018, with the exception of the period from May 31, 2017 to July 31, 2017 The Veteran is in receipt of a 30 percent disability rating for ischemic heart disease (IHD) under DC 7005 for the rating period February 11, 2015 to August 1, 2018. Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 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 and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1. Separate ratings may be assigned either initially or during any appeal for an increased rating for separate periods of time based on facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran’s IHD has been rated under DC 7005, which provides that a 10 percent evaluation is assigned for a workload of greater than 7 METs but not greater than 10 METs, which results in dyspnea, fatigue, angina, dizziness, syncope, or continuous medication required. A 30 percent evaluation is assigned for a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted when there is more than one episode of congestive heart failure in the past year, or a workload of greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating contemplates documented coronary artery disease resulting in 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. 38 C.F.R. § 4.104, DC 7005. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination 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. 38 C.F.R. § 4.104, Note (2). When evaluating disabilities of the cardiovascular system under DCs 7000-7007, 7011, and 7015-7020, it must be ascertained in all cases whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram (EKG), echocardiogram (ECG), or X-ray) is present and whether or not there is a need for continuous medication. 38 C.F.R. § 4.100. METs testing is also required in all cases except: (1) when there is a medical contraindication; (2) when the left ventricular ejection fraction has been measured and is 50% or less; (3) when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; (4) when a 100% evaluation can be assigned on another basis. Id. If left ventricular ejection fraction (LVEF) testing is not of record, the cardiovascular disability must be evaluated based on the alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran’s cardiovascular disability. 38 C.F.R. § 4.104, DC 7018, for implantable cardiac pacemakers, advises to evaluate (after a two-month temporary total rating for implantation or reimplantation) under Codes 7010 (for supraventricular arrhythmias), 7011 (for ventricular arrhythmias), or 7015 (for atrioventricular block), and provides for a minimum 10 percent rating after implantation. The Veteran was provided with a VA examination in April 2015. The noted diagnoses were myocardial infarction and coronary artery disease, both diagnosed in 2014. The examiner noted continuous use of medication for heart conditions and that the Veteran did not have congestive heart failure. Left ventricular ejection fraction (LVEF) was noted to be 55 percent. An interview based METs evaluation showed that the Veteran experienced dyspnea and fatigue at a workload of >5-7 METs. It was noted that the heart condition alone did not impact the Veteran’s ability to work. Regarding exercise, the Veteran described walking daily. Regarding hobbies, the Veteran stated hunting and fishing. VA treatment records show that in May 2015, the Veteran specifically denied chest pain, dyspnea with exertion, nocturnal dyspnea, peripheral edema, and history of murmur, palpitations, or myocardial infarction. Dizziness and syncope were also denied. In August 2017, a private examination of the heart showed LVEF of 65 to 75 percent. There are several VA medical records from December 2016 to February 2018. Records from February 2017 note no chest pain, palpitations, or edema and that heart rate and rhythm were normal. Notes from August 2017 and February 2018 are virtually identical to the February 2017 report. In April 2018, a private examiner completed a VA Disability Benefits Questionnaire for heart conditions. Noted heart conditions were implanted pacemaker, hypertension, dizziness, and palpitations. Sick sinus syndrome and a history of bradycardia were also noted. Continuous medication for heart conditions was noted. There was no history of congestive heart failure. No METs testing by exercise or interview was conducted. Regarding ability to work, the examiner stated, “depends on symptoms.” Additionally, the private examiner noted that the Veteran had a cardiac pacemaker implanted on May 31, 2017. The Veteran has specifically requested a 60 percent rating for his heart condition. A 60 percent evaluation under DC 7005 requires evidence showing more than one episode of 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 LVEF of 30 to 50 percent. Here, there is no evidence of congestive heart failure and the Veteran’s LVEF measure, at worst, was 55 percent and at best 75 percent. Regarding the workload at which the Veteran experienced dyspnea, fatigue, angina, dizziness, or syncope due to this service-connected heart condition, the record only provides one METs rating during the period on appeal. During the April 2015 VA examination, the examiner noted a METs rating, based on an interview, that the Veteran experienced symptoms at greater than 5 but less than 7 METs with the reported symptoms being “bilateral lower leg pain related to peripheral vascular disease.” The examiner also noted that the peripheral vascular disease was due to the Veteran’s long history of smoking. Finally, it was noted that the Veteran reported that “he has increased his daily walking which has increased his functional capacity to walk longer distances.” Other records subsequent to the VA examination show virtually no reports of dyspnea, fatigue, angina, dizziness, or syncope, although there was one note of dizziness from the April 2018 examination. Records from August 2017 show LVEF of 65 to 75 percent. Chest pain, dyspnea, and palpitations were specifically denied several times during the appeal period. During the Board hearing in April 2019, the Veteran testified to having shortness of breath three or four times per day and dizziness if standing up quickly and stated that these symptoms have been present since February 2015. The Veteran is competent to describe these types of symptoms as they are observable by a layperson and his account is deemed credible. However, the Board finds these statements less credible, given the contemporaneous medical records that show continued denial of such symptoms. Furthermore, the evaluation of the severity of these symptoms is a medical question requiring expertise and testing by medical professionals. The Veteran does not have the requisite medical experience and is therefore not competent to provide an opinion regarding the specific level of disability he is experiencing. Overall, the evidence of record supports a rating of 30 percent during the period on appeal. The Board has considered whether a higher disability evaluation is available under any other potentially applicable provision of the rating schedule, but found, with the exception of DC 7018, which is addressed below, no other applicable provision was warranted. See 38 C.F.R. § 4.104, DCs 7001-7019. Additionally, the Board notes that a higher disability rating is not available under DC 7010 for supraventricular arrhythmias, and rating criteria under both 7011 and 7015 is the same as under DC 7005. The evidence of record does not show symptoms of a severity in excess of those contemplated by the 30 percent rating criteria under DC 7005. As such, entitlement to an increased rating higher than 30 percent, from February 11, 2015 to August 1, 2018, with the exception of the period from May 31, 2017 to July 31, 2017, is denied. 2. Entitlement to a temporary total rating for coronary artery disease from May 31, 2017 to July 31, 2017 The Board notes that the Veteran had a pacemaker implanted on May 31, 2017. DC 7018 provides for a 100 percent rating following hospital admission for implantation of a cardiac pacemaker. Since a cardiac pacemaker was implanted on May 31, 2017, a 100 percent is warranted for 2 months following that date. A higher rating is not available under DC 7010 for supraventricular arrhythmias, and rating criteria under both 7011 and 7015 is the same as under DC 7005. Accordingly, the Board finds that the evidence of record is in favor of a temporary 100 percent rating for the period on appeal from May 31, 2017 to July 31, 2017. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David M. Sebstead, 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.