Citation Nr: 21006467 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 14-32 702 DATE: February 4, 2021 ORDER From September 25, 2009, to February 27, 2017, entitlement to a rating of 30 percent, but not higher, for coronary artery disease is granted, subject to the law and regulations governing the payment of monetary benefits. From February 28, 2017, entitlement to a rating in excess of 60 percent for coronary artery disease is denied. FINDINGS OF FACT 1. From September 25, 2009, to February 27, 2017, the Veteran presented with evidence of cardiac hypertrophy; there was no chronic congestive heart failure in the past year, workload of less than 5 METs, or left ventricular dysfunction with an ejection fraction of 50 percent or less. 2. From February 28, 2017, the Veteran’s coronary artery disease did not result 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. CONCLUSIONS OF LAW 1. From September 25, 2009, to February 27, 2017, the criteria for a rating of 30 percent, but no higher, for the Veteran’s coronary artery disease have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.321, 4.104, Diagnostic Code 7005 (2019). 2. From February 28, 2017, the criteria for an increased rating in excess of 60 percent for the Veteran’s coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.321, 4.104, Diagnostic Code 7005 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1975 to February 1977 and in the United States Army from January 1985 to March 1985. This matter comes before the Board of Veterans’ Appeals (Board) from December 2008 and March 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In August 2017, the Veteran testified at a central office hearing before the undersigned. A transcript of that hearing is of record. This claim was previously before the Board in April 2020, at which time it was remanded for additional development. Increased Rating 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 or her 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 by the schedule are considered adequate to compensate veterans for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Coronary Artery Disease The Veteran’s cardiac disability has been rated as 10 percent disabling from September 25, 2009, to February 27, 2017, and as 60 percent disabling thereafter. Under Diagnostic Code 7005, a 10 percent evaluation is warranted where there is a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness or syncope; or, continuous medication required. A 30 percent evaluation is warranted where there is a workload of greater than 5 METs but not greater than 7 METs, where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted where there is evidence of 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, resulting in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Finally, a 100 percent evaluation is warranted where there is 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. 38 C.F.R. § 4.104, Diagnostic Code 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). 1. From September 25, 2009, to February 27, 2017, entitlement to a rating in excess of 10 percent for coronary artery disease The Veteran received a cardiology diagnostic study consultation in July 2009 and at that time, a cardiovascular stress test revealed 10 METs. The Veteran received a cardiology diagnostic study consultation in October 2009 and the physician noted that the left ventricle was normal in size. There was severe concentric left ventricular hypertrophy but left ventricular systolic function was normal. Ejection fraction was visually estimated at 55 percent to 65 percent. There were no regional wall motion abnormalities noted and the left atrial size was normal. A December 2009 VA examination indicated METs achieved was 8.4. Stress test results revealed changes in the inferior and lateral leads suggestive of silent ischemia. No chest pain was reported. The Veteran received a private echocardiographic report in February 2012 which revealed mild left atrial enlargement, mild left ventricular hypertrophy, normal biventricular function and size, and normal valve function. The estimated left ventricular ejection fraction was 65 percent. Based on the results of the October 2009 cardiology diagnostic study and February 2012 private echocardiographic report, the Board finds that a rating of 30 percent, but not higher, is warranted for coronary artery disease due to evidence of cardiac hypertrophy. A rating in excess of 30 percent is not justified. The medical evidence did not report a left ventricular ejection fraction of less than 50 percent, nor did it report METs of 5 or less. Also, there is no medical evidence of acute congestive heart failure or chronic congestive heart. For these reasons, a disability rating in excess of 30 percent is not warranted. 2. From February 28, 2017, entitlement to a rating in excess of 60 percent for coronary artery disease The Veteran received a VA examination in February 2017 and the examiner indicated that he did not require continuous medication for his heart condition. There was no myocardial infarction, congestive heart failure, or cardiac arrythmia. The Veteran did not have any infectious cardiac conditions, pericardial adhesions, and had not had any non-surgical or surgical procedures for the treatment of a heart condition. There was no cardiac hypertrophy or cardiac dilatation. Exercise stress testing was not required as part of the Veteran’s current treatment plan and such testing was without significant risk. An interview-based METs test was therefore completed which revealed a METs level of greater than 3 to 5 METs with dyspnea, fatigue, angina, dizziness, and syncope. This METs level provided was solely due to the Veteran’s heart condition. At the August 2017 Board hearing, the Veteran testified that he had not had an echocardiogram since 2008 or 2009. He noticed some dyspnea when doing work outside and it worsened a little over a year ago. The Veteran used to be able to do strenuous walking and exercise, and he could no longer do yard work for more than 30 minutes. With regards to the gap in treatment from December 2009 to February 2017, the Veteran testified that he sought private treatment if he needed to see a doctor immediately. He was not, however, seeing a cardiologist or specialist for his heart condition nor seeing any physician on a regular basis for the past seven or eight years. The Veteran did not take any medication for his heart, and his wife testified that she noticed he started to slow down around 2010 with his activities. Pursuant to the April 2020 Board remand, the Veteran received a VA examination in October 2020 and the physician noted that he did not require continuous medication for his heart condition. There was no myocardial infarction, congestive heart failure, or cardiac arrythmia. The Veteran did not have any infectious cardiac conditions, pericardial adhesions, and had not had any non-surgical or surgical procedures for the treatment of a heart condition. There was no cardiac hypertrophy, but evidence of cardiac dilatation. An EKG revealed sinus bradycardia and left axis deviation, and an echocardiogram revealed a left ventricular ejection fraction of 60 percent. Exercise stress testing was not required as part of the Veteran’s current treatment plan and such testing was without significant risk. An interview-based METs test was therefore completed which revealed a METs level of greater than 3 to 5 METs with dyspnea. This METs level provided was not solely due to the Veteran’s heart condition; the estimated METs level due solely to the Veteran’s cardiac condition was 7 to 10 METs. On review of the evidence, the Board finds that a rating in excess of 60 percent for the Veteran’s coronary artery disease is not warranted from February 28, 2017. The evidence of record for this period does not demonstrate that the Veteran experienced chronic congestive heart failure, nor did he have a workload of 3 METs or less. Furthermore, the Veteran’s ejection fraction was never less than 30 percent. Therefore, the Board finds that the evidence is against entitlement to the next higher schedular rating of 100 percent. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Daniels, 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.