Citation Nr: 21006554 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 16-01 190 DATE: February 4, 2021 ORDER Entitlement to a rating in excess of 30 percent for coronary artery disease is denied. FINDING OF FACT Coronary artery disease manifested by 5 metabolic equivalents (METs) but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1–4.7, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1967 to February 1969. The Veteran testified before the undersigned Veterans Law Judge at a March 2019 Travel Board hearing. With respect to the Board hearing, the undersigned clarified the issues on appeal, identified potential evidentiary deficits, and clarified the type of evidence that would support the Veteran’s claim. These actions complied with any duties owed during a hearing. 38 C.F.R. § 3.103. Ratings Principles Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R., Part 4. The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If the evidence for and against a claim is an equipoise, the claim will be granted. 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. Derwinksi, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). 1. Coronary artery disease The Veteran’s coronary artery disease is evaluated at 30 percent disabling under Diagnostic Code 7005. The Veteran seeks a higher rating. Diagnostic Code 7005 provides a 30 percent evaluation is warranted for 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 evaluation 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 when a 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, Diagnostic Code 7005. A note prior to the Diagnostic Code explains that one 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. 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. 38 C.F.R. § 4.104, Note (2). The Veteran’s claim was received in August 2012 and the current rating has been in effect since. A VA examination to assess the coronary artery disease occurred in May 2013. The examiner found workload of greater than five METs but not greater than seven METs resulting in fatigue. The Veteran also required continuous medication. The remarks section reads that the Veteran had status-post liver and kidney transplant as of February 2012, which confounds his functional cardiac capacity. The Veteran did not and does not have angina. The Veteran was asymptomatic with respect to his heart condition (no chest pains) and was found to have 95 percent blockage of his coronary artery and had a stent placed for his pre-op work up pending his February renal and liver transplant (per self-report). He does not have any scars related to his heart disease. A private echocardiogram dated in July 2016 indicates that the left ventricle appeared to be hyperdynamic. An August 2016 private treatment record notes that estimated left ventricle ejection fraction is greater than 70 percent and that left ventricular wall thickness is severely increased. An activity level exercise test showed mild results, with greater than 3 METs. The Veteran denied chest pain (CP), dyspnea on exertion (DOE), and was able to walk up two flights of stairs without shortness of breath (SOB). A March 2018 private treatment record indicates an activity level exercise test showed mild results, with greater than 3 METs. A May 2018 private treatment record states an activity level exercise test showed moderate results, with greater than 4-10 METs. Again, there was no dyspnea on exertion and the Veteran was able to walk-up two flights of stairs without chest pain or significant dyspnea. At his March 2019 Board hearing, the Veteran indicated that his coronary artery disease had worsened. He also reported he had high blood pressure, fatigue, dizziness, and reported he spent four months in bed due to poor circulation. The Board remanded in order to obtain a new examination. A VA examination was obtained in September 2020. Medical history was reported as there was not much in the way of recent treatment notes regarding heart. This may be due to other morbidities primarily liver/kidney transplant. The Veteran reported he walks about 100 feet to mailbox and walks around his house. The Veteran had atrial fibrillation, intermittent, with no known episodes in the last 12 months. Treatment includes taking aspirin and atorvastatin. Theoretical METs was given as other morbidities limit activity. The examiner estimated a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope. The Veteran required continuous medication. A 30 percent evaluation was awarded for workload of greater than five METs but not greater than seven METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. Medical records and VA examinations do not show any of the manifestations required for a higher rating. There was one report of four-to-ten METs on a private record and several of METs greater than three. None of these records show that the Veteran had METs of four, only that the estimated range was somewhere above three. The medical opinion that METs were greater than 3 is non-specific and the Board remanded to obtain an actual estimate that could be used in the evaluation of the disability. The VA examinations specifically show five METs but not greater than seven METs. The Board has considered the Veteran’s report of symptoms, but they are less probative of the rating criteria as compared with the medical evidence. His assertion of an increase in severity was considered. However, the more probative evidence consists of the medical evidence prepared by a skilled examiner. The preponderance of the evidence is against a rating in excess of 30 percent. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Yoffe, 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.