Citation Nr: 21008411 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 13-09 125 DATE: February 17, 2021 ORDER From January 1, 2005 to December 7, 2010, entitlement to a rating in excess of 30 percent for the Veteran’s coronary artery disease (CAD) is denied. FINDING OF FACT From January 1, 2005 to December 7, 2010, the Veteran’s CAD was manifested by a workload of greater than 5 METs but less than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. CONCLUSION OF LAW From January 1, 2005 to December 7, 2010, the criteria for entitlement to a rating in excess of 30 percent for CAD have not been met. 38 U.S.C. §§ 1110, 1155; 38 C.F.R. §§ 3.303, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1969 to March 1971. This case comes before the Board of Veterans’ Appeals (Board) on appeal from October 2004, March 2006, June 2007, and November 2020 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The appeal was last remanded by the Board in February 2020 for additional development. A review of the claims file shows that there has been substantial compliance with the Board’s prior remand directives and thus, no further action in this regard is warranted. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). With the initial rating assigned with the award of service connection for a disability, “staged” ratings to reflect distinct periods when different levels of impairment were shown are for consideration. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). Diagnostic Code 7005 assesses arteriosclerotic heart disease (CAD). A 30 percent rating is assigned where a workload greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction (LVEF) of 30 to 50 percent; or for more than one episode of acute congestive heart failure in the past year. A 100 percent rating is assigned where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; for an LVEF of less than 30 percent; or for chronic congestive heart failure. 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). Under Diagnostic Code 7006, a 100 percent rating is assigned for three months following a myocardial infarction, documented by laboratory tests. 38 C.F.R. § 4.104 Diagnostic Code 7006 The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when: (1) the weight of the evidence supports the claim, or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For the period from January 1, 2005 to December 7, 2010, entitlement to a rating in excess of 30 percent for coronary artery disease The Veteran contends that for the period from January 1, 2005 to December 7, 2010, his CAD was 100 percent disabling. Factual Background A September 2004 VA treatment record indicates that the Veteran had a myocardial infarction and had three stents placed. A May 2005 echocardiogram contained in VA treatment records notes that the Veteran had a left ventricular ejection fraction (LVEF) of 70 percent. The Veteran was afforded a VA examination for his diabetes in June 2005. The June 2005 VA examiner’s report noted that the Veteran had a myocardial infarction in September 2004 resulting in an angioplasty and stent placement. The VA report also noted that the Veteran reported walking eight blocks daily with dyspnea on exertion at four blocks and constant fatigue. The Veteran reported that he did not do any housework or yardwork because of his posttraumatic stress disorder. The Veteran denied dizziness and syncope. His estimate workload was 6 METs. A November 2005 VA treatment record notes that the Veteran had three stents placed in September 2004. A June 2006 VA treatment record notes that the Veteran had stents “x 2”. A March 2007 VA treatment record notes that the Veteran had a myocardial infarction in 2005 and had three stents placed. The record also notes that the Veteran had great improvement since the stents with no cardiac symptoms such as angina, dyspnea, fatigue, dizziness, and syncope. The record further notes that the Veteran exercised daily, walked fourteen blocks daily, and had an estimated workload of 7.9 METs according to a stress test. A March 2007 echocardiogram determined the Veteran’s LVEF was 65 percent. The Veteran underwent a stress test in April 2007. The April 2007 VA stress test noted that the Veteran’s LVEF was 70 percent. An April 2008 VA treatment record documents that the Veteran had a stress test a week prior that revealed mild ischemia. A December 2010 VA treatment record documented that the Veteran had three stents placed in 2004. A May 2011 VA treatment record indicates that the Veteran had myocardial infarctions in 2001 and 2005. November 2013 and February 2014 VA examiner’s reports documented myocardial infarctions in September 2004 and December 2010. A February 2020 VA addendum opinion noted that the Veteran had a myocardial infarction in 2005 and another in 2010. The VA examiner also determined, however, that laboratory testing from September 2004 confirmed that the Veteran had a myocardial infarction then as well. The VA examiner explained that the troponin, a cardiac marker, level rose 10.6 which is “way over and above the upper limit of normal 0.4 for that lab.” The examiner further explained that a cardiac catherization performed that same day showed complete occlusion of the circumflex vessel. Another VA addendum opinion was obtained in October 2020. The October 2020 VA examiner determined that the Veteran had three myocardial infarctions. The myocardial infarctions occurred in September 2004, 2005, and December 2010. The examiner explained that an August 2011 cardiology note indicated that a myocardial infarction occurred in 2005 but that the record did not include an exact date. Analysis The Board finds that from January 1, 2005 to December 7, 2010 the evidence reflects that the Veteran’s CAD was never manifested by a workload of 5 METs or less, by an LVEF of less 50 percent or less, nor by any episodes of acute congestive heart failure. A June 2005 VA examiner’s report documented the Veteran’s lowest estimated METs score of 6 METs. And, a March 2007 echocardiogram documented the Veteran’s lowest LVEF at 65 percent. Otherwise, the Veteran’s documented METs and LVEF scores were even higher for this period. The Veteran’s reports of remaining active and walking at least eight blocks a day further support the Veteran’s METs and LVEF scores. To the extent that the Veteran was unable to perform some activities, the June 2005 VA examiner’s report noted that the Veteran’s posttraumatic stress disorder caused some functional impairment related to housework and yardwork. The Board acknowledges that the evidence of record is unclear in regard to whether the Veteran experienced a myocardial infarction in 2005. The March 2007 and May 2011 VA treatment records document a prior 2005 myocardial infarction without providing the exact date of the 2005 myocardial infarction and do not note the 2004 myocardial infarction. The October 2020 VA addendum opinion determined that the Veteran experienced three myocardial infarctions in September 2004, 2005, and December 2010. The exact date of the 2005 myocardial infarction was again unknown. No evidence of record documented the exact date of the claimed 2005 myocardial infarction nor are laboratory or medical test results available to confirm a myocardial infarction occurred. In order to be entitled to a 100 percent rating for the three months following a myocardial infarction, Diagnostic Code 7006 requires that the myocardial infarction be documented by laboratory tests. Here, since no laboratory tests are available documenting the 2005 myocardial infarction, the Board finds that entitlement to a temporary total disability rating under Diagnostic Code 7006 is not warranted for this period. For the periods from January 1, 2005 to December 7, 2010, the Board finds that no evidence shows that the Veteran had a workload of 5 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, an LVEF of less than 50 percent, nor more than one episode of acute congestive heart failure. Nor was a 2005 myocardial infarction confirmed by laboratory tests. Accordingly, the Board finds that for these periods, the currently assigned 30 percent rating adequately reflected the Veteran’s disability level due to his CAD. Therefore, for the periods from January 1, 2005 to June 28, 2005 and from October 1, 2005 to December 7, 2010, the Veteran’s claim for a rating in excess of 30 percent for his service-connected CAD is denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Palombi, 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.