Citation Nr: 21009843 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 16-42 427 DATE: February 23, 2021 REMANDED The issue of reduction from a 60 to 10 percent rating for coronary artery disease, effective April 1, 2014, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1968 to June 1969. This matter comes before the Board of Veterans’ Appeals (Board) from a January 2014 rating decision. In December 2020, the Veteran and his spouse testified at a virtual Board hearing; a transcript of the hearing is associated with the claims file. The issue of reduction from a 60 to 10 percent rating for coronary artery disease, effective April 1, 2014, is remanded. Service connection for coronary artery disease was granted in a May 2011 rating decision; a 10 percent rating was assigned effective July 1, 2009, and a 60 percent rating was assigned from April 11, 2011. In March 2013, the agency of original jurisdiction (AOJ) ordered a review VA examination based solely on a review of VA treatment records. A September 2013 rating decision proposed to reduce the assigned disability rating for coronary artery disease from 60 percent to 10 percent. In October 2013, the AOJ notified the Veteran of the proposed action, his option to submit medical or other evidence to show that the proposed change should not be made, and his right to request a predetermination hearing. His request for a predetermination hearing was received more than 30 days after the notification letter. The January 2014 rating decision on appeal reduced the rating for coronary artery disease to 10 percent effective April 1, 2014. In November 2015, the Veteran and his spouse participated in an informal conference with a decision review officer (DRO), asserting that his coronary artery disease had not improved since 2011 and that the rating reduction was improper. The Veteran’s spouse also questioned the completeness of the VA examination that was used to reduce the disability rating. They also described ongoing treatment, including by the VA cardiology fellow who completed a Disability Benefits Questionnaire (DBQ) on the Veteran’s behalf in September 2014. At the conclusion of the conference, the AOJ agreed to request a new VA examination. A December 2015 VA examination report reflects that the severity of the Veteran’s coronary artery disease, including an estimation of the metabolic equivalent (METs) level at which dyspnea, fatigue, angina, dizziness, or syncope develops, again was based solely on a review of VA treatment records without an in-person or telehealth examination. At the December 2020 hearing, the Veteran and his spouse described ongoing treatment received for coronary artery disease by his cardiologist and primary care physician and requested that the record be held open for 60 days to allow the Veteran to submit outstanding treatment records, noting that the most recent private cardiology treatment record associated with the claims file was from August 2016. During the hearing, the Veteran’s spouse also explained that the Veteran had a poor memory and was not a reliable historian because he had sustained a traumatic brain injury after fainting at home. To date, no additional treatment records have been received or identified from the Veteran. The Veteran and his spouse have indicated that in addition to receiving VA treatment, he has also been treated for coronary artery disease by private treatment providers; however, between March 2013, when the AOJ obtained a VA examination based on a review of VA treatment records, and the present, the only contemporaneous private treatment record that has been associated with the claims file is a partial report of a cardiac catheterization performed at a private Heart and Vascular Institute in August 2016. The AOJ should request any outstanding private treatment records related to evaluation or treatment for coronary artery disease since March 2013 and assist the Veteran in obtaining those records. Then, the AOJ should arrange for an in-person or telehealth VA examination to assess the severity of the Veteran’s coronary artery disease. Based on the receipt of any additional private treatment records and a new VA examination, the AOJ should review whether the rating reduction from 60 percent to 10 percent for coronary artery disease was proper. The matter is REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain the following records: a) Any ongoing VA treatment records dating since November 2015. b) All private treatment records dating since March 2013 related to evaluation and treatment for coronary artery disease. 2. Schedule the Veteran for an in-person or telehealth VA examination with an appropriate clinician to evaluate the current severity of his coronary artery disease. Provide the Veteran’s electronic claims file to the designated examiner for review. Following a review of the claims file and examination, the designated examiner should identify the severity of the Veteran’s coronary artery disease as described by METs, episodes of acute congestive hearing failure, chronic congestive heart failure, and/or left ventricular dysfunction expressed in the ejection fraction percentage. See 38 C.F.R. § 4.104, Diagnostic Code 7005 (describing the rating criteria for evaluating arteriosclerotic heart disease (coronary artery disease)). If additional private treatment records are received, the examiner also should identify any change in the severity of the Veteran’s coronary artery disease since March 2013 as supported by the treatment records. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Kirscher Strauss 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.