Citation Nr: 21009856 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 15-27 065A DATE: February 23, 2021 ORDER Entitlement to an initial disability rating in excess of 30 percent prior to February 26, 2019 for ischemic heart disease is denied. FINDING OF FACT Prior to February 26, 2019, the Veteran’s ischemic heart disease did not result in more than one episode of acute congestive heart failure in the past year; a workload of greater than 3 METs but not greater than 5 METs, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 30 percent prior to February 26, 2019 for ischemic heart disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1967 to December 1969. This matter comes before the Board of Veterans’ Appeal (Board) on appeal from a September 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office that granted service connection for ischemic heart disease and assigned a disability rating of 30 percent, effective August 31, 2010. In August 2018, the Board remanded the claim for additional development. In a May 2020 rating decision, the RO increased the assigned a total (100 percent) disability rating for ischemic heart disease, effective October 3, 2019. In August 2020, the Board again remanded the claim for additional development, to include a VA medical opinion discussed in detail below. In an October 2020 rating decision, the RO assigned a total (100 percent) disability rating for ischemic heart disease, effective February 26, 2019. As such, the issue on appeal has been recharacterized, as entitlement to a disability rating in excess of 30 percent prior to February 26, 2016. See A.B. v. Brown, 6 Vet. App. 35 (1993). 1. Entitlement to a rating in excess of 30 percent prior to February 26, 2019 for ischemic heart disease Disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In adjudicating increased rating claims, the level of disability in all periods since the effective date of the grant of service connection must be taken into account, to include the possibility that a staged rating may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, the Board will consider whether staged ratings are appropriate to the pending appeals. In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. The Veteran’s ischemic heart disease is rated under Diagnostic Code 7005, for arteriosclerotic heart disease. Under this code, a 100 percent rating is warranted if chronic congestive heart failure is present, 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. A 60 percent rating is warranted for coronary artery disease resulting in 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 30 percent rating is warranted for coronary artery disease resulting in a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electro-cardiogram, echocardiogram, or X-ray. A 10 percent rating is warranted for coronary artery disease resulting in a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. 38 C.F.R. § 4.104, Diagnostic Code 7005. Note (1) to 38 C.F.R. § 4.104, Schedule of Ratings - Cardiovascular System states that cor pulmonale, a form of secondary heart disease, should be evaluated as part of the pulmonary condition that caused it. Note (2) states that 1 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. Id. 38 C.F.R. § 4.100, regarding the evaluation of cardiovascular disorders under diagnostic codes 7000-07, contains the following provisions: (1) In all cases, whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X-ray) is present and whether or not there is a need for continuous medication must be ascertained. (2) Even if the requirement for a 10 percent rating (based on the need for continuous medication) or a 30 percent rating (based on the presence of cardiac hypertrophy or dilatation) is met, MET testing is required except when there is a medical contraindication; when the left ventricular ejection fraction has been measured and is 50 percent or less; when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; and when a 100 percent evaluation can be assigned on another basis. (3) If left ventricular ejection fraction (LVEF) testing is not of record, evaluation should be based on 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. Id. Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity since August 31, 2010, the effective date for the award of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). Private and VA medical records for the period from August 2010 to February 2019 have been obtained and reviewed. After considering the totality of the record, the Board finds the preponderance of the evidence to be against an initial disability rating in excess of 30 percent prior to February 26, 2019 for ischemic heart disease. The Veteran has had ischemic heart disease since 2005. On July 2012 VA examination, continuous medication was noted, but no congestive heart failure. His ischemic heart disease resulted in symptoms of dyspnea and fatigue with a METS level of 5 to 7. There was evidence of cardiac hypertrophy or dilation. An echocardiogram showed LVEF of 55 percent and mild left ventricular hypertrophy. Private medical records document a history of coronary artery bypass grafting in July 2014. The Veteran presented with severe chest pain and pressure. An echocardiogram from March 2014 showed LVEF of 59 percent, and SPECT imaging showed an ejection fraction of 71 percent. There was no evidence of ischemic dilation. VA treatment records contain a May 2016 echocardiogram showing LVEF of 55 to 60 percent mildly dilated. There was evidence of moderate concentric left ventricular hypertrophy. The Veteran was afforded another VA examination in May 2016. It was noted that he had ischemic heart disease (listed as coronary artery disease) treated with continuous medication. A myocardial infarction in 2014 was noted, but there was no evidence of congestive heart failure. METS was not addressed because the examiner found that the Veteran’s other conditions affected his exercise tolerance. The examiner noted that the Veteran was scheduled for a subsequent echocardiogram. However, in August 2018 the Board remanded the claim for additional development because the referenced echocardiogram and associated results were not of record. Further, the Board found that the March 2016 VA examination was inadequate because it lacked findings for rating criteria purposes. Consequently, a new VA examination was obtained in October 2019, after the February 2019 period on appeal. VA treatment records contain a January 2019 Thallium Stress Test with an impression of dilated left ventricle demonstrating a large predominantly fixed perfusion defect of moderate intensity suggesting mild peripheral improvement (ischemia) during rest. The estimate LVEF was 38 percent, but noted to be potentially underestimated given the suboptimal gated acquisition. During a February 26, 2019 VA cardiology visit, an impression of congestive heart failure, systolic, secondary to 2014 myocardial infarction, was provided. In August 2020, the Board remanded the claim to obtain a VA medical opinion on the severity of the Veteran’s ischemic heart disease prior to October 3, 2019. In August 2020, a VA examiner opined that chronic congestive heart failure first manifested on February 26, 2019 when the Veteran was diagnosed with congestive heart failure. Prior to this date, there was no mention of acute congestive heart failure or hospitalizations. The examiner referenced May 2018 and January 2019 VA cardiology treatment records that do not mention congestive heart failure, a chronic disability. Based on the examiner’s opinion, in an October 2020 rating decision, the RO assigned a total (100 percent) rating for ischemic heart disease from February 26, 2019. Based on the above, the Board finds that the preponderance of the evidence is against an initial disability rating in excess of 30 percent prior to February 26, 2019 for ischemic heart disease. Throughout the applicable appeal period, the Veteran’s ischemic heart disease has not resulted in more than one episode of acute congestive heart failure in the past year, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent, the criteria for a 60 percent rating. Although January 2019 VA treatment records show an estimated LVEF of 38 percent, it was noted to be “potentially underestimated given the suboptimal gated acquisition.” On the contrary, LVEF levels, demonstrated by echocardiograms, have consistently ranged from 55 to 60. See July 2012 VA Examination, March 2014 VA Echocardiogram, and May 2016 VA Echocardiogram. The Board recognizes that ischemic heart disease has been manifested by symptoms of dyspnea and fatigue, however, the evidence of record does not demonstrate the requisite METs workload of greater than 3 METs but not greater than 5 METs for a 60 percent rating. At worst, the Veteran has had a METs level of 5 to 7. See July 2012 VA Examination. The Board acknowledges that the RO sought development for chronic congestive heart failure, a symptom that warrants a total (100 percent) rating. However, the Board finds that prior to February 26, 2019, the Veteran’s ischemic heart disease did not result in chronic congestive heart failure. The August 2020 VA examiner opined that the earliest mention of congestive heart failure was on February 26, 2019. This opinion is consistent with VA treatment records on that date showing an initial diagnosis of chronic obstructive heart failure. Prior to this date, there is no mention of congestive heart failure. On the contrary, on July 2012 and May 2016 VA examinations, examiners found no evidence of congestive heart failure. As such, the preponderance of the evidence is against an initial disability rating in excess of 30 percent prior to February 26, 2019 for ischemic heart disease. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Baker, 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.