Citation Nr: 21009982 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 18-02 891 DATE: February 23, 2021 ORDER Entitlement to a rating in excess of 30 percent for coronary artery disease (CAD) is denied. FINDING OF FACT The Veteran’s CAD has been manifested a workload of greater than 5 METS but not greater than 7 METs resulting in dyspnea; but not more than one episode of acute congestive heart failure, workload of 5 METs or less, or a left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSION OF LAW The criteria for entitlement to an initial rating in excess of 30 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1967 to May 1970. The matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2016 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Board remanded this claim for further development, namely, to obtain an addendum VA examination that reconciles the contradictory evidence of record. The development was performed, and the matter is now ready for adjudication. Preliminarily, the Board notes that in the Veteran’s February 2021 brief, he states that he believes he has developed a scar and hypertension due to his service -connected CAD. However, the sole claim before the Board is whether his CAD is entitled to a disability rating in excess of 30 percent. If the Veteran wishes to submit claims for service connection for a chest scar associated with his CAD or entitlement to service connection for hypertension secondary to CAD, he is encouraged to do so on the appropriate claim forms. Increased Ratings Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; see generally 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for distinct periods of time, based on the facts found, is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Gilbert, 1 Vet. App. at 53. Entitlement to a disability rating in excess of 30 percent for CAD The Veteran’s CAD is rated under Diagnostic Code 7005. Under this code, a 30 percent rating 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 dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for myocardial infarction resulting in more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs causing 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 myocardial infarction resulting 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. If non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, the adjudicator is to request a medical opinion as to which condition is causing the current signs and symptoms. 38 C.F.R. § 4.104, Diagnostic Code 7005. For rating diseases of the heart, one MET (metabolic equivalent) 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 rating, 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. Based on the evidence of record, the Board holds that the preponderance of the evidence is against a finding that the Veteran’s CAD warrants a rating higher than 30 percent. In a June 2016, a VA disability benefits questionnaire (DBQ), a private nurse practitioner indicated that the Veteran had CAD, aortic aneurysm and aortic dissection, all diagnosed in 2010. He underwent coronary artery bypass surgery in December 2010. On physical examination, he had a heart rate of 60, with regular heart rhythm and normal heart sounds. His blood pressure was 130/78. There was no evidence of cardiac hypertrophy. The nurse practitioner referenced the Veteran’s June 2016 echocardiogram, which showed a left ventricular ejection fraction (LVEF) of 50-55 percent and a June 2016 exercise stress test that showed a METs level of 2.3. The nurse practitioner also stated that the Veteran has other non-cardiac medical conditions limiting his METs level, but she did not specify the other conditions. The nurse practitioner stated that the Veteran’s CAD did not affect his ability to work. In October 2016, a VA examiner reviewed the evidence of record and completed a VA DBQ for the Veteran’s CAD. The VA examiner noted the Veteran has diagnoses of CAD and coronary artery bypass graft from December 2010. The Veteran takes Carvedilol, a continuous medication for his CAD. The Veteran has not had a myocardial infarction, congestive heart failure, a cardiac arrythmia, a heart valve condition, an infectious heart condition, or a pericardial adhesion. The Veteran underwent a coronary artery bypass surgery in December 2010 due to a coronary occlusion. The Veteran does have a scar that is not painful or unstable. The scar is separately service-connected. There was no evidence of cardiac hypertrophy or cardiac dilatation. The examiner referenced the Veteran’s June 2016 echocardiogram and noted that the Veteran’s LVEF was 55 percent with normal wall motion and thickness. The October VA examiner stated that an exercise stress test was not performed as it was not required as part of Veteran’s current treatment plan and this test is not without significant risk. The Veteran underwent an interview-based METs test in January 2016 and reflected that the Veteran reported only dyspnea attributable to a cardiac condition at a METs level greater than 7 but less than 10.This METs level limitation is due solely to the heart condition that the Veteran is claiming in the diagnosis section. The VA examiner explained that the METs were calculated using the Canadian Cardiovascular Society (CCS) classification system. The CCS system takes into account ejection fraction, left ventricular hypertrophy, left ventricular dilation, use of nitrates, coronary occlusion and perfusion scan. This gives a true estimation of cardiac METs and excludes other comorbid conditions. Based on the CCS system, the Veteran’s cardiac METs level is greater than 7 but less than 10. In a March 2017 VA DBQ report, an updated review and interview of the Veteran was provided by the earlier October 2016 VA examiner. Prior findings from October 2016 were reiterated. New findings provided that during a February 2017 interview-based METs test, the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. The VA examiner stated that the Veteran’s CAD does not impact his ability to work. Based on the CCS system, the Veteran’s cardiac METs level is greater than 10. The lower, subjective estimate of METs is due to obesity and de-conditioning. In a January 2018 letter, the private nurse practitioner that completed the June 2016 DBQ stated that the Veteran had a treadmill test in June 2016. The Veteran reached a METs level of 2.3 and was unable to reach 85 percent of his maximum predicted heart rate due to shortness of breath. The nurse practitioner also stated that the Veteran had a Cardiolite stress test in June 2016. This test showed a maximum METs level of 1.0. The results were attached for review. In the November 2019 appellant brief, the Veteran’s representative stated that the METs score speaks for itself as to the severity of the Veteran’s heart condition. The Veteran’s representative also stated that other contributing conditions have not been specified and cannot be objectively identified or ruled out as contributing to test results determining METs. Based on the conflicting evidence described above, the Board remanded the claim to obtain an addendum VA examination that reconciles this medical evidence. In February 2020, the Veteran participated in this addendum VA examination. Therein, the Veteran denied symptoms of palpitations, paroxysmal nocturnal dyspnea, pre-syncope, syncope, orthopnea, angina, or any other chest pain. The only symptom he reported was mild dyspnea, shortness of breath, when he walks. The examiner noted that an echocardiogram revealed left ventricular ejection fraction (LVEF) of 60 to 65 percent. Further, based on an interview-based METs test, the examiner determined that the Veteran has a workload of 7 METs resulting in dyspnea and mild shortness of breath with moderate amounts of exercise, consistent with a 30 percent rating. The examiner, however, terminated the test due to leg/calf pain as well as fatigue and dyspnea. There was no evidence of congestive heart failure. The February 2020 VA examiner opined that the Veteran’s reports of mild shortness of breath when walking is consistent with his personal history and that the severity of his CAD is “consistent with no changes since 2016.” The examiner also stated that the October 2016 and March 2017 METs estimates more accurately reflect the level of severity of the Veteran’s CAD. The examiner reasoned that the June 2016 exercise stress test “are consistent with no significant heart pathology at the moment when those cardiologic studies were conducted. The examiner also explained that the METs levels of 2.3 and 1.0 reported by the private nurse practitioner are a “false positive result” as the “lack of clinical symptoms at any level of activity in the medical records . . . did not support those METs levels.” After a careful review of the June 2016 stress test, the February 2020 examiner indicated that this test failed to reveal heart hypertrophic or dilation, abnormal wall motion, abnormal ejection fraction; these findings are “consistent with no significant heart pathology at the moment that those cardiologic studies were conducted.” Based on the above, especially the detailed and thorough February 2020 addendum VA examination, the Board finds that the Veteran is warranted a rating of no more than 30 percent. The Board notes that the record shows that the Veteran exhibited LVEF of 60 to 65 percent, with a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea during the appeal period, consistent with a 30 percent rating. As such, the Board finds that during the appeal period the Veteran is entitled to no more than a 30 percent rating. No additional higher or alternative ratings under different Diagnostic Codes are warranted as the Veteran’s CAD has not resulted in more than one episode of acute congestive heart failure, workload of 5 METs or less, or a left ventricular dysfunction with an ejection fraction of 30 to 50 percent.  38 C.F.R. § 4.104, Diagnostic Code 7005. The Board affords the February 2020 addendum VA examination great probative weight as it is based on a review of the entire claims folder and personal examination of the Veteran and explains in great detail as to why the October 2016 and March 2017 METs estimates more accurately reflect the level of severity of the Veteran’s CAD vis-à-vis the June 2016 private nurse practitioner’s DBQ. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). (Continued on the next page)   The Board has additionally considered the Veteran’s lay statements that his CAD is worse than it is currently rated, however, he does not have the medical knowledge or training necessary to estimate the specific testing criteria relevant to the severity of his CAD pursuant to Diagnostic Code 7005. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Based on the evidence of record, the Board finds that a rating in excess of 30 percent for CAD is not warranted. As such, the benefit-of-the-doubt doctrine is inapplicable.  38 C.F.R. § 4.3. For these reasons, the claim is denied. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Finelli, 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.