Citation Nr: 21010544 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 20-17 079 DATE: February 25, 2021 ORDER Entitlement to an effective date earlier than February 20, 2015 for the grant of service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to an effective date earlier than January 3, 2017 for the grant of a 30 percent rating for coronary artery disease is denied. Entitlement to an initial disability rating of 70 percent for posttraumatic stress disorder (PTSD) is granted. Entitlement to a disability rating in excess of 30 percent for coronary artery disease (CAD) is denied. Entitlement to a disability rating in excess of 30 percent for emphysema with chronic obstructive pulmonary disease (COPD), asthmatic bronchitis, and bronchiectasis is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. There is no indication of a claim of service connection for PTSD prior to February 20, 2015. 2. The Veteran’s claim for service connection for coronary artery disease was granted in a January 2013 rating decision, with a 60 percent rating granted from August 20, 2011 to March 27, 2012 and a 10 percent rating granted on and after March 28, 2012. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year, and it is final. 3. VA received a claim for a TDIU based in part on the Veteran’s coronary artery disease on January 3, 2017. In a May 2017 rating decision, VA granted a 30 percent rating for coronary artery disease on and after January 3, 2017. There is no indication of an attempt to claim an increased rating for coronary artery disease between January 2013 and January 3, 2017 and it is not factually ascertainable that an increase in disability occurred within one year prior to January 3, 2017. 4. Throughout the period on appeal, the Veteran’s PTSD has been manifested by occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 5. Throughout the period on appeal, the Veteran’s CAD is not manifested by congestive heart failure, a workload of 5 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 50 percent or less. 6. Throughout the period on appeal, the Veteran’s emphysema with COPD, asthmatic bronchitis, and bronchiectasis is manifested by Forced Expiratory Volume in one second (FEV-1) of 68 percent predicted, Forced Vital Capacity (FVC) of 99 percent predicted, ratio of FEV-1 to Forced Vital Capacity (FEV-1/FVC) of 69 percent, and Diffusion Capacity of the Lung for Carbon Monoxide (DLCO) of 71 percent predicted. There is no maximum exercise capacity less than 21 ml/kg/min oxygen consumption, cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure, or outpatient oxygen therapy. 7. The Veteran’s service-connected disabilities have met the percentage requirements for the award of a schedular TDIU, and the evidence indicates that the nature and severity of these disabilities prevent him from performing gainful employment for which his education and occupational experience would otherwise qualify him. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date prior to February 20, 2015 for the grant of service connection for PTSD are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 19.52, 20.1103. 2. The criteria for entitlement to an effective date prior to January 3, 2017 for the grant of a 30 percent rating for coronary artery disease are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 19.52, 20.1103. 3. With resolution of reasonable doubt in the Veteran’s favor, on and after February 20, 2015, the criteria for a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for a disability rating in excess of 30 percent for CAD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.104, Diagnostic Code 7005. 5. The criteria for a rating in excess of 30 percent for emphysema with COPD, asthmatic bronchitis, and bronchiectasis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.96, 4.97, Diagnostic Code 6603. 6. With resolution of reasonable doubt in the Veteran’s favor, the criteria for the award of a TDIU have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army for 20 years from April 1959 to June 1979, including service in the Vietnam War, for which his decorations included the Bronze Star Medal. These matters are on appeal from May 2017, July 2017, and April 2018 rating decisions. In the March 2018 Notice of Disagreement (NOD), the Veteran’s attorney checked the “effective date of award” box with regard to emphysema with chronic obstructive pulmonary disease (COPD), asthmatic bronchitis, and bronchiectasis. The May 2017 rating decision denied an increased rating for this disability. To be valid, an NOD must “identify the specific decision and issue or issues therein with which the claimant disagrees.” Because a rating decision denying an increased rating claim does not make a determination regarding an effective date, the NOD is not valid with respect to an effective date. Were the Board to consider the issue, it would constitute a freestanding earlier effective date claim and would be dismissed as a matter of law pursuant to Rudd v. Nicholson, 20 Vet. App. 296 (2006). Therefore, the Board does not need to address the matter further. In his April 2020 substantive appeal (VA Form 9), the Veteran requested a hearing before a Veterans Law Judge. In a January 2021 statement, the Veteran’s attorney withdrew the request for a hearing. The Board therefore deems the hearing request withdrawn pursuant to 38 C.F.R. § 20.603(e). The Veteran was afforded VA examinations for his psychiatric disability in June 2015, October 2016, and May 2020. The Veteran’s attorney contends in a January 2021 statement that these examinations were all inadequate because they did not explain why their findings regarding the Veteran’s symptoms differed from those of the private examiner or the Veteran’s VA treatment records. The VA examinations are adequate because they were based upon consideration of the Veteran’s pertinent medical history, his lay assertions and current complaints, and because they describe his psychiatric symptoms in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Neither the Veteran nor his attorney have raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Effective Date Unless specifically provided otherwise by statute, the effective date of an award for compensation benefits based on (1) an original claim, (2) a claim reopened after final adjudication, or (3) a claim for increase, is the date VA received the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400; Lalonde v. West, 12 Vet. App. 377, 382 (1999). With regard to a claim for increase, the effective date can be up to one year earlier than the date of the claim if it is factually ascertainable, based on all evidence of record, that an increase in disability occurred within one year of the date of claim. 38 C.F.R. § 5110(b)(3); 38 C.F.R. § 3.400; Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010). If the increase occurred more than one year prior, the increase is effective the date of the claim. Gaston, 605 F. 3d at 980; see also Harper v. Brown, 10 Vet. App. 125 (1997). 1. PTSD – Effective Date The Veteran first submitted a claim for entitlement to service connection for PTSD on February 20, 2015. The Board has reviewed the claims file for any document, submitted before the Veteran’s February 20, 2015, claim, that could be considered a claim for service connection for a psychiatric disability. The Board has found no communication from the Veteran to VA that could be construed as a formal or informal claim of entitlement to service connection for a psychiatric disability prior to the claim submitted on February 20, 2015. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than February 20, 2015, for service connection for PTSD, which is the date of the claim that led to the grant of service connection. 2. CAD – Effective Date The Veteran first submitted a claim for entitlement to service connection for CAD in August 2012. VA granted service connection for CAD in a January 2013 rating decision and assigned a 60 percent rating from August 20, 2011 to March 27, 2012 and a 10 percent rating on and after March 28, 2012. The Veteran did not submit an NOD or new and material evidence within the one year period following the decision. The decision became final and not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 19.52, 20.1103. The Board has reviewed the claims file for any document, submitted after the January 2013 rating decision but before the Veteran’s January 3, 2017, claim for a TDIU, that could be considered a claim for an increased rating for CAD. The Board has found no communication from the Veteran to VA that could be construed as a formal or informal claim of entitlement to an increased rating for CAD prior to the claim submitted on January 3, 2017. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. In order for the Veteran to be awarded an effective date based on the prior rating decision, he has to show clear and unmistakable error (CUE) in the prior decision as a collateral attack. Flash v. Brown, 8 Vet. App. 332, 340 (1995). Any claim of CUE must be pled with specificity. See Andre v. Principi, 301 F.3d 1354 (Fed. Cir. 2002). This specific allegation must assert more than merely disagreement with how the facts of the case were weighed or evaluated. Persuasive reasons must be given as to why the result would have been manifestly different but for the alleged error. Neither the Veteran nor his attorney have raised CUE. An effective date earlier than January 3, 2017 for a 30 percent rating for CAD is therefore only warranted if it is factually ascertainable that an increase in disability occurred within one year prior to January 3, 2017. Neither the Veteran nor his attorney have contended that such an increase is factually ascertainable and the Board has found nothing by which it could factually ascertain such an increase. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than January 3, 2017, for a 30 percent rating for CAD, which is the date of the claim that led to the grant of an increased rating. Increased Ratings 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. “Staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claim for a higher initial evaluations for the Veteran’s PTSD, the Board has considered all evidence of severity from the effective date for the award of service connection for that claim. Fenderson v. West, 12 Vet. App. 119 (1999). With regard to the CAD and respiratory claims, when entitlement to compensation has already been established and an increased rating is at issue, the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed. Hart, at 509; see also 38 U.S.C. § 5110(b)(3) (2012); 38 C.F.R. § 3.400(o)(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. 3. PTSD – Increased Rating The Veteran contends that his PTSD warrants a higher rating than that currently assigned. It is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, for PTSD, with a 30 percent rating on and after February 20, 2015. The full period of service connection is on appeal. Under 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 provides that a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, occupation, or own name. Id. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. See Vazquez–Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). VA treatment records in March 2015 and June 2015 noted a restricted affect. A June 2015 VA treatment record characterized the Veteran’s PTSD as mild. The Veteran was afforded a VA examination in June 2015, by a psychologist. The psychologist diagnosed other specified trauma and stressor related disorder. The Veteran reported that he had been married twice, was still married to his second spouse, and had three adult children from his previous marriage but they were not in contact with him, which he ascribed to his former spouse. He also reported that he used to get together with former coworkers to watch football, but had not felt like doing so in the past four years. He reported that he had worked for his state government, but retired in February 2008 after a 27-year career. The psychologist listed the Veteran’s symptoms for rating purposes as depressed mood and anxiety. However, the psychologist also noted that the Veteran had a constricted affect, spoke in a monotone voice, and was dysthymic. There was no evidence of a psychotic process and he was not suicidal or homicidal. The psychologist characterized the Veteran’s overall level of functional impairment as symptoms not severe enough either to interfere with occupational and social functioning or to require continuous medication, which is consistent with a noncompensable rating. The Veteran has submitted a July 2016 examination report by a private psychologist. The Veteran reported that he had been married to his current spouse since 1987. He also reported that he had no close friends and characterized himself as a “loner” but added that his sister was like a friend to him and lived with him and his spouse. He added that he mostly stayed home other than to go to medical appointments. He reported that, prior to his retirement, he was in a job in which he could keep to himself with the door shut, doing all of his work on a computer and even then never turning his back to the door. His spouse added that, even under those circumstances, he periodically had angry outbursts at work severe enough that coworkers would call her to calm him down. The Veteran also reported nightmares almost every night, avoidance of crowds, a startle response, frequent intrusive memories, hypervigilance, suspiciousness, flashbacks, panic attacks brought on by nightmares or loud noises, concentration issues, persistent inability to experience positive emotions, persistent negative beliefs, and depression. The psychologist diagnosed PTSD and major depressive disorder, moderate with melancholic features, secondary to his PTSD. The psychologist listed the Veteran’s symptoms for rating purposes as near continuous panic or depression affecting his ability to function independently, impaired impulse control, difficulty in adapting to stressful circumstances, panic attacks more than once a week, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The psychologist found that, based on the Veteran’s mental health symptoms, he would evidence moderate to severe impairment in his ability to communicate, remember and follow instructions, to use judgment, show insight, and think abstractly, to concentrate and interact with coworkers or customers, to adapt to changes, stress, and demands at work, to work in public or in an enclosed space, and to work in a loosely supervised situation requiring little interaction with the public. The clinician characterized the Veteran’s overall level of functional impairment as occupational and social functioning with deficiencies in most areas, which is consistent with a 70 percent rating. The psychologist opined that, based on these symptoms, it is as likely as not that the Veteran will be unable to maintain substantial and gainful employment. The Veteran was afforded an additional VA examination in October 2016, by a psychologist. The psychologist diagnosed chronic PTSD. The psychologist listed the Veteran’s symptoms for rating purposes as depressed mood, anxiety, suspiciousness, and chronic sleep impairment. The Veteran’s mood was generally dysphoric with congruent affect, but the content of his speech was logical and relevant and was of normal rate and tone. His thinking was deemed to be reality based. While somewhat dysphoric, the Veteran was not overly depressed, suicidal, or psychotic. The psychologist characterized the Veteran’s overall level of functional impairment as symptoms not severe enough either to interfere with occupational and social functioning or to require continuous medication, which is consistent with a noncompensable rating. During a February 2017 VA treatment appointment, the Veteran reported increased anxiety and isolation and that he coped by “staying at home and being in predictable situations.” The clinician noted that the Veteran’s marriage “appears to be a strong support system.” The Veteran reported that his relationship with his children was distant but that they had visited him on occasion and he recently met his grandson for the first time. During a VA treatment appointment later in February 2017, the Veteran reported that he sometimes becomes so upset that he has to walk away from the situation. During a March 2017 VA treatment appointment, the Veteran reported that he had gone to a family gathering and that this significantly increased his anxiety level but that he did not leave. He also reported that he went to a restaurant with his spouse and was triggered by crashing dishes. During a May 2017 VA treatment appointment, the Veteran reported two incidents in which he “could have lost his cool but didn’t,” neither avoiding the situation nor becoming enraged. During an October 2017 VA treatment appointment, the clinician noted that the Veteran’s spouse was “very supportive.” The Veteran was afforded an additional VA examination in May 2020, by a psychologist. The psychologist diagnosed PTSD. The Veteran reported getting along very well with his spouse but denied having any friends, characterizing himself as “more or less a loner.” The psychologist listed the Veteran’s symptoms for rating purposes as anxiety and chronic sleep impairment. The Veteran reported a “good” mood on the day of the examination but the psychologist noted that it sounded like his mood was anxious most days. His affect was euthymic with normal range and variation. There were no signs of mania or hypomania. The Veteran’s speech was at a normal rate with normal volume and pronunciation. His thought process was logical, with no evidence of delusions or hallucinations. He was alert and oriented. He was not noted to have any significant memory concerns. He denied active suicidal or homicidal ideation, plan or intent. Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, his psychiatric symptoms and overall disability picture warrant an evaluation of 70 percent for PTSD throughout the period on appeal. During that period, the record contains evidence of near-continuous panic or depression affecting the ability to function independently, impaired impulse control, and difficulty in adapting to stressful circumstances. The Board also notes that, in the July 2016 private examination, the psychologist characterized the Veteran’s overall level of functional impairment as occupational and social impairment with deficiencies in most areas, which is consistent with a 70 percent rating. For these reasons, the Board finds that Veteran’s symptoms most nearly approximate those that warrant a 70 percent rating throughout the entire period on appeal. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board does not, however, find the criteria for a 100 percent evaluation are more nearly approximated by the Veteran’s symptoms at any point during the period on appeal. The record does not contain evidence of any of the symptoms listed in the criteria for a 100 percent rating or symptoms similar to those listed in the 100 percent rating criteria. Even the constant presence of some symptoms listed in the criteria for a 100 percent rating would be insufficient because the overall guiding criterion for a 100 percent rating is that both total occupational and total social impairment be present. 38 C.F.R. § 4.130; see, e.g., Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). In this case, the Veteran’s symptoms have not been shown to be so severe that he has both total occupational and total social impairment. The Board acknowledges that, in this decision, it has found the Veteran to be unemployable due to his service-connected disabilities. However total social impairment is not shown. “Total” is defined as “whole, not divided; full; complete,” and “utter, absolute.” Black’s Law Dictionary, 1498 (7th ed. 1999). The Veteran has been able to maintain some personal relationships, specifically with his spouse and his sister. The Board acknowledges that these relationships are sometimes strained or distant, but that is reflected in the current 70 percent rating for “deficiencies in most areas,” the criteria for which include inability to establish and maintain effective relationships. Because the Veteran is not totally socially impaired, a 100 percent rating is not warranted. The Board also notes that many of the Veteran’s reported symptoms throughout the period on appeal are included among those specifically listed in the General Rating Formula for Mental Disorders, pursuant to which a 70 percent disability rating has been assigned. See 38 C.F.R. § 4.130. Importantly, the Board notes that symptoms noted in the rating schedule are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran’s extent of occupational and social impairment. Accordingly, in this case, the Board finds that the existence and severity of the Veteran’s psychiatric symptoms are adequately contemplated by the 70 percent rating criteria. As noted above, many of the symptoms are specifically listed in the General Rating Formula for Mental Disorders, and the others are common psychiatric symptoms that-while not specifically listed-are comparable indicators of the type of occupational and social impairment contemplated in the Rating Formula. The Board has also considered the Veteran’s assertions and those of his spouse regarding his psychiatric symptoms, which they are competent to provide. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The lay evidence is also credible. The symptoms described in those lay statements comport with the 70 percent rating that has now been assigned. However, these lay statements do not provide any basis upon which to assign a higher rating because they do not reflect total social impairment. In sum, the Board finds that, resolving reasonable doubt in the Veteran’s favor, his impairment due to PTSD has been most consistent with a 70 percent disability rating throughout the period on appeal. 4. CAD – Increased Rating The Veteran contends that his CAD warrants a higher rating than that currently assigned. It is currently rated under 38 C.F.R. § 4.104, Diagnostic Code 7005, for CAD, with a 60 percent rating from August 20, 2011 to March 27, 2012, a 10 percent rating from March 28, 2012 to January 2, 2017, and a 30 percent rating on and after January 3, 2017. As stated above, VA received the Veteran’s claim for an increased rating on January 3, 2017. Diagnostic Code 7005 provides that a 30 percent rating is warranted for documented CAD resulting in 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. 38 C.F.R. § 4.104, Diagnostic Code 7005. A 60 percent rating is warranted for documented CAD resulting in more than one episode of congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating is warranted for documented CAD 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. Id. The Veteran was afforded a VA examination for heart conditions in April 2017. The Veteran reported that his heart was “barely ticking.” He also reported chest pain approximately twice a week, depending on activity. The clinician noted that the Veteran’s treatment plan included taking continuous medication for CAD. The clinician also noted that the Veteran had not had a myocardial infarction, congestive heart failure, a cardiac arrhythmia, a heart valve condition, an infectious cardiac condition, or pericardial adhesions. There was no evidence of cardiac hypertrophy or dilatation. The clinician noted the results of a November 2016 echocardiogram, including a left ventricular ejection fraction of 50-55 percent, but later clarified that the specific number was 52 percent. The clinician found that cardiac stress testing was medically contraindicated for compensation and pension purposes because METs are easily estimated based on the Veteran’s known disease, level of physical activity, and reported symptoms. Based on an interview-based METs test, the clinician determined the Veteran’s METs to be between greater than 5 and 7 solely due to his heart condition. The clinician found that the Veteran’s heart disability would have an impact on his ability to work but only noted the Veteran’s report of a limited activity level due to chest pain. Based on the evidence described above, the Board finds that the Veteran’s CAD does not warrant an evaluation higher than 30 percent during the period on appeal. Over the course of this period, while the evidence shows a workload of between greater than 5 and 7 METs and left ventricular dysfunction with an ejection fraction of 52 percent, it does not show congestive heart failure, a workload of 5 METs or less, or left ventricular dysfunction with an ejection fraction of 50 percent or less. The Board has also considered the Veteran’s assertions regarding his cardiac symptoms, which he is competent to provide. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). His statements are also credible. However, the competence of a lay person to provide a medical opinion must be determined on a case by case basis. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The rating criteria for CAD are specific and, absent a diagnosis of congestive heart failure, require an estimate of the workload of which his heart is capable or of its ejection fraction, which are calculations regarding medical knowledge. Thus, to the extent that the Veteran’s statements regarding his symptoms constitute a contention that those symptoms match the criteria for an increased rating, their probative value is low. In sum, the Board finds that the effects of the Veteran’s CAD are most consistent with the currently-assigned disability rating of 30 percent on and after January 3, 2017. 5. Emphysema with COPD, Asthmatic Bronchitis, and Bronchiectasis The Veteran contends that his emphysema with COPD, asthmatic bronchitis, and bronchiectasis warrants a higher rating than that currently assigned. It is currently rated under 38 C.F.R. § 4.97, Diagnostic Code 6603, with a 10 percent rating from July 1, 1979 to May 20, 2014 and a 30 percent rating on and after May 21, 2014. VA received the Veteran’s claim for an increased rating on January 3, 2017. Diagnostic Code 6603 pertains to pulmonary emphysema, which is evaluated as follows: FEV-1 less than 40 percent of predicted value, FEV-1/FVC less than 40 percent, DLCO less than 40 percent predicted, maximum exercise capacity less than 15 ml/kg/min oxygen consumption, cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure, or outpatient oxygen therapy (100 percent); FEV-1 of 40 to 55 percent predicted, FEV-1/FVC of 40 to 55 percent, DLCO of 40 to 55 percent predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min (60 percent); or FEV-1 of 56 to 70 percent predicted, FEV-1/FVC of 56 to 70 percent, or DLCO of 56 to 70 percent predicted (30 percent). 38 C.F.R. § 4.97, Diagnostic Code 6603. COPD is evaluated under 38 C.F.R. § 4.97, Diagnostic Code 6604; its rating criteria are identical to those listed in Diagnostic Code 6603 for pulmonary emphysema. Chronic bronchitis is evaluated under 38 C.F.R. § 4.97, Diagnostic Code 6600; its rating criteria are identical to those listed in Diagnostic Code 6603 for pulmonary emphysema. Bronchiectasis is evaluated under 38 C.F.R. § 4.97, Diagnostic Code 6601; its rating criteria for ratings of 30 percent or greater require incapacitating episodes, defined as ones requiring bedrest and treatment by a physician. A 10 percent rating is warranted for intermittent productive cough with acute infection requiring a course of antibiotics at least twice a year. Bronchial asthma is evaluated under 38 C.F.R. § 4.97, Diagnostic Code 6602 as follows: FEV-1 less than 40 percent of predicted value, FEV-1/FVC less than 40 percent, or more than one attack per week with episodes of respiratory failure, or requiring daily use of systemic (oral or parenteral) high dose corticosteroids or immunosuppressive medications (100 percent); FEV-1 of 40 to 55 percent predicted, FEV-1/FVC of 40 to 55 percent, or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids (60 percent); FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent, or daily inhalational or oral bronchodilator therapy, or inhalational antiinflammatory medication (30 percent); or FEV-1 of 71 to 80 percent predicted, or FEV-1/FVC of 71 to 80 percent, or intermittent inhalational or oral bronchodilator therapy. If the DLCO is not of record, VA is to rate based on alternative criteria as long as the examiner states why the test would not be useful or valid in a particular case. 38 C.F.R. § 4.96. Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. Id. VA is to use post-bronchodilator PFT results for rating purposes unless the post-bronchodilator results were poorer than the pre-bronchodilator results. Id. When the PFT results are not consistent with clinical findings, VA is still to evaluate based on the PFT results unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. Id. When there is a disparity between the results of different PFTs, so that the level of evaluation would differ depending on which test result is used, VA is to use the test result that the examiner states most accurately reflects the level of disability. Id. The Veteran was afforded a VA examination for respiratory conditions in March 2017. The clinician diagnosed asthma and chronic bronchitis. The Veteran reported that his breathing was “doing bad,” including fatigue and shortness of breath “all the time.” The Veteran’s respiratory disabilities required inhalational bronchodilator and antiinflammatory medication, but not oral or parenteral corticosteroid medications, oral bronchodilators, antibiotics, or outpatient oxygen therapy. The clinician also noted bronchiectasis. With regard to asthma, the Veteran had not had any asthma attacks with episodes of respiratory failure in the past twelve months or any physician visits for required care of exacerbations. With regard to bronchiectasis, the Veteran had daily cough with acute infection, but no incapacitating episodes of infection due to bronchiectasis. The post-bronchodilator PFT results showed FVC of 99 percent predicted, FEV-1 of 68 percent predicted, FEV-1/FVC of 69 percent, and DLCO of 71 percent predicted. The clinician provided no opinion as to which result most accurately reflected the Veteran’s level of disability. The clinician did not complete exercise capacity testing. The clinician found that the Veteran’s respiratory disabilities had an impact on his ability to work because, according to the Veteran’s report, his breathing status limited his activities around his home and he had to pace himself. The preponderance of the evidence described above shows that the Veteran’s emphysema with COPD, asthmatic bronchitis, and bronchiectasis does not warrant a rating in excess of 30 percent at any point during the period on appeal. There is no evidence of cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure, or outpatient oxygen therapy. There is also no evidence of maximum oxygen consumption of less than 21 ml/kg/min. The March 2017 PFT showed FVC of 99 percent predicted, FEV-1 of 68 percent predicted, FEV-1/FVC of 69 percent, and DLCO of 71 percent predicted. The FEV-1, FEV-1/FVC, and DLCO results warrant a 30 percent rating under Diagnostic Code 6603. A 30 percent rating is therefore warranted. The Board has considered the Veteran’s lay statements, as discussed above. He is competent to report his own observations with regard to the symptoms of his service-connected respiratory disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). His statements are credible. However, nothing in those statements as discussed above is consistent with the criteria for a rating in excess of 30 percent. Diagnostic Code 6603 applies directly and specifically to pulmonary emphysema and Diagnostic Codes 6600 and 6604, which apply directly and specifically to chronic bronchitis and COPD, respectively, list rating criteria identical to those in Diagnostic Code 6603. Because there is no evidence of incapacitating episodes, a rating in excess of 30 percent under Diagnostic Code 6601 for bronchiectasis would not be warranted. Because there is no evidence of the use of corticosteroids or other immunosuppressive medications, a rating in excess of 30 percent under Diagnostic Code 6602 for bronchial asthma would not be warranted. There are no other Diagnostic Codes that might apply to the Veteran’s emphysema with COPD, asthmatic bronchitis, and bronchiectasis. In reaching the conclusions above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claims except to the extent granted above, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. TDIU VA will grant a total disability rating when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from securing and following substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the purposes meeting the requirement of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). The period on appeal began on February 20, 2015, the day VA received the Veteran’s claim for service connection for PTSD. As of that date, the Veteran’s current combined disability rating, after the increased rating for PTSD granted above, is 90 percent: his PTSD is rated 70 percent disabling, his emphysema with COPD, asthmatic bronchitis, and bronchiectasis is rated 30 percent disabling, his CAD is rated 10 percent disabling (later increased to 30 percent on and after January 3, 2017), his acne vulgaris with lichen planus is rated 10 percent disabling, his bilateral hearing loss is rated 10 percent disabling, his tinnitus is rated 10 percent disabling, and his status post right knee injury, status post hemorrhoidectomy, and paresthesia of the right lower lip have noncompensable ratings. See 38 C.F.R. § 4.25. The criteria for consideration of a schedular TDIU are therefore met throughout the period on appeal. The Board has discussed the evidence regarding occupational impairment caused by the Veteran’s PTSD in the context of the increased rating claim above. The July 2016 private examiner opined that the Veteran was unemployable as a result of his service-connected PTSD and provided a detailed rationale for his conclusions. The Board therefore finds that the evidence is at least evenly balanced as to whether the Veteran’s service-connected disabilities have rendered him unemployable under the applicable regulations. As reasonable doubt must be resolved in favor of the Veteran, entitlement to a TDIU is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. N. NELSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ryan Frank, 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.