Citation Nr: 21011680 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 14-28 667 DATE: March 2, 2021 ORDER Entitlement to an effective date prior to July 11, 2002 for the award of service connection for coronary artery disease is denied. Entitlement to an initial rating in excess of 30 percent prior to June 16, 2011 for coronary artery disease is denied. Entitlement to a rating in excess of 60 percent from June 16, 2011 for coronary artery disease is denied. FINDINGS OF FACT 1. The Veteran submitted a claim of entitlement to service connection for coronary artery disease on July 11, 2002; there is no evidence in the claims file demonstrating that the Veteran filed an informal claim prior to that date. 2. Prior to June 16, 2011, the Veteran’s coronary artery disease manifested, at worst, in workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. 3. From June 16, 2011, the Veteran experienced dyspnea, from coronary artery disease alone, that, at worst resulted from a workload of greater than 3 METs but not greater than 5 METs. Due to other conditions, the Veteran’s coronary artery disease is best evaluated by left ventricular ejection fraction, which has never been below 30 percent. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date prior to July 11, 2002 for the award of service connection for coronary artery disease have not been met. 38 U.S.C. § 1155, 5110 (2012); 38 C.F.R. §§ 3.400, 3.816(c) (2019). 2. The criteria for entitlement to an initial rating in excess of 30 percent prior to June 16, 2011 for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.104, Diagnostic Code 7005 (2019). 3. The criteria for entitlement to a rating in excess of 60 percent from June 16, 2011 for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.104, Diagnostic Code 7005 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1971 to November 1974. He served honorably as light weapons infantryman in Vietnam during the Vietnam War, and the Board is grateful for his service and sacrifice. The Veteran testified before the Board at an April 2017 hearing. These matters were previously before the Board in March 2018 and June 2020. Most recently, the Board remanded the case in light of the Veteran’s claims that evidence was missing in his file and to clarify whether the Veteran wished to have a hearing before a decision review officer (DRO). More specifically, in its prior Remand, the Board determined that the Veteran should be afforded an opportunity to supplement the record with additional evidence given that (1) it was unclear whether the Veteran submitted evidence in response to the agency of original jurisdiction’s (AOJ’s) prior April 2018 or May 2019 letters that had not been incorporated in the claims file, to include two prior Disability Benefits Questionnaires (DBQs); (2) that the Veteran asserted that he incurred at least one heart attack each year since 2001, and the evidence as it existed at the time did not contain treatment records identifying treatment for, or a history of regular heart attacks; and (3) that the Veteran asserted that other unnamed records were also missing from the file. In compliance with the Board’s instructions, the AOJ sent the Veteran and his representative letters on July 9, 2020 and August 13, 2020 specifically requesting that the Veteran submit or authorize VA to obtain on his behalf, any outstanding treatment records relevant to his claim, to specifically include any missing DBQs and prior treatment for recurrent heart attacks. The AOJ also afforded the Veteran an opportunity to schedule a DRO hearing. Neither the Veteran nor his representative responded to the letters, nor did they submit, or authorize VA to obtain any additional outstanding medical records. The Veteran also did not respond to the opportunity to appear at a DRO hearing. Accordingly, the Board considers the AOJ to have substantially complied with the Board’s Remand instructions, and the Board will proceed with adjudication. 1. Entitlement to an effective date prior to July 11, 2002 for the award of service connection for coronary artery disease The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on a claim for service connection “shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor.” 38 U.S.C. § 5110(a). The implementing regulation clarifies this to mean that the effective date of an award of service connection “will be the date of receipt of the claim or the date entitlement arose, whichever is later.” 38 C.F.R. § 3.400. Effective March 24, 2015, VA amended its adjudication regulations to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). These amendments are applicable with respect to claims and appeals filed on or after March 24, 2015, and, therefore, are not applicable in the present case. Id. at 57,686. Under the former regulations governing informal claims, any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought. Here, the AOJ awarded service connection for coronary artery disease, effective July 11, 2002. This effective date was based on the date VA received the Veteran’s VA Form 21-526, Application for Compensation And/Or Pension. The Veteran contends that he made an informal claim for service connection in July 2001, at the same time he alleges he requested VA coverage for the private treatment associated with his heart condition. The Board has found no evidence of record to support the Veteran’s contention. Private treatment records demonstrate that the Veteran was admitted to the hospital on July 27, 2001 with complaints of chest pain. Evaluation revealed an acute inferior wall myocardial infarction due to occlusion of the mid right coronary artery and the Veteran was treated with angioplasty. Treatment records then show that, between the July 2001 procedure and September 7, 2001, the Veteran attended seven cardiac rehabilitation sessions. There is no evidence in the record to show that the Veteran contacted VA regarding coverage of his treatment at that time. On February 5, 2002, private and VA treatment records show that the Veteran’s private physician faxed medication requests to the Vancouver VA clinic of the Portland VA Medical Center. On February 15, 2002, the Veteran called the VA clinic, stating that he was a fee basis patient, and asking whether he could fax in his own medication order or if his physician needed to do this. On February 21, 2002, the Veteran contacted the VA clinic to determine whether a fax of his prescriptions had been received. There is no indication that the Veteran made any claim of service connection during these communications. VA treatment records then show that on May 6, 2002, the Veteran sent a letter to Vancouver VA clinic. In that letter the Veteran stated that he was requesting outpatient non-VA medical services as he was in need of prompt medical services due to the severity and nature of his posttraumatic stress disorder and heart disease. He noted that an appointment with his cardiologist, Dr. E.Y., had been scheduled and approved in April, but had been rescheduled for May 10, 2002. August 2002 VA treatment records show that the Veteran had been approved for six weeks of cardiac rehabilitation therapy with Bend Memorial Clinic. First, the Board observes that there is nothing in the record identifying a request for service connection at the time of the Veteran’s July 2001 myocardial infarction and angioplasty. Indeed, the first evidence of record showing that the Veteran contacted VA regarding treatment for his heart condition is the February 2002 communication regarding prescriptions. Moreover, the Veteran’s request for VA coverage of his cardiac rehabilitation treatment is first shown in the record in May 2002; however, there is no indication of a claim for benefits at that time. Thus, even understanding that VA regulations allowed for informal claims during this period, there is nothing to demonstrate a request for service connection benefits prior to the July 11, 2002 claim form. The elements of any claim, whether it is a formal claim or an informal claim, must include a communication in writing that expresses an intent to apply for benefits. Sellers v. Wilkie, 30 Vet. App. 157 (2018) (citing to Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009)). Here, there is no indication that the Veteran expressed such an intent prior to his formal claim. Moreover, it is well established that the mere presence of medical evidence does not establish an intent to seek service connection. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998); see also Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006) (“[W]here there can be found no intent to apply for VA benefits, a claim for entitlement to such benefits has not been reasonably raised.”); Rodriguez v. West, 189 F.3d 1351, 1353 (Fed. Cir. 1999) (noting that even an informal claim for benefits must be in writing). The Board notes that the Veteran has testified to a belief that VA has lost a significant portion of his correspondence. The Board is sympathetic to this assertion; however, the Veteran’s VA medical records during this period appear to be comprehensive. These records clearly document the Veteran’s requests for coverage of his private treatment. If, as the Veteran has testified, his claim for benefits occurred at approximately the same time as his request for coverage, the record does not support the Veteran’s narrative that his request came in July 2001. Instead, the record supports a finding that the Veteran first requested coverage for his private treatment in May 2002, with a request for disability benefits approximately two months later. The Board has also considered whether application of the provisions of 38 C.F.R. § 3.816 avail the Veteran in this case. Indeed, although the Veteran was awarded service connection for CAD prior to the effective date of the regulation that established presumptive service connection for ischemic heart disease as a covered herbicide disease, the AOJ considered the application of the special effective date rules outlined in 38 C.F.R. § 3.816 during the appeal period (as noted by the Board in its March 2018 Remand), and the Board will do the same. They key provision lies at 38 C.F.R. § 3.816(c)(2)—where a Nehmer class member is entitled to disability compensation for a covered herbicide disease, and the claim was either pending before VA on May 3, 1989, or was received by VA between that date and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease, the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose, except as otherwise provided regarding claims filed within one year from the date of separation from service. See 38 C.F.R. § 3.816(c)(2). A claim will be considered a claim for compensation for a particular covered herbicide disease if: (i) the claimant’s application and other supporting statements and submission may reasonably be viewed, under the standards ordinarily governing compensation claims, as indicating an intent to apply for compensation for the covered herbicide disability; or (ii) VA issued a decision on the claim, between May 3, 1989, and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease, in which VA denied compensation for a disease that reasonably may be construed as the same covered herbicide disease for which compensation has been awarded. 38 C.F.R. § 3.816(c)(2)(i)-(ii). In this case, for the reasons discussed above, the Board has found that the Veteran’s date of claim for service connection for CAD was July 11, 2002, which falls within the time period between May 3, 1989 and the effective date of the regulation establishing the presumption on August 31, 2010. Under § 3.816(c)(i), a claim will be considered a claim for a covered herbicide disease under the standards ordinarily governing compensation claims, as indicating an intent to apply for compensation. The Board has discussed above why the evidence does not demonstrate the requisite intent to apply for disability compensation (i.e., service-connection) for CAD prior to July 11, 2002. Thus, because the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose, and because the Veteran’s disability clearly arose prior to receipt of his claim, the Board may not assign an effective date for the award of service connection prior to the more recent July 11, 2002 date of claim under the provisions of 38 C.F.R. § 3.816(c). In sum, the preponderance of the evidence is against a finding that the Veteran submitted a claim for service connection for coronary artery disease prior to July 11, 2002 that can be considered an informal claim for benefits, and there is no other provision under the law that permits the assignment of an earlier effective date for the award of service connection on the facts of this case. The benefit sought must therefore be denied. Increased Ratings 2. Entitlement to an initial rating in excess of 30 percent prior to June 16, 2011 for coronary artery disease 3. Entitlement to a rating in excess of 60 percent from June 16, 2011 for coronary artery disease Disability evaluations are determined by the application of the facts presented to the VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. (1999); Hart v. Mansfield, 21 Vet. App. (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disabilities. 38 C.F.R. § 4.14. Generally, separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has also held that within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise. Cullen v. Shinseki, 24 Vet. App. 74 (2010). In a July 2009 decision, the Board granted entitlement to service connection for coronary artery disease. The AOJ effectuated the Board’s decision in a September 2009 rating decision. In that decision, the AOJ assigned a 0 percent rating, effective the date of the Veteran’s July 2002 claim. In a May 2011 rating decision, the AOJ revised the initial rating of the disability, assigning a rating of 30 percent, effective the date of the claim. Then, in July 2011 rating decision, the AOJ granted an increased rating of 60 percent, effective June 16, 2011—the date of a VA examination. Thus, coronary artery disease is rated at 30 percent from the date of the claim until June 16, 2011, and is rated at 60 percent thereafter. As the initial rating remains on appeal, the Board evaluates the propriety of the rating from the effective date of service connection. Coronary artery disease is evaluated under 38 C.F.R. § 4.104, Diagnostic Code 7005. Under Diagnostic Code 7005, a rating of 30 percent is warranted for documented coronary artery disease resulting in: a condition in which 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 electrocardiogram, echocardiogram, or X-ray. A rating of 60 percent is warranted when there is more than one episode of congestive heart failure in the previous year, or; when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A rating of 100 percent is warranted when the condition results in chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of less than 30 percent. Note (2) of 38 C.F.R. § 4.104 clarifies that 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 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. As was briefly discussed above, the Veteran sought treatment for chest pain in July 2001, prior to the claim. At that time, doctors performed cardiac catheterization and discovered that the Veteran had suffered an acute inferior wall myocardial infarction due to occlusion of the mid right coronary artery. The condition was treated with angioplasty and stenting of the vessel. The Veteran attended cardiac rehabilitation sessions. In September 2001 follow-up treatment, the Veteran denied chest pain or shortness of breath. The Veteran was noted to perform exercise equivalent to 7.9 METs without issue. An echocardiogram performed later that month showed that the left ventricle was normal in size, exhibiting normal systolic function. Wall motion abnormalities were not seen and wall thickness was normal. Left ventricular volumes were normal and ejection fraction was calculated at 65 percent. December 2001 treatment records note that the Veteran was doing well from a cardiac standpoint ant that he had been exercising at an athletic club. The Veteran exhibited no cardiac vascular symptoms. The Veteran had experienced some palpitations during a panic attack, but no syncope. The impression was that coronary artery disease was clinically stable with no evidence of angina. In February 2002, treatment records show the Veteran reported feeling “good.” The Veteran reported exercising regularly with swimming and hiking. After successfully going through the cardiac rehabilitation program with his private provider, the Veteran reported no shortness of breath or chest pain. The Veteran underwent a VA examination in February 2003. At that time, the examiner noted that the Veteran was following up with his cardiologist about once per year and that the cardiologist had observed normal left ventricular function. According to the examiner’s report, the Veteran had experienced no chest pain since that time. Indeed, the examiner noted that the Veteran reported exercising every day to achieve a heart rate of 130 to 144—to include swimming, hiking, and playing basketball—without any chest pain or dyspnea. The examiner opined that this exercise was at a high MET level, estimated at 10 or greater. Subsequent to the February 2003 examination, VA treatment records primarily document pharmacy notations for medication management until May 2010. Throughout this time, records acknowledge the Veteran’s ongoing private treatment and requests for approval of non-VA treatment. The Board notes that these private treatment records are not associated with the claims file, and have not otherwise been submitted by the Veteran or his representative after the AOJ’s requests. May 2010 VA treatment records document the ongoing diagnosis of coronary artery disease with no angina. In July 2010, the Veteran was seen for complaints of chest pain. Myocardial infarction was ruled out by enzyme testing and a treadmill Cardiolite stress test was negative for ischemia. An echocardiogram showed left ventricular ejection fraction of 60 to 65 percent. In October 2010, the Veteran reported recurrent chest pain. The assessment was that it was not unstable angina, but may have been variant angina. At a February 2011 primary care appointment, the Veteran was assessed with suspected coronary vasospasm or Prinzmetal’s angina. Similarly, in June 2011 treatment, a review of systems noted recurrent, “anginal type pain” during panic attacks that was presumed to be coronary vasospasm. An echocardiogram performed the next week was described as essentially normal with an excellent ejection fraction. In June 2011, the Veteran then underwent a new VA examination. At that time, the examiner reported diagnoses of ischemic heart disease, coronary vasospasm, and status post myocardial infarction. The examiner noted that the Veteran did not have congestive heart failure. A diagnostic exercise test was not conducted, rather METs testing was evaluated based on the Veteran’s responses. The Veteran reported experiencing dyspnea at greater than 3 and less than or equal to 5 METs—consistent with light yard work, mowing the lawn, or brisk walking. The examiner reported that there was no evidence of cardiac hypertrophy or dilatation. In the echocardiogram performed just prior to the examination, left ventricular ejection fraction was greater than 55 percent. Subsequent to the VA examination, the Veteran’s cardiac treatment records are once again intermittent. In December 2014, the Veteran was arrested for disruptive behavior at the Durham VA Medical Center pharmacy. During the process of being arrested, the Veteran complained of chest pains and was taken to the emergency department. Medical personnel determined that the Veteran’s claimed chest pain was not related to a cardiac event. In March 2016, the Veteran was treated at Wake Forest Medical Center for complaints of chest pain. Although reports of his actual treatment are not of record, VA treatment records show that the Veteran underwent a myocardial perfusion scan and transthoracic echocardiogram at that time. Both of these tests showed left ventricular ejection fraction of 55 to 60 percent with no wall abnormalities. In an April 2016 VA treatment note, the Veteran’s doctor described the results of these tests as “reassuring.” In a June 2016 pre-anesthetic evaluation prior to undergoing a colonoscopy, the anesthesiologist reported no arrhythmia, no angina, and no congestive heart failure. The Veteran reported good exercise tolerance and was noted to be able to climb two flights of stairs. In June 2019, the Veteran requested a cardiology consultation at Asheville VA Medical Center. He stated that he experienced unstable angina when he got into a confrontation, which happened about once a year. In January 2020, the Veteran once again underwent a VA examination. At that time, the examiner reported diagnoses of an old, acute myocardial infarction, coronary artery disease, unstable angina, and ventricular arrhythmia. The examiner acknowledged the Veteran’s history of myocardial infarction with an angioplasty and stent placement in 2001. The examiner also relayed the Veteran’s report of a diagnosis of unstable angina with episodes of chest pain in November 2003, June 2005, May 2010, July 2010, June 2011, December 2013, October 2014, March 2015, and June 2018. The examiner reported that the Veteran’s most recent available electrocardiogram (EKG) was in June 2018 and showed sinus tachycardia with multiple premature ventricular contractions and minimal ST depression. Thus, based on these findings, the examiner reported a cardiac arrhythmia with intermittent frequency. The examiner noted that the Veteran had undergone several echocardiograms, and the most recent available in the record showed normal left ventricular function with an ejection fraction of 55 percent. The examination report showed no infectious heart condition or pericardial adhesions. On physical examination, the Veteran’s heart rate was regular and heart sounds were normal. There was no jugular-venous distension, auscultation of the lungs was clear and peripheral pulses were normal. There was no peripheral edema. There was also no evidence of cardiac hypertrophy or cardiac dilatation. In an interview-based METs test, the Veteran reported dyspnea at 1 to 3 METs, with the Veteran reporting that he became dyspneic getting in and out of the shower. However, the examiner reported that the METs level limitation was not solely due to the Veteran’s cardiac condition. In a retrospective opinion, the examiner reported that it was at least as likely as not that the Veteran continued to have significant coronary artery disease since his initial cardiac event in 2001, and that ejection fraction was the most accurate measurement of cardiac function alone. Based on the foregoing, prior to June 16, 2011, the evidence does not support a rating in excess of 30 percent. As was documented in the discussion of the Veteran’s history above, prior to that date, there is no evidence in the record demonstrating that a workload of 5 METs or fewer resulted in dyspnea, fatigue, angina, dizziness, or syncope. There is also no evidence of left ventricular dysfunction with an ejection fraction of 50 percent or less. Furthermore, the record consistently shows that the Veteran has not experienced congestive heart failure. The Board acknowledges the Veteran’s April 2017 hearing testimony in which he expressed that his symptoms have been essentially the same since the July 2001 myocardial infarction. The Board finds, however, that this assertion is in conflict with the documented medical evidence. Indeed, subsequent to his cardiac rehabilitation in 2001, the Veteran reported to his medical providers that he was exercising at high levels of METs without symptoms. It was not until the June 16, 2011 VA examination in which the evidence first documented dyspnea at a workload equivalent to 5 or fewer METs. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). Thus, there is no basis for rating the Veteran’s coronary artery disease higher than 30 percent prior to June 16, 2011. The Board also acknowledges the Veteran’s argument at his Board hearing that because the June 16, 2011 examination came in the context of an initial rating claim, the rating based on that examination should go back to the initial date of his claim. However, as was addressed above, when the evidence demonstrates that a disability manifests in symptoms approximating different disability ratings at different points in the appeal, as in this case, a staged rating is appropriate. See Fenderson v. West, 12 Vet. App. (1999); Hart v. Mansfield, 21 Vet. App. (2007). The Board further acknowledges the Veteran’s argument that his disability should have been evaluated under Diagnostic Code 7006 for myocardial infarctions. Under Diagnostic Code 7006, a 100 percent rating is applied during and for three months following myocardial infarction that is documented by laboratory tests. Thereafter, the disability is evaluated under the same criteria as Diagnostic Code 7005. Here, since the Veteran did not file a claim for his heart condition until approximately one year after suffering the myocardial infarction, the initial three-month period under Diagnostic Code 7006 does not apply. From June 16, 2011 forward, a rating in excess of 60 percent is not warranted for the Veteran’s coronary artery disease. As was addressed in the discussion of medical evidence, at no point has the Veteran’s left ventricular ejection fraction been found to be less than 30 percent. Prior to the January 2020 VA examination, there is also no evidence that the Veteran experienced dyspnea, fatigue, angina, dizziness, or syncope due to a workload of 3 METs or fewer. To the extent that the Veteran reported episodes of intermittent angina, they were not associated with any workload, and based on the Veteran’s descriptions and testimony, appear to be more related to psychiatric symptoms. At the January 2020 VA examination, the interview-based METs test found that the Veteran reported dyspnea getting in and out of the shower. However, the examiner reported that this was not due solely to the Veteran’s heart condition. The examiner reported that it was not possible to identify the exact contribution of the Veteran’s heart condition to the dyspnea at 3 or fewer METs. As a result, the examiner reported that left ventricular ejection fraction was the best evaluator of the Veteran’s heart disability. At no point during the period on appeal did left ventricular ejection fraction warrant a rating in excess of 60 percent. The Board acknowledges several other contentions the Veteran has made regarding this claim. First, the Veteran argued at his Board hearing, that because his heart disability was initially deemed secondary to his PTSD, and because he is rated at 100 percent for PTSD, the heart disability should also have been rated at 100 percent for the entirety of the claim. While the Board understands the contention, the Board wishes to clarify that disability ratings are intended to represent the severity of the individual disability itself. The fact that one disability is caused or aggravated by another disability does not mean that those disabilities should be rated in correlation to one another unless VA is specifically instructed to do so by regulation. Second, the Board notes a December 2019 phone call with VA in which he stated that he had had at least one heart attack per year since 2001. Similarly, at his Board hearing, the Veteran reported being hospitalized 15 times for heart-related issues during the period on appeal. This allegation is simply not reflected in the Veteran’s medical record. Indeed, as was noted above, the Veteran was found to be recovering well from his July 2001 myocardial infarction for several years without incident. The Board also acknowledges that in the December 2019 phone call, the Veteran stated that he had submitted two private disability benefit questionnaires (DBQs) that were not in his file. As noted above, subsequent to the Board’s June 2020 remand, in July and August 2020, the AOJ specifically invited the Veteran to submit the DBQs that were not of record and to authorize VA to obtain any outstanding private treatment records that might support the Veteran’s allegations regarding his heart attacks and hospitalizations. To date, the Veteran has not submitted such evidence, nor has he authorized VA to obtain it. Thus, the Board must evaluate the claim based on the evidence of record. Finally, the Board notes the Veteran’s testimony that he was a medic during service and has post-service paramedic training, and is thus more qualified than a layperson regarding the observation of his disability. However, regarding the most significant factor in evaluating the Veteran’s disability in this case—noted by the January 2020 examiner to be left ventricular ejection fraction—such may not be measured by observation alone and must be measured by echocardiogram. Similarly, congestive heart failure cannot be diagnosed by mere observation. The Board has also considered whether the Veteran’s heart disability may be evaluated under a different diagnostic code. Specifically, the Board notes that ventricular arrhythmia, which was diagnosed in the January 2020 VA examination, is evaluated under Diagnostic Code 7011. However, Diagnostic Code 7011 applies to sustained ventricular arrhythmia, whereas the Veteran’s ventricular arrhythmia was determined to be intermittent. Moreover, aside from situations in which the claimant has an implantable Cardioverter-Defibrillator in place, Diagnostic Code 7011 evaluates symptoms under the same criteria as Diagnostic Code 7005. Therefore, such alternative evaluation is not appropriate. Accordingly, based on all of the above, the preponderance of the evidence is against a finding that the Veteran’s coronary artery disease warrants a rating in excess of 30 percent prior to June 16, 2011, and in excess of 60 percent thereafter, and his claims for higher ratings must be denied. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Giaquinto, 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.