Citation Nr: 21012299 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 13-25 384A DATE: March 4, 2021 ORDER Entitlement to an initial rating greater 10 percent prior to April 21, 2010, greater than 60 percent from April 21, 2010, to April 26, 2011, greater than 10 percent from April 27, 2011, to May 30, 2013, greater than 30 percent from May 31, 2013, to July 23, 2020, and greater than 60 percent thereafter, for coronary artery disease is denied. FINDINGS OF FACT 1. Prior to April 21, 2010, the service-connected coronary artery disease (CAD) was manifested by continuous medication required with no evidence of impairment of metabolic equivalents (METs) resulting in dyspnea, fatigue, angina, dizziness, or syncope, and no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. 2. From April 21, 2010, to April 26, 2011, the service-connected CAD was manifested by an ejection fraction of 30 to 50 percent and continuous medication being required with no evidence of chronic congestive heart failure (CHF), a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or an ejection fraction less than 30 percent. 3. From April 27, 2011, to May 30, 2013, the service-connected CAD was manifested by continuous medication required, a workload of greater than 10 METs, and an ejection fraction greater than 50 percent, with no evidence of CHF or cardiac hypertrophy or dilatation. 4. From May 31, 2013, to July 23, 2020, the service-connected CAD was manifested by echocardiogram evidence of cardiac hypertrophy and dilatation, continuous medication required, an ejection fraction greater than 50 percent, and a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, and no evidence of CHF. 5. Effective July 24, 2020, the service-connected CAD was manifested by a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, continuous medication required, echocardiogram evidence of cardiac dilatation and hypertrophy, and an ejection fraction of more than 50 percent, and no evidence of chronic CHF. CONCLUSION OF LAW The criteria for an initial rating greater than 10 percent prior to April 21, 2010, greater than 60 percent from April 21, 2010, to April 26, 2011, greater than 10 percent from April 27, 2011, to May 30, 2013, greater than 30 percent from May 31, 2013, to July 23, 2020, and greater than 60 percent thereafter, for service-connected coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.104, Diagnostic Code (DC) 7005 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service in the U.S. Army from June 1969 to December 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from December 2010, July 2013, and September 2020 Rating Decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). When this matter came before the Board previously in May 2020, it was remanded for additional development to afford the Veteran another VA medical examination. The Board finds that there has been substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Having reviewed the record evidence, the Board finds that the issue on appeal should be characterized as stated above. Entitlement to an initial rating greater than 10 percent for service-connected coronary artery disease prior to April 21, 2010 In April 2009, the Veteran’s private medical treatment records reported “a trace of mitral regurgitation but no significant left ventricular dysfunction,” and “[n]o pericardial effusion” according to echocardiogram. At the time, the Veteran was noted to have been “working out with 35 pound weights.” A private treatment record dated September 2009 indicates the Veteran endorsed left shoulder and arm pain, as well as, exertional dizziness. The Veteran was scheduled for an in-person VA examination in December 2010; however, he reportedly did not attend. Thereafter, the RO issued the December 2010 Rating Decision granting entitlement to service connection for CAD with a 10 percent disability rating effective November 27, 2009 (the date VA received his claim), based upon continuous medication being required, and the Veteran timely appealed the assigned rating. The Board has considered the Veteran’s statements that his CAD is more disabling than currently and initially evaluated during this time period. The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the Veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). On the other hand, such competent evidence concerning the nature and extent of the Veteran’s CAD has been provided by the medical personnel who have treated him during the appeal period. The medical findings contained in the treatment records most directly address the criteria under which this disability is evaluated. The record contains no evidence suggesting that, prior to April 21, 2010, the service-connected CAD resulted in cardiac hypertrophy or dilatation, CHF, an ejection fraction of 50 or less, surgical treatment, or impairment of METs resulting in dyspnea, fatigue, angina, or syncope. Taken together, the record evidence dated during this time period supports the disability rating currently and initially assigned for the service-connected CAD. The Veteran also has not identified or submitted any evidence demonstrating his entitlement to a higher initial rating for his service-connected CAD during this time period. Thus, the Board finds that the criteria for an initial rating greater than 10 percent for CAD prior to April 21, 2010, have not been met. Entitlement to an initial rating greater than 60 percent for service-connected CAD from April 21, 2010, to April 26, 2011 On April 21, 2010, the Veteran underwent a cardiovascular evaluation including a nuclear stress test with a private physician, Dr. H.R., which revealed an ejection fraction of 47 percent. An echocardiogram revealed normal left ventricular size, normal functioning cardiac valve structures, and no pericardial effusion. The Board has considered the Veteran’s statements that his CAD is more disabling than currently and initially evaluated. Although the Veteran is competent to report symptoms, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. Id. For this period, the record contains no evidence suggesting that the service-connected CAD resulted in chronic CHF, a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or an ejection fraction less than 30 percent. His ejection fraction was 47 percent on April 27, 2010, a finding which supports the current 60 percent rating assigned during this time period. Taken together, the record evidence dated during this time period supports the disability rating currently and initially assigned for the service-connected CAD. The Veteran also has not identified or submitted any evidence demonstrating his entitlement to a higher initial rating for his service-connected CAD during this time period. Thus, the Board finds that the criteria for an initial rating greater than 60 percent from April 21, 2010, to April 26, 2011, for CAD have not been met. Entitlement to an initial rating greater than 10 percent for service-connected CAD from April 27, 2011, to May 30, 2013 The Veteran underwent a stress test with a private provider in April 2011, which showed an estimated workload of 10.4 METs. An echocardiogram study revealed a left ventricular ejection fraction of 60 percent, and a stress test indicated an ejection fraction of 52 percent. In June 2011, the Veteran reportedly denied chest pain or discomfort, palpitations, intermittent leg claudication, and dyspnea. The Veteran underwent an in-person VA examination in July 2013, at which time the VA examiner reported continuous medication treatment. Further, the VA examiner reported no CHF and referenced the April 2011 stress test, EKG, and echocardiogram revealing a workload greater than 10 METs and an ejection fraction of 52 percent. The VA examiner also reported no evidence of cardiac hypertrophy or dilatation. The Board has considered the Veteran’s statements that his CAD is more disabling than currently and initially evaluated during this time period. Although he is competent to report symptoms, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. Id. The Board acknowledges the Veteran’s contention made in September 2013 that, “a [compensation and pension] examination was not conducted to truly evaluate [his] current METs level and status of [his] service connected [CAD].” According to the Veteran, the examination “consisted of one blood pressure reading with [his] shirt on.” Despite these lay assertions, the Board nevertheless finds the July 2013 VA examiner’s report is probative and persuasive evidence against the claim for an increased rating for the period at issue. This examination report appears to be based upon a review of the claims file, detailed in-person clinical interview, and a thorough cardiovascular examination targeting the rating criteria and supported by clear rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The record contains no evidence suggesting that, during the period at issue, the service-connected CAD resulted in cardiac hypertrophy or dilatation, CHF, ejection fraction of 50 or less, surgical treatment, or impairment of METs resulting in dyspnea, fatigue, angina, or syncope. The Veteran’s estimated METs were above 10 in April 2011. He denied experiencing chest pain in July 2011. There was no CHF on VA examination in July 2013. The ejection fraction consistently was above 50 percent. Taken together, the record evidence dated during this time period supports the disability rating currently and initially assigned for the service-connected CAD. The Veteran also has not identified or submitted any evidence demonstrating his entitlement to a higher initial rating for his service-connected CAD during this time period. Thus, the Board finds that the criteria for an initial rating greater than 10 percent from April 27, 2011, to May 30, 2013, for CAD have not been met. Entitlement to an initial rating greater than 30 percent for service-connected CAD from May 31, 2013, to July 23, 2020 The Veteran’s private treating physician, Dr. A.D., completed an Ischemic Heart Disease Disability Benefits Questionnaire (DBQ) in October 2013. According to Dr. A.D., the Veteran does not have CHF and stress testing conducted October 2013 revealed a workload of 10.1 METs resulting in angina. Dr. A.D. reported diagnostic testing including an EKG dated May 31, 2013, and echocardiogram dated June 2013 revealed “mild” cardiac hypertrophy or dilatation, with an ejection fraction of 65 percent. The Board has considered the Veteran’s statements that his CAD is more disabling than currently and initially evaluated during this time period. Although he is competent to report symptoms, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. See Rucker, 10 Vet. App. at 74; Layno, 6 Vet. App. at 469. The record contains no evidence suggesting that, during the period at issue, the service-connected CAD resulted in CHF, ejection fraction of 50 or less, surgical treatment, or workload of greater than three METs but not greater than five METs resulting in dyspnea, fatigue, angina, or syncope. The Veteran’s ejection fraction was 65 percent in July 2013. His private treating clinician stated in October 2013 that he did not have CHF. His METs again were above 10 although this resulted in angina. Taken together, the record evidence dated during this time period supports the disability rating currently and initially assigned for the service-connected CAD. The Veteran also has not identified or submitted any evidence demonstrating his entitlement to a higher initial rating for his service-connected CAD during this time period. Thus, the Board finds that the criteria for an initial rating greater than 30 percent from May 31, 2013, to July 23, 2020, have not been met. Entitlement to an initial rating greater than 60 percent for service-connected CAD effective July 24, 2020 In July 2020, the Veteran underwent a telephonic VA examination, and the VA examiner reported reviewing the claims file. Additionally, an echocardiogram study was conducted in August 2020, which revealed a left ventricular ejection fraction of 55.9 percent. According to the VA examiner, the Veteran requires continuous medication for his service-connected CAD. Further, the VA examiner reported no CHF, arrhythmias, or hospitalizations during the period at issue. However, while the VA examiner did not report cardiac hypertrophy involvement, he did report cardiac dilatation as confirmed by the August 2020 echocardiogram. The VA examiner also conducted an interview based METs test, which the examiner estimated revealed greater than three METs but not greater than five METs resulting in dyspnea, fatigue, and angina. The Board finds the VA examiner’s report probative and persuasive evidence as it appears to be based upon a thorough review of the claims file and interview of the Veteran and is supported by clear rationale and is not contradicted by the other medical evidence of record. See Nieves-Rodriguez, 22 Vet. App. 295. The Board has considered the Veteran’s statements that his CAD is more disabling than currently and initially evaluated during this time period. Although he is competent to report symptoms, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. See Rucker, 10 Vet. App. at 74; Layno, 6 Vet. App. at 469. For this period, the record contains no evidence suggesting that the service-connected CAD resulted in chronic CHF, a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or an ejection fraction less than 30 percent. VA examination showed no CHF. An interview-based METs test resulted in estimated METs between 3 and 5 METs. And the ejection fraction was 55.9 percent. Taken together, the record evidence dated during this time period supports the disability rating currently and initially assigned for the service-connected CAD. The Veteran also has not identified or submitted any evidence demonstrating his entitlement to a higher initial rating for his service-connected CAD during this time period. Thus, the Board finds that the criteria for an initial rating greater than 60 percent effective July 24, 2020, have not been met. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.