Citation Nr: 21012544 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 13-32 603 DATE: March 4, 2021 ORDER Entitlement to a rating for obstructive lung disease, rated under bronchial asthma, previously evaluated as pulmonary sarcoidosis with bronchial asthma, of 60 percent, but no higher, prior to October 27, 2015, and after October 9, 2019, is granted. Entitlement to a rating for obstructive lung disease, rated under bronchial asthma, previously evaluated as pulmonary sarcoidosis with bronchial asthma, in excess of 30 percent from October 27, 2015 to October 9, 2019, is denied. Entitlement to an initial rating for supraventricular arrhythmia with atrial fibrillation of 60 percent, but no higher, prior to October 9, 2019, is granted. Entitlement to an initial rating for supraventricular arrhythmia with atrial fibrillation in excess of 30 percent from October 9, 2019, is denied. Entitlement to a total disability rating based on individual unemployability prior to January 11, 2012 is denied. FINDINGS OF FACT 1. The Veteran has a diagnosis of obstructive lung disease. 2. For the period on appeal, the Veteran’s obstructive lung disease manifested without an FEV-1/FVC of less than 56 percent, more than one attack per week with episodes of respiratory failure, without at least monthly visits to a physician for required care of exacerbations, without daily use of systemic (oral or parental) immuno-suppressive medications, and without at least three courses per year of systemic corticosteroid medications. 3. Prior to October 27, 2015, the Veteran’s obstructive lung disease manifested with an FEV-1 of 40 percent to 55 percent predicted. 4. From October 27, 2015 to October 9, 2019, the Veteran’s obstructive lung disease manifested with an FEV-1 of 56 percent to 70 percent predicted. 5. From October 9, 2019, the Veteran’s obstructive lung disease manifested with an FEV-1 of 40 percent to 55 percent predicted. 6. For one year prior to the date of receipt of the claim, there was no factually ascertainable increase in any of the Veteran’s service-connected disabilities. 7. For the period on appeal, the Veteran has not had congestive or acute heart failure. 8. Prior to October 9, 2019, the Veteran’s supraventricular arrhythmia with atrial fibrillation manifested in a workload of greater than 3 but less than 5 MET’s resulting in dyspnea, fatigue, and angina; but without sustained ventricular arrhythmia, ventricular aneurysmectomy, an automatic implantable Cardioverter-Defibrillator, chronic congestive heart failure, a workload of 3 MET’s or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. 9. From October 9, 2019, the Veteran’s supraventricular arrhythmia with atrial fibrillation manifested in a workload of greater than 5 but less than 7 MET’s resulting in dyspnea and fatigue; but without sustained ventricular arrhythmia, ventricular aneurysmectomy, an automatic implantable Cardioverter-Defibrillator, chronic or acute congestive heart failure, a workload of 5 MET’s or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 50 percent. CONCLUSIONS OF LAW 1. The criteria for a rating for obstructive lung disease, rated as bronchial asthma, of 60 percent, but no higher prior to October 27, 2015, and after October 9, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.3, 4.96, Diagnostic Code 6602. 2. The criteria for a rating for obstructive lung disease, rated as bronchial asthma, in excess of 30 percent for the period from October 27, 2015, to October 9, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.3, 4.96, Diagnostic Code 6602. 3. The criteria for a rating for supraventricular arrhythmia with atrial fibrillation of 60 percent, but no higher, prior to October 9, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.104, Diagnostic Code 7011. 4. The criteria for a rating for supraventricular arrhythmia with atrial fibrillation in excess of 30 percent from October 9, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.104, Diagnostic Code 7011. 5. The criteria for a total disability rating based on individual unemployability prior to January 11, 2012 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served from September 1974 to December 1977. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The matter was previously before the Board in June 2015, March 2018, and May 2020, where it was remanded for additional development. It now returns to the Board for adjudication. In its May 2020 order of remand, the Board directed the RO to attempt to obtain VA treatment records from certain periods in 2014 and 2015 from the Durham and Fayetteville VA Medical Centers, and from the Leesville Internal Medicine private medical center. The record shows that the RO contacted the Durham and Fayetteville VA Medical Centers, which responded that no records existed from the 2014-2015 time periods sought. The RO informed the Veteran of this fact in August 2020. The RO also sent the Veteran a VA Form 21-4142 medical records privacy form to authorize the release of records from the Leesville Internal Medicine center. The Veteran did not respond. The duty to assist is not a one-way street, and the Veteran bears some responsibility to aid the VA in developing his claim. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). (The RO was able to obtain records from Leesville Internal Medicine through September 2012, anyway.) The Board concludes that the RO substantially complied with the terms of the remand order concerning medical record development. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating 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. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. 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. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. I. Increased Rating for Lung Disability The Veteran seeks an increased rating for his service-connected lung disability, evaluated in the rating decision as pulmonary sarcoidosis with bronchial asthma, currently rated at 30 percent under combined diagnostic code 6846-6602. A. Diagnostic Code for Lung Disability Before discussing the rating to which the Veteran is entitled, the Board must first discuss the appropriate diagnostic code to assign to the Veteran’s lung disability. The Veteran has been service connected for a lung disability since March 1977, which was evaluated at the time as sarcoidosis. March 1977 Rating Decision. But in an October 2019 VA examination, the examiner concluded that the Veteran does not have sarcoidosis. The examiner reasoned that because the examination revealed a normal chest x-ray, with no mediastinal lymphadenopathy of the lungs, it was more than likely that the Veteran did not have sarcoidosis. Rather, his service-connected lung disability was obstructive lung disease. When considering the value of medical opinion evidence, the probative value of the opinion is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-01 (2008); Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Here, the October 2019 opinion was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinion is also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s lung disability is better diagnosed as obstructive lung disease, not sarcoidosis. The Board assigns the opinion substantial probative weight, and concludes that the preponderance of the evidence shows that the Veteran’s service-connected lung disability is attributable to obstructive lung disease, not sarcoidosis. The Veteran is currently evaluated under combined diagnostic code 6846-6602. The Veteran was assigned this diagnostic code in a March 2001 rating decision. March 6, 2001 Rating Decision. Under diagnostic code 6846 (sarcoidosis), the rating criteria permit a veteran to be evaluated under the criteria for diagnostic code 6602 (bronchial asthma), if the symptoms more closely resemble these criteria or evaluation under such criteria would be more advantageous to the veteran. 38 C.F.R. § 4.96; see 38 C.F.R. § 4.7. But § 4.96(a) only permits a veteran to be rated under either 6602 (bronchial asthma) or 6846 (sarcoidosis), not both. Id. If the Board finds that the evidence supports a more appropriate diagnostic code than the one previously assigned, it may assign a new one. Butts v. Brown, 5 Vet. App. 532, 538 (1993). Under 38 C.F.R. § 3.344(a), if, as here, a rating has been in effect for more than five years, the Board is tasked with evaluating any change in diagnosis " so as to produce the greatest degree of stability of disability evaluations consistent" with the law. Here, after having reviewed the record, because the Veteran has been diagnosed as not having sarcoidosis, and because the best evaluation of the Veteran’s obstructive lung disease remains the rating criteria for bronchial asthma, the Board concludes that the more appropriate diagnostic code is simply 6602 (bronchial asthma), without the combined alternate criteria for 6848 (sarcoidosis). The Veteran will, then, continue to be rated under the same diagnostic code he has been since 2001. The Board wishes to make clear that assigning the new diagnostic code does not disadvantage the Veteran. The Board is permitted to change a diagnostic code to reflect an underlying change in the diagnosis of a Veteran’s disability without effecting a severance of the disability’s service-connected status. Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Put another way, the Board is not altering the conclusion that the Veteran’s lung disability is service connected; rather, it is only adjusting the proper degree of the disability to more accurately reflect the evidence. Id. at 1300 (citing Collaro v. West, 136 F.3d 1304, 1307 (Fed. Cir. 1998)). The Board acknowledges that the rating criteria for diagnostic code 6846 (sarcoidosis) may provide an alternative method for showing entitlement to a higher rating that uses different criteria than the criteria for diagnostic code 6602 (bronchial asthma). But, the criteria for all ratings higher than the Veteran’s current 30 percent evaluation require manifestations of pulmonary involvement. Here, the Veteran is already service connected for a heart disability, supraventricular arrhythmia with atrial fibrillation, under diagnostic code 7099-7011, ventricular arrhythmias. Any increase in disability of the Veteran’s heart disability, then, would entitle him to a higher rating under this diagnostic code. Because evaluations of the same manifestation of a disability under separate diagnoses is prohibited by regulation, the Veteran would not be entitled to a higher rating under the rating criteria for diagnostic code 6846 (sarcoidosis). 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The Veteran is therefore not prejudiced by the reformulation of his lung disability to diagnostic code 6602 (bronchial asthma) alone. The preponderance of the evidence is in favor of finding that the Veteran’s currently service-connected lung disability is attributable to obstructive lung disease, not sarcoidosis, and that the most appropriate diagnostic code to compensate the Veteran is diagnostic code 6602 (bronchial asthma). The Board will assign the Veteran’s lung disability diagnostic code 6602 for the period on appeal. B. Diagnostic Code Criteria Under 38 C.F.R. § 4.96, diagnostic code 6602, bronchial asthma, a 10 percent rating is warranted where there is a Forced Expiratory Volume-1 (FEV-1) of 71- to 80-percent predicted, or; FEV-1/Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy. A 30 percent rating is warranted where there is a 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 anti-inflammatory medication. A 60 percent rating is warranted where there is a FEV-1 of 40- to 55-percent predicted, or; 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. A 100 percent rating is warranted where there is a FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. The additional provisions concerning the evaluation of respiratory conditions under 38 C.F.R. § 4.96(d) do not apply to ratings under diagnostic code 6602. C. Discussion 1. Pulmonary Function Test Results The Veteran underwent a pulmonary function test in February 2008. The results were: February 2008 PFT Pre-bronchodilator Post-bronchodilator FEV-1 50 percent predicted FEV-1 56 percent predicted FEV-1/FVC 71 percent FEV-1/FVC 77 percent The Veteran underwent a VA examination in June 2012. The examiner noted that at the time of the examination, the Veteran did not require oral or parenteral corticosteroid medications. The examiner performed a PFT. The results were: June 2012 PFT Pre-bronchodilator Post-bronchodilator FEV-1 46 percent predicted FEV-1 65 percent predicted FEV-1/FVC 99 percent FEV-1/FVC 103 percent The Veteran underwent a VA examination in November 2015. The examiner noted that at the time of the examination, the Veteran did not require oral or parenteral corticosteroid medications. The examiner also noted that asthma was the predominate disability responsible for the Veteran’s continued use of inhaled bronchodilators. The examiner incorporated the results of a May 2015 PFT. The results were: May 2015 PFT Pre-bronchodilator test not performed Post-bronchodilator FEV-1 73 percent predicted FEV-1/FVC 67 percent The examiner noted that a pre-bronchodilator test was not taken because the Veteran had taken bronchodilators earlier in the day before the exam. The Veteran underwent a PFT in October 2015. The procedure note indicates no post-bronchodilator study was performed, making this a pre-bronchodilator exam. Oct. 27, 2015 PFT Test Summary by Dr. G.C. The results were: October 2015 PFT Pre-bronchodilator Post-bronchodilator test not performed FEV-1 62 percent predicted FEV-1/FVC 84 percent The Veteran underwent an October 2019 VA examination. The examiner performed a PFT. The results were: October 2019 PFT Pre-bronchodilator Post-bronchodilator FEV-1 45 percent predicted FEV-1 61 percent predicted FEV-1/FVC 69 percent FEV-1/FVC 75 percent The PFT’s were conducted by medical professionals who possess the necessary education, training, and expertise to conduct the requested tests. Additionally, the test results are not contradicted by other medical evidence in the record. Furthermore, there are no competing tests of record. See Guerrieri, 4 Vet. App. at 470-71. The Board finds that the PFT’s are entitled to probative weight. Although the May 2015 PFT only showed a post-bronchodilator score of 73 percent predicted, the Board concludes that this is not sufficient to show that it was more likely than not that the Veteran’s pre-bronchodilator score would have been in excess of 55 percent predicted in May 2015. The Veteran’s PFT results otherwise consistently showed that the Veteran’s pre-bronchodilator results were substantially lower than his post-bronchodilator results, which is consistent with the record showing that the Veteran’s inhaled bronchodilators were effective in aiding his breathing. Additionally, nothing in the record indicates a marked increase in the Veteran’s overall ability to breath that would make it more likely than not that his pulmonary function in May 2015 was better compared to the other test dates. The Board acknowledges that treatment records from the Leesville Internal Medicine facility note that the Veteran recorded an FEV-1 of 20 percent predicted in or around February 2008. See, e.g., Sept. 7, 2012 Leesville Progress Note. Examination of these treatment records does not show that the Leesville facility actually performed the PFT. Instead, the note only appears in the “past medical history” section of the treatment records. There is no indication of where or by whom this PFT was performed; to the extent that the past medical history purports to be a recitation of a test result given to the Veteran by a medical professional, the records do not identify this professional. See generally Voerth v. West, 13 Vet. App. 117, 121 (1999). Additionally, this note appears as early as a March 5, 2008 Progress Note, and there is no indication that the Veteran had a PFT with a similarly low FEV-1 result between February 2008 and the June 2012 PFT. In contrast, the February 2008 PFT results are in the record. The Board finds that the February 2008 PFT results are more likely than not the more accurate test results. See D’Aries v. Peake, 22 Vet. App. 97, 107 (2008). Consequently, the Board finds it less likely than not that the Veteran’s FEV-1 was less than 40 percent predicted at any time during the period on appeal. 2. Other Bronchial Asthma Criteria The record does not show that the Veteran experienced asthma attacks with episodes of respiratory failure in any particular frequency, and not with a frequency of more than one per week. Similarly, the record does not show that the Veteran required visits to a physician for required care of exacerbations with a frequency of at least once per month. Although the Veteran did visit emergency care for breathing problems, see, e.g., July 2013 Treatment Notes, the record shows the frequency for treatment was, at most, perhaps yearly or less often. The Board acknowledges that the assessment of the Veteran’s asthma is described as both “mild” and “moderate” at various points during his treatment records for the period on appeal. As the rating criteria for diagnostic code 6602 contain more specific criteria for which there is evidence in the record, the Board does not award these descriptors any weight. Although the October 2019 VA examination did indicate that the Veteran required use of a systemic corticosteroid, the examiner concluded that the Veteran required only intermittent treatment, defined as at most only one treatment per year. The record does not show that the Veteran required such treatment at a higher frequency. The June 2015 and November 2012 VA examinations concluded that the Veteran did not need systemic corticosteroid treatment at all. The treatment records do not show records of the Veteran being prescribed such systemic corticosteroids. The Board finds that the record does not show that the Veteran required, or was prescribed on a regular basis, systemic, oral or parenteral, high dose corticosteroids or immuno-suppressive medications with a frequency of at least three times per year at any time during the period on appeal. 3. Period from One Year Prior to Date of Claim Under 38 C.F.R. § 3.400(o)(2), although the effective date of a rating increase is normally the date of receipt of the claim, if the Veteran can show that there has been a factually ascertainable increase in the disability within one year prior to the date of the claim, the Veteran will be entitled to an effective date of that increase. 38 U.S.C. § 1110; 38 C.F.R. § 3.400. After reviewing the claims file, the Board finds that the record does not show a factually ascertainable increase in the Veteran’s lung disability within the period from January 11, 2012 and January 11, 2011. The record does not contain specific tests that would show, for example, a decrease in the Veteran’s FEV-1 or FEV/FVC test results, or document an increase in prescribed medications that would correlate with an increase in disability. The Board acknowledges the December 9, 2011 letter from Dr. A.B. stating that the Veteran’s condition had gotten worse shortly prior to the writing of the letter. The letter does not contain any specific findings of fact that would enable the Board to conclude that the Veteran’s disability increased in a factually ascertainable way within the one year prior to the date of receipt of the claim, particularly as the letter speaks about the Veteran’s disease progressing "over the years," which is not specific enough to form the basis for a finding of a factually ascertainable increase. The Board finds that the Veteran has not shown a factually ascertainable increase in his disability for the period between January 11, 2011 and January 11, 2012 and, therefore, is not entitled to an increased rating for that period. 4. Conclusion After reviewing the evidence of record, the Board finds that for the period on appeal, the Veteran did not record a FEV-1/FVC of less than 56 percent, experience more than one asthma attack per week with episodes of respiratory failure, require daily systemic immuno-suppressive medication, require systemic corticosteroid use at least three times per year or more, or require at least monthly visits to a physician for required care of asthma exacerbations. The Board also finds the Veteran’s FEV-1 was between 40 percent and 55 percent predicted prior to October 27, 2015; between 56 and 70 percent predicted from October 27, 2015 to October 9, 2019; and between 40 percent and 55 percent predicted from October 9, 2019. Accordingly, the Board concludes that the Veteran is entitled to a rating of 60 percent prior to October 27, 2015, a rating of 30 percent from October 27, 2015 to October 9, 2019, and a rating of 60 percent from October 9, 2019, but no higher. II. Initial Increased Rating for Supraventricular Arrhythmia The Veteran seeks an increased initial rating for his service-connected supraventricular arrhythmia with atrial fibrillation, currently rated at 30 percent by analogy under diagnostic code 7099-7011 for ventricular arrhythmias. A. Diagnostic Code Standards The Veteran is currently rated by analogy under 38 C.F.R. § 4.104, Diagnostic Code 7011. Under DC 7011, at 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where 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 dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 MET’s or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, or; for an indefinite period from the date of hospital admission for initial evaluation and medical therapy for a sustained ventricular arrhythmia, or; for an indefinite period from date of hospital admission for ventricular aneurysmectomy, or; with an automatic implantable Cardioverter-Defibrillator (AICD) in place. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. One metabolic equivalent (MET) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. B. Discussion The Veteran underwent a June 2012 VA examination. The examiner concluded that, among other things, the Veteran experienced dyspnea, fatigue, and angina at a workload of between three and five MET’s. Additionally, a recorded ejection fraction of only 50 percent was recorded in January 2012. This corresponds to a 60 percent rating. The Veteran underwent a November 2015 VA examination. The examiner attempted to conduct an interview-based MET test which resulted in an estimated workload with symptoms at between one and three MET’s. But the examiner concluded that because the Veteran’s MET workload capacity was affected by multiple conditions other than his heart condition, it was not possible to make an estimate based solely on his arrhythmias. The subsequent October 2019 VA examination was unable to clarify this estimate. Awarding the benefit of the doubt to the Veteran, the Board finds that this examination cannot show that the Veteran would not be entitled to a lower rating than 60 percent. The Veteran underwent an October 9, 2019 VA examination. The examiner concluded that the Veteran experienced dyspnea and fatigue at a workload of between three and five METs, but that as the Veteran’s MET capacity was affected by multiple conditions other than his heart conditions, the Veteran’s heart-based workload was between five and seven METs. Here, the VA examinations were provided by VA medical professionals who the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinions are also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s estimated METs are correct. Furthermore, there are no competing medical opinion of record. See Guerrieri, 4 Vet. App. at 470-71; Hernandez-Toyens, 11 Vet. App. at 382. The Board assigns the June 2012, November 2015, and October 2019 VA examinations substantial probative weight. The remainder of the Veteran’s VA and private medical records do not show that the Veteran ever was hospitalized for sustained ventricular arrythmia, ventricular aneurysmectomy, had an automatic implantable Cardioverter-Defibrillator, suffered from chronic or acute congestive heart failure, had dyspnea, fatigue, angina, dizziness, or syncope at a workload of three METs or less, or had an ejection fraction of less than thirty percent during the period on appeal. Additionally, the Veteran’s records do not show that the Veteran had an ejection fraction of less than fifty percent on or after October 9, 2019. The Board acknowledges the notation in the October 2019 VA examination that there is a worsening of the Veteran’s heart symptoms. But, the evidence of record does not show evidence of symptoms that would entitle the Veteran to a rating higher than 30 percent. A condition may worsen without manifesting in such a way as to warrant a higher rating; in any event, it is possible the condition has worsened compared to a point in time where the symptoms were, in fact, better, and worsening only produced symptoms that approximate a 30 percent rating. 1. Congestive Heart Failure As previously noted by the Board, a May 30, 2017 nursing preoperative report in the Veteran’s VA treatment records recorded the Veteran as experiencing congestive heart failure. The same day, though, an anesthesiology preoperative report recorded the Veteran as not having experienced congestive heart failure. Accordingly, the Board ordered a VA examination to confirm whether or not the Veteran has experienced congestive heart failure. The Veteran underwent a July 2020 VA examination. The examiner concluded that it was less likely than not that the Veteran experienced congestive heart failure, as a review of a variety of echocardiograms did not show any history or record of congestive heart failure. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. The Board concludes that the Veteran did not experience congestive heart failure at any time during the period on appeal. C. Conclusion The Board concludes that it is at least as likely as not that the Veteran’s heart disability more closely approximates a workload of greater than 3 but no more than 5 MET’s causing dyspnea, fatigue, and angina in the Veteran prior to October 9, 2019, but without symptoms more closely resembling the listed symptom of higher ratings; and more closely approximates a workload of greater than 5 and less than 7 MET’s causing dyspnea and fatigue, but without symptoms more closely resembling the listed symptom of higher ratings, from October 9, 2019. Accordingly, the Board concludes that the Veteran is entitled to a rating of 60 percent prior to October 9, 2019, and a rating of 30 percent from October 9, 2019. Total Disability Rating Based on Individual Unemployability The Veteran is currently entitled to an extraschedular total disability rating based on individual unemployability (TDIU) from January 11, 2012. In his claim for an increased rating for his service-connected lung disability, the Veteran stated his lungs had worsened to the point that he was totally unable to work. Because a claim for an increased evaluation also includes an implied claim for entitlement to a TDIU where there are allegations of worsening disability and unemployability, Rice v. Shinseki, 22 Vet. App. 477 (2009), the Veteran’s January 2012 claim included a claim for a TDIU. The effective date of a claim for a non-initial increased rating, including a TDIU, is the date of receipt of a claim or, if shown, the date of an ascertainable increase in disability up to one year prior to the date of the receipt of a claim. 38 C.F.R. § 3.400; Dalton v. Nicholson, 21 Vet. App. 23, 34 (2007). Thus, although the Veteran has been granted a TDIU from January 11, 2012, because the period on appeal for an increased rating may be longer than that, the issue of a TDIU remains on appeal. See Harper v. Wilkie, 30 Vet. App. 356, 360 (2018). For the one year prior to January 11, 2012, the Veteran was service connected for his lung disability and for residuals of a right extensor tendon repair (of the right wrist). The Veteran would not be entitled to a schedular TDIU under § 4.16(a), but may still warrant consideration on an extraschedular basis under § 4.16(b) if he is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. See 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). While the Board may not assign an extraschedular TDIU in the first instance, it may consider whether a referral to the Director of Compensation Services for consideration is warranted. See Ray v. Wilkie, 31 Vet. App. 58, 62-66 (2019). But if a factually ascertainable increase in the Veteran’s disability pertaining to his entitlement to a TDIU is not shown, the Veteran would not be entitled to a TDIU prior to the date of the receipt of his claim. 38 C.F.R. § 3.400; see Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). An increase in disability for the purpose of considering a TDIU is not identical to the increase in disability necessary to show entitlement to a higher rating. Dalton, 21 Vet. App. at 34. As discussed above, the record does not show a factually ascertainable increase in the Veteran’s service-connected lung disability for the year prior to the receipt of the claim, nor does it show any increase in the Veteran’s right wrist disability (nor is there any evidence to suggest that the right wrist disability is a factor in the Veteran’s employability). Additionally, the Board finds that the record also does not show a factually ascertainable increase in the Veteran’s service-connected disabilities in a way that would decrease the Veteran’s ability to secure or follow a substantially gainful occupation. The Board acknowledges that the Veteran demonstrated an increase in disability in February 2008, but this is more than one year before the date of receipt of the claim and may not be considered. Gaston, 605 F.3d at 984. Additionally, the consideration of the Veteran for an extraschedular TDIU noted that the Veteran had not been employed full time since 1990. January 2020 DROC Memo. The Board acknowledges that the Veteran’s service-connected heart disability, in conjunction with his lung disability, may have decreased the Veteran’s ability to work prior to the effective date of January 2012. But a TDIU may only be evaluated based on the disabling effects of service-connected disabilities. 38 C.F.R. § 4.16. The Veteran is only entitled to an effective date for his heart disability as of January 2012, and the Board therefore may not consider it prior to that date. The Board acknowledges the December 9, 2011 letter from Dr. A.B. stating that the Veteran’s condition had gotten worse shortly prior to the writing of the letter, and that the worsening condition had caused the Veteran to become unemployable. The letter does not contain any specific findings of fact that would enable the Board to conclude that the Veteran’s disability increased in a factually ascertainable way within the one year prior to the date of receipt of the claim, particularly as the letter speaks about the Veteran’s disease progressing “over the years,” which is not specific enough to form the basis for a finding of a factually ascertainable increase. The Board finds that the preponderance of the evidence is against finding a factually ascertainable increase in the Veteran’s disability would affect the Veteran’s ability to secure or follow a substantially gainful occupation between January 11, 2011 and January 11, 2012, and as such, the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b). In the absence of a factually ascertainable increase, the Veteran is only entitled to an effective date as of the day of the receipt of the claim. 38 C.F.R. § 3.400(o). Therefore, the Veteran is not (Continued on the next page)   entitled to a referral for extraschedular consideration for a TDIU for the one year prior to the date of the claim. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael D. Wagner, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.