Citation Nr: 21013675 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 12-06 697 DATE: March 10, 2021 ORDER Entitlement to an increased rating for right shoulder tendonitis, currently rated 20 percent disabling, is denied. Entitlement to an increased rating for neck strain with arthritis, currently rated 20 percent disabling, is denied. Entitlement to higher initial ratings for premature ventricular and atrial contractions (currently rated noncompensably disabling prior to November 10, 2008; rated 10 percent disabling from November 10, 2008, to December 12, 2018; and rated 30 percent disabling from December 13, 2018, onward) is denied. FINDINGS OF FACT 1. The Veteran’s right (major) shoulder tendonitis has not been productive of limitation of motion of the arm to no more than midway between side and shoulder (flexion and/or abduction limited to 45 degrees). There was no factually ascertainable increase within a year prior to the date of the claim on appeal. 2. The Veteran’s neck strain with arthritis has not been productive of limitation of forward flexion of the cervical spine to 15 degrees or less; nor ankylosis of the entire cervical spine, nor intervertebral disc disease (IVDS) with incapacitating episodes having a total duration of at least 4 weeks during a 12 month period. There was no factually ascertainable increase within a year prior to the date of the claim on appeal. 3. For the period prior to November 10, 2008, the Veteran’s premature ventricular and atrial contractions were not productive of impairment such that a workload of greater than 7 METs resulted in dyspnea, fatigue, angina, dizziness, or syncope; nor was continuous medication required; nor was there chronic congestive heart failure, associated hospital admission, nor treatment with an automatic implantable Cardioverter-Defibrillator (AICD). 4. For the period from November 10, 2008, to December 12, 2018, the Veteran’s premature ventricular and atrial contractions were not productive of impairment such that a workload of greater than 5 METs resulted in dyspnea, fatigue, angina, dizziness, or syncope; nor was there evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray; nor was there chronic congestive heart failure, associated hospital admission, nor treatment with an AICD. 5. For the period from December 13, 2018, onward, the Veteran’s premature ventricular and atrial contractions have not been productive of impairment such that a workload of greater than 3 METs results in dyspnea, fatigue, angina, dizziness, or syncope; nor has there been left ventricular dysfunction with an ejection fraction of 50 percent or less; nor has there been chronic congestive heart failure, associated hospital admission, nor treatment with an AICD. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for the Veteran’s service-connected right shoulder tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5024-5201 (as in effect prior to February 7, 2021), and 4.71a, Diagnostic Code 5024-5201 (as in effect from February 7, 2021). 2. The criteria for a rating in excess of 20 percent for the Veteran’s service-connected neck strain with arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242-5237 (as in effect prior to February 7, 2021), and 4.71a, Diagnostic Code 5242-5237 (as in effect from February 7, 2021). 3. For the period prior to November 10, 2008, the criteria for a compensable rating for the Veteran’s premature ventricular and atrial contractions have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, and 4.104, Diagnostic Code 7011. 4. For the period from November 10, 2008, to December 12, 2018, the criteria for a rating in excess of 10 percent for the Veteran’s premature ventricular and atrial contractions have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, and 4.104, Diagnostic Code 7011. 5. For the period from December 13, 2018, onward, the criteria for a rating in excess of 30 percent for the Veteran’s premature ventricular and atrial contractions have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, and 4.104, Diagnostic Code 7011. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1987 to October 2007. This case is before the Board of Veterans’ Appeals (Board) on appeal from an April 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), and also a March 2017 RO rating decision. The heart disability issue arises from the April 2008 rating decision. The neck disability and right shoulder disability issues arise from the March 2017 rating decision. The Veteran testified at a Board videoconference hearing before the undersigned in September 2017. A transcript of the hearing is of record. During the pendency of the appeal, a November 2011 RO rating decision granted an increased 10 percent rating for premature ventricular contractions, effective from November 10, 2008. This case was previously before the Board in February 2018. That February 2018 Board decision remanded certain issues on appeal. During the processing of the Board’s February 2018 remand directives, the RO issued a rating decision in February 2019 that granted an increased 30 percent rating for premature ventricular contractions, effective from December 13, 2018. This case was again before the Board in May 2020, when the Board resolved a number of issues on appeal with final decisions, and the Board remanded the rating issues concerning neck disability, right shoulder disability, and heart disability to the Agency of Original Jurisdiction (AOJ) for additional development. The issues remanded by the Board in May 2020 have now returned to the Board for further appellate review. Increased Rating Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issues on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all contents of the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating periods on appeal to see if the history supports a higher rating during the rating periods on appeal. Additional references to the Veteran’s service-connected disabilities are presented in evidence of record beyond that discussed below, including in VA medical reports associated with the Veteran’s treatment. The additional evidence of record does not present findings that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. Special Considerations for Musculoskeletal Disability Ratings Generally, in evaluating musculoskeletal disabilities, consideration must be given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The United States Court of Appeals for Veterans Claims (Court) has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Pain may be taken into consideration when rating functional loss. However, pain on motion is not, itself, functional loss, but may result in functional loss only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination[, or] endurance.” 38 C.F.R. § 4.40. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (citing 38 C.F.R. § 4.40). 38 C.F.R. § 4.40 (functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170. In Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court addressed the adequacy of medical opinions that decline to present clear estimations by citing that such estimations would be mere speculation. The Court explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering a DeLuca opinion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, VA examiners should offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of Veterans. VA examiners have a duty to elicit information from the Veteran when attempting to describe functional loss associated with pain during unobserved exacerbations. If a non-speculative opinion still cannot be offered, the VA examiner must explain the basis for this conclusion. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation (whether based on lack of expertise, insufficient information, or unprocured testing) of the individual examiner. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, arthritis established by X-ray findings is rated on the basis of limitation of motion of the affected joints. When, however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (identified as degenerative arthritis prior to the regulatory change and degenerative arthritis other than post-traumatic after the changes). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, however, arthritis is rated as 10 percent disabling when shown by X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, or as 20 percent disabling when shown by x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. Finally, it is the intention of the VA rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. Burton v. Shinseki, 25 Vet. App. 1 (2011). During the pendency of the instant appeal, VA promulgated new regulations governing ratings for musculoskeletal system and muscle disabilities, effective February 7, 2021. See 85 Fed. Reg. 76,453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a Veteran’s appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to her claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. 1. Entitlement to an increased rating for right shoulder tendonitis, currently rated 20 percent disabling, is denied. The Veteran contends that she is entitled to a higher rating for right shoulder tendonitis, asserting that the impairment is more severe than the assigned rating reflects. The beginning of the rating period on appeal in this case is defined by the date upon which the Veteran filed the claim (or a qualifying notice of intent to file the claim) on appeal: May 22, 2015. The Veteran’s service-connected right shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5024-5201. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four numbers reflect the diagnosed disability. The second four numbers, after the hyphen, identify the criteria used to evaluate that disability. Diagnostic Code 5024 for “Tenosynovitis, tendinitis, tendinosis or tendinopathy” provides that the joint is to be rated as degenerative arthritis, based on limitation of motion of affected parts. While some of the language involved in the provisions of Diagnostic Code 5024 has been adjusted, these provisions are substantially unchanged by the new regulations effective February 7, 2021. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Diagnostic Code 5200, etc.). 38 C.F.R. § 4.71a, Diagnostic Code 5003. These provisions are substantially unchanged by the new regulations effective February 7, 2021. The Veteran’s right shoulder disability is thus ultimately rated by application of the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level (clarified as flexion and/or abduction limited to 90 degrees under the new regulations) warrants a 20 percent rating, whether involving the major or the minor extremity. Limitation of motion of the arm midway between side and shoulder (clarified as flexion and/or abduction limited to 45 degrees under the new regulations) warrants a 20 percent rating for the minor extremity, and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side (clarified to note flexion and/or abduction in the new regulations) warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for right shoulder tendonitis. The evidence of record shows that the Veteran is right hand dominant, as confirmed in the October 2020 VA shoulder examination report. The Board acknowledges the Veteran’s lay reports of symptoms and that there has been right shoulder functional loss during flare-ups due to “pain … from overuse” making her “[u]nable to lift objects more than 90 degrees,” and making “carrying[,] lifting, reaching … limited,” as described in the most recent October 2020 VA examination report. The October 2020 VA shoulder examination report shows that the VA examiner accepted the Veteran’s description that “Pain” and “Fatigue” caused functional loss during flare-ups that limited flexion to 70 degrees, abduction to 80 degrees, external rotation to 70 degrees, and internal rotation to 80 degrees. The October 2020 VA examiner furthermore clinically determined that the Veteran, following repetitive use of the right shoulder during the examination, had functional impairment that limited flexion to 85 degrees, abduction to 70 degrees, external rotation to 35 degrees, and internal rotation to 35 degrees. Clinical testing during the October 2020 VA examination did not otherwise reveal any observation or estimation indicating any greater limitation of motion of the right shoulder. The October 2020 VA examination report shows that clinical examination revealed “objective evidence of pain,” including on passive range of motion and non-weight bearing inspection of the joint, and the Board finds that the Veteran’s right shoulder pain is clearly contemplated in the VA examiner’s measurements and estimations of limitation of motion associated with “Pain” and “Fatigue,” informed by acceptance of the Veteran’s own accounts of her limitations during unobserved exacerbations. Even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements do not result in symptoms more nearly approximating limitation of motion of the arm to midway between side and shoulder level of the major extremity (or with flexion and/or abduction limited to 45 degrees since February 7, 2021, or limitation of motion of the arm to 25 degrees from the side (including flexion and/or abduction since February 7, 2021). An earlier December 2018 VA shoulder examination report contains documentation of the Veteran’s description of flare-ups, substantially similar to the description considered documented in the October 2020 VA examination report. While aspects of the December 2018 examination were inadequate, as identified in the Board’s prior remand, the inadequacies have been resolved by the 2020 VA examination; the remainder of the December 2018 examination is adequate and has been considered. The December 2018 VA examination report also notes objective evidence of pain, with limited ranges of motion, further limited on repetitive use. The greatest degree of impairment shown in the December 2018 VA examination report is in the limitation of flexion to 95 degrees, abduction to 80 degrees, external rotation to 40 degrees, and internal rotation to 30 degrees on observed repetitive use. The Board notes that the Veteran’s descriptions of impairment during unobserved flare-ups in December 2018 were substantially similar to those presented in October 2020 when the October 2020 VA examiner accepted the descriptions of functional impairment and characterized them in terms of degrees of limited ranges of motion. A February 2017 VA shoulder examination report presents clinically observed measurements of the Veteran’s limitation of right shoulder ranges of motion, and further presents estimations of limited motion associated with unobserved exacerbations based upon the Veteran’s own accounts. Informed by clinical testing and the Veteran’s own description of functional impairment, the February 2017 VA examiner presented range of motion measurements (and estimations of unobserved exacerbations associated with repeated use over time) that reflected no greater limitation, and no further support of the Veteran’s claim, than the ranges of motion presented in the more recent evidence discussed above. A May 2016 VA shoulder examination report shows that the Veteran described functional impairment substantially similar to the reports discussed above, featuring flare-ups with painful impairment of her capacity to lift, push, or carry things of any weight; she also reported that she “can’t throw with the R arm” during flare-ups. The May 2016 VA examiner noted objective evidence of pain during range of motion testing, and the Board particularly notes that pain was noted to begin at the 60 degree position of right shoulder abduction. Assuming hypothetically, for the sake of the Veteran’s argument, that such pain resulted in functional limitation of right shoulder abduction to 60 degrees, this may represent a greater degree of limitation than was shown in the more recent evidence discussed above. However, abduction limited to 60 degrees nevertheless fails to meet the applicable criteria for a disability rating in excess of 20 percent, and thus the limitation does not present support for assignment of the increased rating sought in this case. The May 2016 VA examination report’s presentation of right shoulder ranges of motion otherwise show no greater limitation, and no further support of the Veteran’s claim, than the ranges of motion presented in the more recent evidence discussed above. The other evidence of record, including the January 2008 and August 2007 VA shoulder rating examination reports from prior to the rating period on appeal in this case, show no greater limitation, and no further support of the Veteran’s claim, than the ranges of motion presented in the more recent evidence discussed above. The Board also notes that the Veteran’s description of impairment during her September 2017 Board hearing was substantially consistent with the impairment described in the evidence above. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. The October 2020 VA examination report shows that the VA examiner specifically determined that the Veteran did not have a pertinent impairment of the humerus, clavicle, or scapula. None of the other evidence of record otherwise demonstrates pertinent impairment of the humerus, clavicle, or scapula. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 20 percent for right shoulder tendonitis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Court and VA’s General Counsel have interpreted the laws and regulations pertaining to the effective date for an increase as providing that, if the increase occurred within one-year prior to the claim, the increase is effective as of the date the increase was factually ascertainable. 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400(o); VAOPGCPREC 12-98 (1998). In this case, the AOJ awarded a 20 percent rating (increased from a noncompensable rating previously in effect) for the Veteran’s right shoulder disability effective from the May 22, 2015, date of the claim on appeal. The Board has now considered whether any worsening of the disability within one-year prior to the claim warranted an increased rating. However, the Board finds no evidence making it factually ascertainable that the Veteran’s right shoulder disability underwent an increase in severity to meet the criteria for an increased rating on any identifiable date within a year prior to the May 22, 2015, date of claim. None of the evidence of record shows a factually ascertainable increase in the Veteran’s right shoulder disability impairments causing the criteria for an increased rating to have been met on a factually ascertainable date within the year prior to May 22, 2015. Accordingly, the Board finds no factually ascertainable date of increase in the severity of right shoulder disability impairment during the one-year period prior to the claim dated May 22, 2015, to serve as a basis for awarding an increased rating effective from prior to that date of the claim. 2. Entitlement to an increased rating for neck strain with arthritis, currently rated 20 percent disabling, is denied. The Veteran contends that she is entitled to a higher rating for neck strain with arthritis, asserting that the impairment is more severe than the assigned rating reflects. The beginning of the rating period on appeal in this case is defined by the date upon which the Veteran filed the claim (or a qualifying notice of intent to file the claim) on appeal: May 22, 2015. The Veteran’s neck strain with arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237 for cervical spine strain with arthritis. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four numbers reflect the diagnosed disability. The second four numbers, after the hyphen, identify the criteria used to evaluate that disability. Under the new regulations, Diagnostic Code 5237 is unchanged and Diagnostic Code 5242 has been amended to include degenerative disc disease other than intervertebral disc disease (IVDS), as well as degenerative arthritis. Both Diagnostic Codes are rated under the General Rating Formula for Diseases and Injuries of the Spine which is unchanged by the new regulations effective February 7, 2021. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating IVDS Based on Incapacitating Episodes, also unchanged by the new regulations, provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for neck strain with arthritis. The Board acknowledges the Veteran’s lay reports of symptoms, including during the October 2020 VA neck rating examination report, of functional loss due to pain, fatigue, and weakness during flare-ups and following repetitive use over time. The Veteran described, as documented in the October 2020 VA examination report, that she is “[u]nable to drive, during flareups, no biking, unable to teach or perform any kind of physical activity.” The same report further documents the VA examiner’s assessment, informed by the Veteran’s account of her symptomatic impairments, that “[c]ervical strain arthritis limits her availability to write on the board for very long with her right hand before pain occurs, she is also unable to reach overhead to pull down overhead screens. She also states she is no longer able to perform forestry work due to her inability to use the necessary tools for the job such as an ax or debris clearing tool.” The VA examiner reported that she had “0-1 week work time lost in last 12 months.” However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of the cervical spine limited to 15 degrees or less; or favorable ankylosis of the entire cervical spine. The October 2020 VA examination report shows clinical observed forward flexion of the cervical spine to 40 degrees, with objective evidence of pain productive of functional loss. The Veteran was unable to perform repetitive use testing. However, the VA examiner accepted the Veteran’s description of functional impairment during exacerbations following repetitive use over time and during flare-ups, and the VA examiner noted that the Veteran’s description of the impairment could be described in terms of range of motion featuring limitation of forward flexion to 35 degrees following repetitive use, and forward flexion to 30 degrees during flare-ups. These presentations of limitation reflect the Veteran’s described functional loss due to “Pain,” “Fatigue,” and “Weakness.” Although the October 2020 VA examination report notes a slight decrease in right elbow muscle strength (“4/5” for flexion and extension), this is not indicated to represent any impairment of the Veteran’s neck. The Veteran has a separately rated service-connected right elbow disability, and the October 2020 VA examination report expressly finds that there is no radiculopathy associated with the cervical spine disability and there is no intervertebral disc syndrome of the Veteran’s cervical spine. None of the information presented in the October 2020 VA examination report indicated impairment comparable to ankylosis or limitation of cervical spine forward flexion to 15 degrees or less. While aspects of the December 2018 examination were inadequate, as identified in the Board’s prior remand, the inadequacies have been resolved by the 2020 VA examination; the remainder of the December 2018 examination is adequate and has been considered. A December 2018 VA neck rating examination report shows that the Veteran described that her functional impairment of the neck featured “[d]ifficulty with moving her neck, can be difficult to move at times and require stretching to move.” She described that “[t]he flare ups of the neck can be described as constant aching pain that is aggravated by driving, turning her head too far.” The Board finds that these descriptions of unobserved exacerbations are substantially similar to, or at least do not indicate impairment greater than, the Veteran’s descriptions that were accepted by the October 2020 VA examiner and used to inform the October 2020 VA examination report’s characterizations and estimations of impairment. The December 2018 VA examination report otherwise shows clinical measurement of cervical spine forward flexion to 25 degrees, with objective evidence of pain. Cervical spine forward flexion was further limited to 20 degrees after three repetitions of testing, with the limitation attributed to pain. The December 2018 VA examiner stated that the Veteran’s impairment during unobserved exacerbations associated with repetitive use over time and flare-ups would also be due to pain, and “ROM would vary depending on activities performed and pain experienced during” the exacerbations. The December 2018 VA examiner did not otherwise specify range of motion estimates for unobserved exacerbations. The October 2020 VA examination report was purposed to address this particular matter and, as discussed above, the October 2020 VA examination report presents a medical expert’s characterization of functional loss, accepting the Veteran’s description of symptomatic impairment, in terms of range of motion. As discussed above, this evidence indicates that the impairment described by the Veteran associated with unobserved exacerbations is not comparable to ankylosis or limitation of cervical spine forward flexion to 15 degrees or less. The December 2018 VA examiner noted objective evidence of pain during many aspects of clinical testing of the cervical spine, including during passive range of motion testing and during non-weight bearing of the neck. The Board notes that the Veteran’s functional impairment due to pain is accounted for in the range of motion figures presented by the October 2020 VA examination report to characterize the impairment during exacerbations, based upon the Veteran’s consistent descriptions. The Board finds no evidence indicating that functional impairment has been comparable to ankylosis or limitation of cervical spine forward flexion to 15 degrees or less. None of the information presented in the December 2018 VA examination report indicated impairment comparable to ankylosis or limitation of cervical spine forward flexion to 15 degrees or less. A February 2017 VA neck rating examination report shows that the Veteran described “right upper quarter pain with or without motion,” with “no arm numbness.” At that time, the Veteran denied flare-ups of the cervical spine disability, but did report functional loss or functional impairment of the cervical spine featuring “limitations in ROM and prolonged fixed positions of the neck.” The Board finds that these descriptions of the Veteran’s symptomatic impairment are substantially similar to, or at least do not indicate impairment greater than, the Veteran’s descriptions that were accepted by the October 2020 VA examiner and used to inform the October 2020 VA examination report’s characterizations and estimations of impairment. The February 2017 VA examination report otherwise shows clinical measurement of cervical spine forward flexion to 35 degrees, with objective evidence of pain. The result was the same following three repetitions of testing. The VA examiner stated that although the cervical spine disability impacts her ability to work, the Veteran “can perform any type of occupational task without significant restrictions.” None of the information presented in the February 2017 VA examination report indicated impairment comparable to ankylosis or limitation of cervical spine forward flexion to 15 degrees or less. A May 2016 Disability Benefits Questionnaire (DBQ) completed by a private provider shows that the Veteran described her functional impairment during flare-ups as featuring “difficulty looking over shoulder, lifting, sleeping. Most outdoor activities.” Furthermore, she described that the cervical spine disability “[l]imits … ability to perform her duties when the neck is bothering her…. Carrying a backpack and using tools triggering.” She also described the cervical spine disability “affects her quality of life[:] driving, recreational activities like playing volleyball, swimming, softball all are affected by her condition. Bicycling is also affected.” The Board finds that these descriptions of functional impairment are substantially similar to, or at least do not indicate impairment greater than, the Veteran’s descriptions that were accepted by the October 2020 VA examiner and used to inform the October 2020 VA examination report’s characterizations and estimations of impairment (including during unobserved exacerbations). The May 2016 DBQ otherwise shows clinical measurement of cervical spine forward flexion to 20 degrees, with a notation of objective evidence of painful motion beginning at the 10 degree position of forward flexion. Pain may be taken into consideration when rating functional loss. However, pain on motion is not, itself, functional loss, but may result in functional loss only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination[, or] endurance.” 38 C.F.R. § 4.40. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (citing 38 C.F.R. § 4.40). 38 C.F.R. § 4.40 (functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board finds no clear basis for concluding that the Veteran’s pain during cervical spine forward flexion testing documented on the May 2016 DBQ resulted in functional loss limiting the function of cervical spine forward flexion to 15 degrees or less. The Board notes that the Veteran was able to maintain cervical spine forward flexion to 20 degrees through repetitive use testing, and the more recent evidence discussed above indicates that the Veteran’s cervical spine forward flexion has not been limited to 15 degrees or less, including with consideration of functional loss. Despite the pain associated with forward flexion beyond the 10 degree position, the Board finds that none of the information presented in the May 2016 DBQ indicated functional impairment comparable to ankylosis or functional limitation of cervical spine forward flexion to 15 degrees or less. The May 2016 DBQ indicates that the Veteran did have intervertebral disc syndrome (IVDS), and that it involved incapacitating episodes of “[a]t least 1 week but less than 2 weeks” in the “past 12 months.” This information does not suggest any basis for award of a rating in excess of 20 percent. A rating in excess of 20 percent on the basis of IVDS requires incapacitating episodes having a total duration of at least 4 weeks during a 12-month period. Consideration has been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran has ever been prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The VA examinations discussed above generally indicate no IVDS or pertinent incapacitating episodes, and the only contrary evidence is the May 2016 DBQ’s indication of IVDS with “less than 2 weeks” duration of incapacitating episodes in the prior year. The criteria for an increased rating in excess of 20 percent based upon IVDS requires incapacitating episodes having a total duration of at least 4 weeks during a 12 month period. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. The Board finds that the evidence of record does not provide a basis for finding that the criteria for an increased rating in excess of 20 percent based upon IVDS have been met in this case. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with her cervical spine disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for neck strain with arthritis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Court and VA’s General Counsel have interpreted the laws and regulations pertaining to the effective date for an increase as providing that, if the increase occurred within one-year prior to the claim, the increase is effective as of the date the increase was factually ascertainable. 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400(o); VAOPGCPREC 12-98 (1998). In this case, the AOJ awarded a 20 percent rating (increased from a noncompensable rating previously in effect) for the Veteran’s neck disability effective from the May 22, 2015, date of the claim on appeal. The Board has now considered whether any worsening of the disability within one-year prior to the claim warranted an increased rating. However, the Board finds no evidence making it factually ascertainable that the Veteran’s neck disability underwent an increase in severity to meet the criteria for an increased rating on any identifiable date within a year prior to the May 22, 2015, date of claim. None of the evidence of record shows a factually ascertainable increase in the Veteran’s neck disability impairments causing the criteria for an increased rating to have been met on a factually ascertainable date within the year prior to May 22, 2015. Accordingly, the Board finds no factually ascertainable date of increase in the severity of neck disability impairment during the one-year period prior to the claim dated May 22, 2015, to serve as a basis for awarding an increased rating effective from prior to that date of the claim. 3. Entitlement to higher initial ratings for premature ventricular and atrial contractions (currently rated noncompensably disabling prior to November 10, 2008; rated 10 percent disabling from November 10, 2008, to December 12, 2018; and rated 30 percent disabling from December 13, 2018, onward) is denied. The Veteran contends that she is entitled to higher ratings for her service-connected heart disability, asserting that the impairment has been more severe than the assigned ratings reflect. The beginning of the rating period on appeal in this case is defined by the effective date of the award of service connection for the heart disability: November 1, 2007. The Veteran’s service-connected heart disorder has been rated under 38 C.F.R. § 4.104, Diagnostic Code 7011 for ventricular arrhythmias (sustained). A 10 percent rating is assigned for ventricular arrhythmias (sustained) when a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication required. A 30 percent rating is assigned for ventricular arrhythmias (sustained) when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned for ventricular arrhythmias (sustained) when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for ventricular arrhythmias (sustained) when there is chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. A 100 percent rating is also assigned for an indefinite period from date of hospital admission for initial evaluation and medical therapy for a sustained ventricular arrhythmia, or; for indefinite period from date of hospital admission for ventricular aneurysmectomy, or; with an automatic implantable Cardioverter-Defibrillator (AICD) in place. 38 C.F.R. § 4.104, Diagnostic Code 7011. 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 examination of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness or syncope may be used. 38 C.F.R. § 4.104, Note (2). An October 2020 VA heart examination report shows a diagnosis of “premature ventricular contractions and premature atrial contractions,” as well as a diagnosis of “mitral valve prolapse.” These diagnoses were confirmed by clinical findings discussed in the report. The VA examiner clarified that the “[n]ew diagnosis [of] Mitral Valve Prolapse … is separate and unrelated to the service-connected diagnosis.” The Veteran reported “Current symptoms: complains of shortness of breath during exercise and heart irregularities. No results of pain when this happens.” An “Interview-based METs test” revealed that the Veteran experienced “Dyspnea” and “Dizziness” when performing activity at a threshold of more than 5 METs, and the VA examiner clarified that “No,” this limitation was -not- “due solely to the cardiac condition(s) that the Veteran is claiming in the diagnosis section.” The VA examiner reported that “the estimated METs level due solely to the cardiac condition(s) listed above” was “>7-10 METS,” with the VA examiner providing a rationale citing that the “Veteran reports being able to bicycle an[d] do mild exercise without dyspnea.” The October 2020 VA examination report furthermore presents the examiner’s comment that “The Veteran’s LVEF [left ventricular ejection fraction] is the most objective reflection of the current cardiac status.” The VA examiner later specifies that, in reviewing the Veteran’s “last echocardiogram … [a]n ejection fraction of 76 percent was noted.” This report of ejection fraction reflects the Veteran’s combined impairment from all disabilities, and the VA examiner remarked that “due to overlapping conditions it is not possible to determine the ejection fraction % due only to the service-connected pvc-pac without resorting to mere speculation.” However, a more disability-specific report of the ejection fraction is not of practical importance in this case because the combined impact of all disabilities results in an ejection fraction that does not meet the criteria for any increased rating in this case, even if hypothetically interpreting the combined impairment as entirely attributable to service-connected disability. The October 2020 VA examiner reported that “No,” the Veteran’s heart disability does -not- “impact his or her ability to work.” A December 2018 VA heart examination report shows a diagnosis of “history of premature atrial contractions and premature ventricular contractions.” The diagnosis was confirmed in reported clinical findings. The Veteran described that her symptoms featured: “shortness of breath with exertion such as going up an incline and even at rest; also get[s] some chest pain in midchest.” The report documents that the Veteran required continuous medication for control of the disability, noting that the Veteran reported taking propranolol and bisoprolol. An “Interview-based METs test” revealed that the Veteran experienced “Fatigue” when performing activity at more than 5 METs, and this limitation was considered to be “due solely to the heart condition(s) that the veteran is claiming in the diagnosis section.” The VA examiner determined that “Yes,” the heart disability does “impact … her ability to work,” and that “[t]he impact of the heart condition(s) on the claimant’s ability to work is difficulty doing strenuous activity.” The December 2018 VA examination report has already served as the basis for the existing award of a 30 percent rating for the heart disability effective from December 13, 2018; the AOJ deemed that this report represents the earliest showing of impairment manifested by pertinent symptomatology being associated with activities exceeding a threshold of only 5 METs, meeting the criteria for a 30 percent rating. The Board observes that an August 2017 VA treatment report shows that the Veteran participated in testing at an exertion level of “13.4” METs without an indication of significant symptomatology or impairment during the exertion. This information does not present a basis for awarding an increased rating. A November 2008 VA treatment note regarding a “Cardiology Diagnostic Study Consult[ation]” shows that a cardiologist noted “Possibly symptomatic PVC’s,” and that a “Trial of metop[r]olol … can be considered.” This record has already served as the basis for the existing award of a 10 percent rating for the heart disability effective from November 10, 2008; the AOJ deemed that this report reflects the beginning of the Veteran’s need for continuous medication to treat the service-connected heart disability, meeting the criteria for a 10 percent rating. An August 2007 VA examination report shows that the Veteran “was diagnosed with mitral valve prolapse and with palpitations and currently not treated with anything.” The report describes that “Cardiac catheter June 28, 2007, showed minimal mitral valve prolapse with premature ventricular contractions,” and “Stress test April 4, 2007, METs of 14.1” with no indication of significant symptomatology or impairment during the exertion. This information does not present a basis for awarding an increased rating. For the period from December 13, 2018, onward, the Veteran is currently in receipt of a 30 percent rating for the service-connected heart disability. The schedular criteria for the next-higher rating of 60 percent require a finding that a workload of 5 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; a finding that there is left ventricular dysfunction with an ejection fraction of no more than 50 percent. None of the evidence of record indicates that either condition has been met. The evidence most favorable to the Veteran indicates that the METs threshold at which pertinent symptoms manifest is greater than 5 METs. The evidence most favorable to the Veteran indicates that the Veteran’s pertinent ejection fraction has not been as low as 50 percent. The evidence presents no suggestion of congestive heart failure or pertinent hospital admission or implant for the service-connected heart disability to otherwise meet criteria for higher ratings for this period. For the period from November 10, 2008, to December 12, 2018, the Veteran is currently in receipt of a 10 percent rating for the service-connected heart disability. The schedular criteria for the next-higher rating of 30 percent require a finding that a workload of 7 METs or less resulted in dyspnea, fatigue, angina, dizziness, or syncope, or; a finding that there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. None of the evidence of record indicates that either condition was met during the pertinent period. There is no showing that pertinent symptoms manifested at a METs threshold of 7 METs or less during this period. The evidence pertaining to this period does not indicate any cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. The evidence presents no suggestion that the Veteran’s pertinent ejection fraction was as low as 50 percent, and no suggestion of congestive heart failure or pertinent hospital admission or implant for the service-connected heart disability to otherwise meet the criteria for higher ratings for this period. For the period prior to November 10, 2008, the Veteran is currently assigned a 0 percent rating for the service-connected heart disability. The schedular criteria for the next-higher rating of 10 percent require a finding that a workload of 10 METs or less resulted in dyspnea, fatigue, angina, dizziness, or syncope, or; a finding that continuous medication was required. None of the evidence of record indicates that either condition was met during the pertinent period. There is no showing that pertinent symptoms manifested at a METs threshold of 10 METs or less during this period. There is no evidence indicating that continuous medication was required for the heart disability during this period. The evidence presents no suggestion of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray; nor that the Veteran’s pertinent ejection fraction was as low as 50 percent; nor the occurrence of congestive heart failure or pertinent hospital admission or implant for the service-connected heart disability to otherwise meet the criteria for higher ratings for this period. The Board finds the objective medical evidence, including that provided in the VA rating examinations and medical treatment records, to be probative and adequate for rating purposes. The preponderance of the evidence is against finding that any increased disability rating is warranted for the Veteran’s service-connected heart disability on appeal. The Board finds that the evidence of record weighs against finding that the Veteran’s service-connected heart disability has manifested in impairment meeting the criteria for any higher ratings during any of the rating periods for consideration in this case. To this extent, the appeal is denied. The Board has considered the doctrine of affording the benefit of the doubt to the appellant, under 38 U.S.C. § 5107, and 38 C.F.R. § 3.102. The Board does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). The Board has considered whether there is any other basis for granting increased ratings, but it has found none. None of the other Diagnostic Code rating criteria for heart disabilities are applicable in this case, as the Veteran does not have the heart disabilities to which the other provisions apply. 38 C.F.R. § 4.104. The Board notes that the Veteran’s treatment records include suggestions that she may have wondered if she had suffered a myocardial infarction during the rating period, but there is no indication that the Veteran has suffered a myocardial infarction. The competent medical evidence of record indicates that she has not suffered a myocardial infarction, including the most recent VA examination report of October 2020 that repeats and confirms prior VA examination report findings that the Veteran has never suffered a myocardial infarction. Increased Ratings Conclusion As discussed above, the preponderance of the evidence is against awarding any additional or increased ratings this case. The Board has considered whether there is any other basis for granting increased and/or additional ratings but has found none. As the preponderance of the evidence is against assignment of any increased and/or additional ratings in this case, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with the disabilities for consideration in this appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Barone, 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.