Citation Nr: 21025067 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 20-04 295 DATE: April 27, 2021 ORDER Entitlement to a disability rating in excess of 60 percent for coronary artery disease (CAD) is denied. Entitlement to a compensable disability rating for hypertension is denied. REMANDED Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected CAD and/or hypertension, is remanded. FINDINGS OF FACT 1. The Veteran’s CAD manifested by a workload of greater than 3 metabolic equivalents (METs) but not greater than 5 METs resulting in dyspnea, fatigue, and dizziness, with no evidence of congestive heart failure. 2. The Veteran’s hypertension has not manifested by diastolic pressure predominately 100 or more; or systolic pressure predominately 160 or more; or a history of diastolic pressure predominately 100 or more and continuous medication for control. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 60 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for entitlement to a compensable disability rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, DC 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1957 to June 1961 and from June 1961 to July 1980. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated March 2018 and February 2019 of the Department of Veterans Affairs (VA) Regional Office (RO). The March 2018 rating decision denied entitlement to service connection for diabetes mellitus, type II, as well as entitlement to a compensable rating for service-connected hypertension. The Veteran filed a notice of disagreement (NOD) in November 2018. A September 2018 rating decision proposed to reduce the assigned rating for service-connected CAD from 60 percent to 30 percent. However, a February 2019 rating decision continued the assigned 60 percent rating for CAD. A statement of the case (SOC) was issued in December 2019, which denied an increased rating for CAD, as well as a compensable rating for hypertension. The SOC also denied service connection for diabetes mellitus, type II. The Veteran perfected a timely appeal in January 2020. The Board previously remanded these matters for further development in July 2020. Increased Ratings Disability ratings are determined by applying a schedule of reductions in earning capacity from specific injuries or a combination of injuries that is based upon the average impairment of earning capacities.  38 U.S.C. § 1155. Each disability must be viewed in relation to its entire history, with emphasis upon the limitations proportionate to the severity of the disabling condition.  38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of “staged rating” is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board acknowledges that multiple distinct degrees of disability might be experienced which result in different compensation levels from the time the increased rating claim was filed until a final decision is made. Staged ratings apply to both initial and increased rating claims. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Board must also fully consider the lay assertions of record. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Where there is a question as to which of the two disability evaluations is applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7. After careful consideration of the evidence of record, any reasonable doubt remaining will be resolved in favor of the Veteran.  38 C.F.R. § 4.3. 1. Entitlement to a disability rating in excess of 60 percent for CAD is denied. The Veteran contends a rating in excess of 60 percent is warranted for his CAD. The Board acknowledges the prior remand requested potentially outstanding records from the Veteran’s cardiologist, a Dr. Haringer Gogia. The Board subsequently sent the Veteran necessary authorization and release forms to obtain these records on his behalf. The Veteran responded, providing necessary authorization and release for other providers, but did not provide authorizations for Dr. Haringer Gogia, nor has he supplied the records himself. Thus, there has been substantial compliance with the Board’s July 2020 remand directives regarding these records. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97 (2008) (“[O]nly substantial compliance with the terms of the Board’s engagement letter [is] required, not strict compliance.”). The Veteran’s CAD is rated under Diagnostic Code (DC) 7005. Under DC 7005, a 30 percent rating is warranted when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; for evidence of cardiac hypertrophy or dilatation 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 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. The Veteran provided a privately completed disability benefits questionnaire (DBQ) regarding his CAD in July 2018. The assessment report reflects a diagnosis of CAD post PTCA / stent placement. It was noted the Veteran is on four medications for his heart and experienced cardiac hypertrophy, as well as dilation of the right ventricle. The provider noted frequent premature ventricular contractions back in 2005 that were now well controlled on medication and that the Veteran had not experienced any in the last 12 months. It was noted that he has never experienced congestive heart failure. MET testing was not conducted and the provider noted that the Veteran’s heart condition does not impact his ability to work. In November 2018, the Veteran supplied a supplemental DBQ including MET testing. Based off an interview conducted that month, the provider estimated the Veteran’s CAD to manifest by a workload of between 1 and 3 METs resulting in dyspnea, fatigue, and dizziness. However, although unable to estimate the impact each had on the Veteran’s MET limitation, the provider noted that to reach this MET level estimation, he also considered nonservice-connected factors such as the Veteran’s age and musculoskeletal limitations. The Veteran attended his first VA CAD examination in December 2018. The examiner noted the Veteran’s heart condition qualified as ischemic heart disease, but that he had never experienced a myocardial infarction, congestive heart failure, arrhythmias, or heart valve conditions. The Veteran’s heart was normal upon EKG testing and a test from January 2018 revealed a left ventricular ejection fraction of 65 percent with normal wall motion. Based off an interview conducted at the examination, the examiner estimated the Veteran’s CAD to manifest by a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea. Notably, the examiner recorded that this MET level estimation was due solely to the Veteran’s CAD. It was noted that the Veteran’s CAD does not impact his ability to work. An echocardiogram from January 2019 revealed a normal left ventricle cavity size and normal global wall motion. However, it also revealed impaired diastolic function, calculated as an ejection fraction of 58 percent. In February 2020, the Veteran again supplied a privately completed DBQ regarding his CAD. The provider noted a normal exercise stress test from October 2018 that revealed no evidence of ischemia. Based off an interview conducted in December 2019, the provider estimated the Veteran’s CAD to manifest by a workload of between 1 and 3 METs resulting in dyspnea, fatigue, angina, and dizziness. However, again, the private provider noted that he included the impact of nonservice-connected factors, such as his age and musculoskeletal limitations, in his MET level estimation. Based on the foregoing, the Board finds that a disability rating in excess of 60 percent for the Veteran’s CAD is not warranted. To receive the next highest rating, the Veteran’s CAD would have needed to manifest by a workload of between 1 and 3 METs resulting in dyspnea, fatigue, dizziness, etc. or result in an ejection fraction of below 30 percent. The only evidence suggesting the Veteran’s CAD manifests as dyspnea at METs between 1 and 3 comes from the estimations provided by the Veteran’s private cardiologist. However, in each of his MET level estimations, the provider included the impact of nonservice-connected factors. On the other hand, the VA examiner noted only the Veteran’s heart condition was considered in their MET level estimation. As such, the Board finds the most probative evidence on the record of the degree of disability resulting from the Veteran’s CAD is the Veteran’s December 2018 VA examination, which preponderates against a rating in excess of 60 percent. The Veteran has never experienced congestive heart failure or an ejection fraction of below 30 percent. The preponderance of the evidence weighs against the claim; there is no doubt to be resolved; a rating in excess of 60 percent for CAD is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7. 2. Entitlement to a compensable disability rating for hypertension is denied. The Veteran seeks a compensable disability rating for his hypertension. The Veteran’s hypertension is evaluated under DC 7101. A 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, DC 7101. The Veteran was provided a VA hypertension examination in March 2017. At the examination, it was noted the Veteran required continuous medication for control of his hypertension. His blood pressure readings were recorded as 144/90, 146/90, and 144/90. The examiner indicated the Veteran’s hypertension did not impact his ability to work. In September 2017, the Veteran’s blood pressure was recorded as 165/87. In October 2017, 127/78. In November 2017, 164/89. At a VA examination in February 2018, the Veteran’s blood pressure was recorded as 144/80, 146/80, and 146/80. In July 2018, 137/82. In December 2018, 159/90. The Board acknowledges that the December 2018 examiner noted the Veteran’s initial blood pressure to be 177/94; however, upon five minutes of rest, the Veteran’s blood pressure was 159/90. In January 2019, the Veteran’s blood pressure was recorded as 131/79. In January 2020, the Veteran’s blood pressure was recorded as 138/72. The Veteran also supplied January 2020 correspondence where he reported that with medication, his blood pressure stays around 146/80. In early February 2020, the Veteran’s blood pressure was recorded as 148/78. Later in February 2020, the Veteran supplied blood pressure readings taken at home. They indicated without medication, Veteran’s blood pressure ranged from 150-170/92-102, and that with medication, the Veteran’s blood pressure ranged from 134-145/82-92. In December 2020, the Veteran’s blood pressure was recorded at a VA examination as 170/90, 160/90, and 164/90. The examiner noted the Veteran did not exhibit diastolic blood pressure of predominately 100 or more and that the Veteran’s hypertension did not impact the Veteran’s ability to work. In January 2021, the Veteran’s blood pressure was recorded as 148/74. Based on the foregoing, the Board finds the Veteran’s hypertension does not warrant a compensable rating. His diastolic readings have not been predominately 100 or more, his systolic readings have not been predominately 160 or more, nor does he have a history of diastolic blood pressure predominately 100 or more with continuous medication for control. While the Veteran’s medical records include four instances where the Veteran’s systolic blood pressure was recorded as 160 or above, in each instance, the Veteran’s systolic blood pressure was shortly thereafter recorded as below 160. For example, in September 2017, the Veteran’s blood pressure was recorded as 165/87; however, a month later it was 127/78. In December 2018, the Veteran’s initial blood pressure was recorded as 177/94, but five minutes later was recorded as 159/90. Thus, the Veteran’s systolic blood pressure has been occasionally, but not predominately 160 or more, which does not warrant a compensable rating. The Board notes this finding is consistent with what the Veteran has reported his hypertensive symptoms to be: that without medication his blood pressure is elevated, but with, it is controlled. The preponderance of the evidence weighs against the claim; there is no doubt to be resolved; a compensable rating for hypertension is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus, type II, to include as due to service-connected coronary artery disease (CAD) and/or hypertension is remanded. The Board sincerely regrets further delay, but finds a remand is necessary before deciding this claim. A remand order confers upon a Veteran a right to substantial compliance with the remand directives. See Stegall, 11 Vet. App. at 271; D’Aries, 22 Vet. App. at 97. Moreover, causation and aggravation are independent concepts and should have separate findings and rationales.  See El-Amin v. Shinseki, 26 Vet. App. 136, 139-41 (2013); Atencio v. O’Rourke, 30 Vet. App. 74 (2018). In July 2020, the Board remanded the Veteran’s claim for service connection for diabetes mellitus, type II and requested a VA examiner address the Veteran’s November 2018 Notice of Disagreement references to literature indicating a link between hypertension and CAD and the increased risk of developing diabetes when opining as to whether the Veteran’s diabetes mellitus, type II is proximately due to or aggravated beyond its natural progression by his hypertension or CAD. The Veteran was provided this VA examination in December 2020. Unfortunately, the examiner did not address the Veteran’s November 2018 references to literature and instead concluded “there is no evidence in medical literature that suggest hypertension and/or coronary artery disease aggravates diabetes mellitus, type II.” As such, the opinion runs afoul of Stegall and remand is required. However, so that the deficiency is not repeated, the Board also notes the December 2020 examiner’s secondary service connection opinions are inadequate. The examiner did not provide separate findings and rationales for causation and aggravation, but the exact same rationale. As such, a remand would be separately required for an adequate VA medical opinion in addition to the violation of Stegall.  See El-Amin, 26 Vet. App. at 149-41; Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Accordingly, the Veteran must be provided another VA medical opinion to address the etiology of his diabetes mellitus, type II. The matter is REMANDED for the following action: The AOJ shall refer the VA claims file to a clinician with appropriate expertise to provide an opinion as to the claimed diabetes mellitus, type II. The clinician is requested to review the claims file in its entirety including all service treatment records, VA, and private treatment records. If the clinician determines that an examination is necessary, one should be scheduled. Following review of the file and this remand, the examiner is asked to opine on the following: a. Is it at least as likely as not that the Veteran’s diabetes mellitus, type II was caused by or is otherwise etiologically related to the Veteran’s military service? b. Is it at least as likely as not that the Veteran’s diabetes mellitus, type II is proximately due to or aggravated beyond its natural progression by the Veteran’s service-connected hypertension and/or coronary artery disease? To ensure compliance with Stegall, the examiner’s opinion as to whether the Veteran’s diabetes mellitus, type II is proximately due to or aggravated by the Veteran’s service-connected hypertension and/or coronary artery disease must include consideration of the literature referenced by the Veteran in his November 2018 Notice of Disagreement. The examiner is reminded that causation and aggravation are independent concepts and should have separate findings and rationales.  See El-Amin v. Shinseki, 26 Vet. App. 136, 139-41 (2013); Atencio v. O’Rourke, 30 Vet. App. 74 (2018).  The examiner is advised that aggravation under 38 C.F.R. § 3.310(b) does not require that there be “permanent” worsening of the nonservice connected disability.    A complete rationale is one that contains clear conclusions with supporting data and a reasoned medical explanation connecting the two. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P.A. Infante, 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.