Citation Nr: 21027565 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 16-63 313 DATE: May 6, 2021 ORDER Entitlement to a 60 percent rating, but no higher, for coronary artery disease (CAD) is granted. Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD), is granted. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's CAD has manifested as a workload of greater than 3 METs, but not greater than 5 METs, which resulted in dyspnea, fatigue, angina, dizziness, or syncope, without a left ventricular dysfunction with an ejection fraction of less than 30 percent. 2. Resolving all doubt in the Veteran's favor, he has an acquired psychiatric disorder related to his period of active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 60 percent rating, but no higher, for coronary artery disease have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from June 1968 to May 1970, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from two separate rating decisions issued in January 2015 by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in March 2020. A transcript of the hearing has been associated with the file. 1. Entitlement to an initial rating higher than 30 percent for coronary artery disease. The Veteran contends that his service-connected CAD should be rated higher than the initial 30 percent provided in the January 2015 rating decision, with an effective date of July 28, 2014. See NOD, January 2015. Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be 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. The Veteran's disability is evaluated under the criteria for arteriosclerotic heart disease (Coronary Artery Disease). In relevant part, these criteria state that for CAD with chronic congestive heart failure, or; a workload of 3 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; a left ventricular dysfunction with an ejection fraction of less than 30 percent, a 100 percent rating is warranted. If there is more than one episode of acute congestive heart failure in the past year, or; a workload of 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, a 60 percent rating is assigned. If a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, the current 30 percent rating is appropriate. 38 C.F.R. § 4.104, DC 7005. A review of the evidence of record reflects that in December 2014 the Veteran underwent a Heart Conditions Disability Benefits Questionnaire (DBQ). An interview based METs test was completed, with the Veteran scoring greater than 3, but less than 5 METs that resulted in dyspnea, fatigue, and angina. The examiner reported that 60 percent of the METs level limitations was due to his heart condition, while there was a 40 percent effect on the METs level due to pulmonary disease. A January 2015 rating decision granted service connection for CAD with an evaluation of 30 percent effective July 28, 2014 based on a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. Additional symptoms included continuous medication and left ventricular dysfunction with an ejection fraction of more than 50 percent. Based on the evidence, the Board finds that a 60 percent rating, but no higher, is warranted for the entire appeal period as the above-cited December 2014 MET interview based test demonstrates a workload of greater than 3, but less than 5 METs. Although the examiner attributed his METs score 60 percent for his CAD and 40 percent to his pulmonary disease, the Board finds all reasonable doubt in finding that his METs score more nearly approximates the criteria for a 60 percent rating. Indeed, the 2014 VA examiner attributed the majority of the METs level to his service-connected CAD. A higher rating is not warranted as the Veteran only requested a 60 percent rating. See Hearing Testimony, Page 3. Additionally, the record does not show that at any time there was a workload of 3 METs or less that resulted in dyspnea, fatigue, angina, dizziness, or syncope, or a left ventricular dysfunction with an ejection fraction of less than 30 percent. Therefore, the Veteran's claim for a 60 percent rating for his service-connected CAD is granted. 2. Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder, is granted. The Veteran has filed a claim for service connection for posttraumatic stress disorder (PTSD), which the Board recharacterized broadly to encompass all psychiatric disorders that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The Veteran seeks service connection for PTSD, which he attributes to his combat experiences while serving in the Republic of Vietnam. Based on the following, the Board finds that service connection for PTSD is warranted. Entitlement to service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f); West v. Brown, 7 Vet. App. 70 (1994). If the Veteran did not engage in combat with the enemy, or if the claimed stressors are not related to combat, the Veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors, and those stressors must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997). VA also amended 38 C.F.R. § 3.304(f) by liberalizing, in certain circumstances, the evidentiary standard for establishing the in-service stressor required for PTSD claims. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran has diagnoses of PTSD and generalized anxiety disorder. See Medical Record, March 2015. An August 2014 psychiatry note reported an increase in recollection of memories from the military and serving in Vietnam. He was diagnosed with a generalized anxiety disorder, and depressive disorder not otherwise specified (NOS). During an October 2014 psychiatry outpatient evaluation, the examiner noted the Veteran served as a door gunner on a helicopter gunship and saw heavy combat in Vietnam. He described being shot at multiple times and witnessed numerous injuries and fatalities. The Veteran reported problems with anxiety, hypervigilance, and an exaggerated startle response to loud noise. Further, during the March 2020 Board hearing, the Veteran reiterated the in-service stressor relating to serving as a door gunner in Vietnam. The examiner noted he was formally diagnosed with PTSD 5-6 months ago. As the Veteran engaged in combat with the enemy, his lay testimony alone establishes the occurrence of the claimed in-service stressor element for service connection. A November 2014 VA examiner determined that the Veteran did not have a diagnosis of PTSD, therefore, provided a negative nexus for service connection. The examiner noted a diagnosis of generalized anxiety disorder. In January 2015, an addendum opinion to the November 2014 examination was provided regarding direct service connection for the Veteran's generalized anxiety disorder. The examiner opined that the Veteran's diagnosis of generalized anxiety disorder was less likely than not related to the Veteran's service. The rationale provided was that the Veteran's symptoms of anxiety began about 10 years ago, following retirement from his civilian job. There was no indication of any symptoms during the 34-year period between his military service and the start of his anxiety symptoms. In a January 2015 Notice of Disagreement, the Veteran noted that over the past few years, he has been experiencing flashbacks, dreams, and more intense feelings of stress and anxiety regarding his service in Vietnam. He noted every mission as a door gunner was a "traumatic experience," and he not only witnessed serious injury and death, but he lived in constant fear of his own death. In an October 2015 mental health outpatient note, the DSM-5 diagnostic criteria were satisfied with elements of PTSD chronic, generalized anxiety disorder, uncomplicated bereavement, and exposure to war in Vietnam. His treatment plan included treatment for PTSD chronic and generalized anxiety disorder. During a February 2020 psychiatry outpatient note, the Veteran was reported as having intrusive thoughts, feelings, memories, and nightmares of the Vietnam War, that have gotten worse after retirement. He reported experiencing nightmares about 50 percent of nights. A diagnosis of PTSD was noted. The Veteran was to continue Zoloft and Remeron for PTSD symptoms such as anxiety and depression. In an April 2021 Statement in Support of Claim, the Veteran noted during his job as a door gunner, he witnessed the fear on fellow soldiers' faces as the helicopter came to capacity and they had to leave soldiers behind. He noted that he is haunted by the look of fear on their faces and the fact that he lived in fear that he might die any day during the war. (Continued on the next page) Based on the foregoing, the Board finds that the evidence is at least in equipoise. Accordingly, affording him the benefit of the doubt, the Board finds that the evidence supports a grant of service connection for PTSD. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Krista Johnson, 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.