Citation Nr: 21030288 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 19-37 302 DATE: May 18, 2021 ORDER Prior to December 11. 2020, entitlement to an initial disability rating of 60 percent, but not higher, for coronary artery disease (heart condition) is granted. Entitlement to a disability rating in excess of 60 percent from December 11, 2020 for the Veteran's heart condition is denied. FINDINGS OF FACT 1. Prior to December 11, 2020, the Veteran's heart condition manifested as a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. 2. From December 11, 2020, the Veteran's heart condition has not manifested as chronic congestive heart failure, a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. Prior to December 11, 2020, the criteria for entitlement to an initial disability rating of 60 percent, but not higher, for the Veteran's heart condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7005. 2. The criteria for entitlement to a disability rating in excess of 60 percent from December 11, 2020 for the Veteran's heart condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1964 to December 1966. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of January 2019 issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this case for further development, to include an additional VA examination. See August 2020 Board Decision. Before addressing the Veteran's claim on the merits, the Board briefly clarifies the scope of the issue on appeal. Following the VA examination directed by the Board, the RO issued a subsequent rating decision raising the Veteran's disability rating for this condition to 60 percent from December 11, 2020. See January 2021 Rating Decision. This resulted in the creation of a staged disability rating for this condition. See January 2021 Rating Codesheet at 1. Increased Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology 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 apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for a higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability rating decisions. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). However, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55 (1994). When the appeal is from the initial rating assigned with the grant for service connection, "staged" ratings (for periods when varying degrees of disability are shown) may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an initial disability rating in excess of 10 percent prior to December 11. 2020, for the Veteran's heart condition. As noted above, the Veteran's heart condition is rated as 10 percent disabling from May 2018 and as 60 percent disabling from December 2020 under Diagnostic Code (DC) 7005. See January 2021 Rating Codesheet. The applicable rating criteria provide that a disability rating of 30 percent is assigned for this condition where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. See 38 C.F.R. § 4.104, DC 7005. The Board notes that MET, in this context, is defined as "the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute." See id. at Note (2). A disability rating of 60 percent is assigned for this condition where there has been more than one episode of acute congestive heart failure in the past year, where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. Finally, a total schedular disability rating is assigned where there is chronic congestive heart failure, where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. The Veteran underwent a VA examination on this issue in July 2018. The July 2018 examiner diagnosed coronary artery disease and supraventricular arrhythmia, among other conditions. See July 2018 VA Examination Report at 3. The Board notes that this examiner opined that the etiology of the Veteran's supraventricular arrhythmia was unknown, but did not explain the reasoning behind this conclusion or otherwise explain why it would not be related to his service-connected heart condition. See id. at 3-5. This examiner noted the Veteran's prior myocardial infarction of February 2017 and indicated that the Veteran had chronic congestive heart failure, but found no episodes of acute congestive heart failure. See id. at 4. This examiner also noted that MET testing was not performed, as "[exercise] stress testing is not required as part of the Veteran's current treatment plan and this test is not without significant risk." See id. at 8. Based on interview results, the examiner found that the Veteran experienced dyspnea and fatigue at a workload between 3 and 5 METs. Id. In an addendum opinion of December 2018, a separate VA examiner clarified that while "[the] Veteran likely has a degree of heart failure... there is no documentation of chronic heart failure from the cardiologist." See January 2019 VA Examination Report at 5 (emphasis added). This examiner noted that a notation for "acute congestive heart failure," once made, will repeat multiple times throughout the Veteran's medical records "as it is automatically put into each note when [providers] go to create a clinic note." Id. The Board notes that this is consistent with the Veteran's VA and private medical treatment records, which reflect an episode of congestive heart failure at the time of his February 2017 myocardial infarction but do not otherwise support the inference that his heart condition manifests as chronic congestive heart failure. See October 2020 Medical Treatment Records at 19; see also October 2020 Medical Treatment Records (Private) at 24. The December 2018 addendum examiner also opined that the Veteran's MET score "is likely [due] to the arrhythmia as there is no documentation of [congestive heart failure]." See January 2019 VA Addendum Opinion at 5. However, this addendum does not explain why a finding of congestive heart failure would be necessary for the Veteran's heart condition to result in an impaired MET workload, and like the July 2018 examination report it does not explain why the Veteran's arrhythmia is more likely than not due to a non-service-connected etiology. "[Most] of the probative value of a medical opinion comes from its reasoning. Neither a VA medical examination report nor a private medical opinion is entitled to any weight... if it contains only data and conclusions." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Because the December 2018 VA examiner explained the basis for her conclusion that the Veteran's congestive heart failure is acute rather than chronic, but did not explain the basis for the conclusion that his MET workload impairment is not a result of his service-connected heart condition, the Board assigns the latter conclusion no probative weight. Instead, the Board finds that the assignment of an initial 60 percent disability rating is warranted because the Veteran's heart condition has consistently manifested as a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea and fatigue. 38 C.F.R. § 4.104, Diagnostic Code 7005. Because the December 2018 examiner explained that the Veteran's heart condition does not manifest as chronic congestive heart failure, and because none of the evidence of record addressing this portion of the rating period otherwise supports the inference that the criteria for a total schedular rating have been met, the Board concludes that such a rating is not warranted. Id. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence of record is against this portion of the Veteran's claim. 38 U.S.C. § 5107. 2. Entitlement to a disability rating in excess of 60 percent from December 11, 2020 for the Veteran's heart condition. Following the Board's remand, the Veteran underwent an additional VA examination in December 2020. As noted above, the RO increased the Veteran's disability rating for this condition to 60 percent on the basis of this examination. See January 2021 Rating Decision. For clarity, the Board briefly notes that this examiner also provided the July 2018 examination. See December 2020 VA Examination Report at 8; cf. July 2018 VA Examination Report at 8. In this more recent examination, this examiner stated that "atrial [fibrillation] [is] not related to [the Veteran's] [coronary artery disease]/[ischemic heart disease]," but again did not explain this conclusion or provide an alternate non-service-connected etiology. See December 2020 VA Examination Report at 2-4. This examiner again found chronic congestive heart failure, but did not rebut the December 2018 addendum's discussion on this point and likewise found no episodes of acute congestive heart failure. See id. at 3. Because this examiner did not explain the reasoning supporting this conclusion, the Board assigns it no probative weight. Nieves-Rodriguez, 22 Vet. App. at 304. This examination also found a left ventricular ejection fraction (LVEF) of 40-45 percent based on a contemporaneous echocardiogram. See id. at 6. Following a contemporaneous interview, this examiner found that the Veteran continued to experience dyspnea and fatigue between 3 and 5 METs. See id. at 7. In light of these examination results, as well as the Veteran's LVEF of 40-45 percent and the absence of chronic congestive heart failure, the Board concludes that the criteria for a total schedular rating have not been met and that such a rating is therefore not warranted. Id. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence of record is against the Veteran's claim. 38 U.S.C. § 5107. [SIGNATURE ON NEXT PAGE] JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Blore, 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.