Citation Nr: 21039957 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 17-00 949 DATE: July 1, 2021 ORDER Entitlement to an initial 10 percent disability rating, but no higher, for valvular heart disease with cardiac murmur prior to November 13, 2019, is granted. REMANDED Entitlement to an initial disability rating in excess of 30 percent for valvular heart disease with cardiac murmur since November 13, 2019, is remanded. FINDINGS OF FACT 1. Prior to November 13, 2019, the preponderance of the evidence shows that continuous medication was required for control of the Veteran's heart disability. 2. Prior to November 13, 2019, the preponderance of the evidence does not show that the Veteran's heart disability was manifest by a workload of 7 or less METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; left ventricular dysfunction with an ejection fraction of less than 50 percent; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray; or congestive heart failure. CONCLUSION OF LAW Prior to November 13, 2019, the criteria for an initial disability rating of 10 percent, but no higher, for valvular heart disease with cardiac murmur have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7000. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from September 1981 to November 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal of a January 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Board remanded these matters for additional development. They have returned to the Board for further appellate review. A June 2020 rating decision granted an increased disability rating of 30 percent for the Veteran's service-connected heart disability, effective November 13, 2019. As the increased rating was not granted for the entire claims period or for the highest available disability rating, it is considered a partial grant and bifurcates the claim. See AB v. Brown, 6 Vet. App. 35 (1993). Accordingly, an initial increased rating claim for valvular heart disease with cardiac murmur prior to November 13, 2019, and an initial increased rating claim for valvular heart disease with cardiac murmur since November 13, 2019, are both presently before the Board and will be addressed herein. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Regulations require that where there is a question as to which of two evaluations is to 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. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where 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; 38 C.F.R. § 3.102. Entitlement to an initial compensable disability rating for valvular heart disease with cardiac murmur prior to November 13, 2019. The Veteran is currently assigned a 30 percent disability rating, effective November 13, 2019, under DC 7000 for valvular heart disease with cardiac murmur. 38 C.F.R. § 4.104. Prior to November 13, 2019, the Veteran was assigned a noncompensable disability rating. The Veteran contends that, prior to November 13, 2019, his symptoms were productive of a higher rating. Under DC 7000, a 10 percent disability evaluation is assigned when a workload of greater than 7 METs (metabolic equivalent), but not greater than 10 METs, results in dyspnea, fatigue, angina, dizziness, or syncope; or, continuous medication is required. 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, there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. A 60 percent disability evaluation is warranted when there is more than one episode of acute congestive heart failure in the past year; a 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 when there is chronic congestive heart failure; 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. 38 C.F.R. § 4.104. In December 2014, the Veteran was provided a VA examination to evaluate the severity of his heart disability which the Board previously determined was inadequate for evaluation purposes. In October 2015, the Veteran underwent an echocardiogram with a private medical clinician. The report showed left ventricle ejection fraction of 60-65 percent. The report showed normal size, normal wall thickness, normal systolic function, and normal wall motion of the left ventricle. The report showed normal size and function of the right ventricle. In October 2019, the Veteran underwent a VA examination to evaluate the severity of his heart disability. The examiner found that continuous medication was required for control of the Veteran's heart condition and listed Atorvastatin at 20 mg daily. The examiner found that the Veteran has not had any non-surgical or surgical procedures for the treatment of a heart condition. The examiner found that the Veteran has not had a myocardial infarction, congestive heart failure, arrhythmia, infectious cardiac conditions, or pericardial adhesions. The VA examination report included the diagnostic testing for a November 2019 echocardiogram performed in conjunction with the examination. The echocardiogram showed left ventricular ejection fraction of 60-65 percent, normal wall motion, and normal wall thickness. The VA examiner found no evidence of cardiac dilation. The examiner performed an exercise stress test that showed a METs level of 16.2. Interview-based METs testing showed dyspnea, fatigue, dizziness, chest tightness, and palpitations, due solely to the Veteran's cardiac condition, at between 7 to 10 METS, consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging (6 mph). The examiner found that the Veteran's exercise stress test most accurately reflects the Veteran's cardiac functional level. The examiner found that the Veteran's heart disability does not impact his ability to work. As noted by the Veteran in his statements, the October 2019 VA examiner found evidence of cardiac hypertrophy and listed the December 2014 echocardiogram as documentation of the hypertrophy. However, an addendum/clarification to the October 2019 VA examination was provided in June 2020. The examiner stated that the December 2014 VA examination is silent for any findings of cardiac hypertrophy. The examiner also noted that the private echocardiogram report and treatment records from October 2015 are also silent for any finding of cardiac hypertrophy. The June 2020 examiner's addendum found that it is at least as likely than not that the earliest evidence of cardiac hypertrophy was the November 13, 2019, echocardiogram report which showed objective evidence of "mild concentric left ventricular hypertrophy." The Board also notes that while treatment records also periodically document the Veteran's complaints and treatment related to his heart disability, nothing in these records during the pendency of the claim show his adverse symptomatology to be markedly worse than what was reported at the above VA examination. Based on the foregoing and resolving reasonable doubt in favor of the Veteran, the Board finds that an increased rating of 10 percent under DC 7000, but no higher, is warranted prior to November 13, 2019, based upon the required use of continuous medication for control of the Veteran's heart disability. Prior to November 13, 2019, the medical evidence of record shows that the Veteran's heart disability was not manifested by a workload of 7 or less METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; left ventricular dysfunction with an ejection fraction of less than 50 percent; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray; or congestive heart failure. Therefore, the Board finds that a disability rating in excess of 10 percent is not warranted for the period prior to November 13, 2019. To the extent that the Veteran believes that a higher disability is warranted for his heart disability, the evidence of record does not support a disability rating in excess of 10 percent prior to November 13, 2019. While the Veteran is competent to report the symptoms of his disability, he is not competent to opine on matters requiring medical knowledge, such as determining the severity of his medical condition at any given time, based on the above criteria. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In summary, the Board finds that prior to November 13, 2019, the criteria for an initial evaluation of 10 percent, but no higher, for the Veteran's service-connected valvular heart disease with cardiac murmur are met. REASONS FOR REMAND Entitlement to a disability rating in excess of 30 percent since November 13, 2019, for valvular heart disease with cardiac murmur. Additional development is necessary before this matter can be adjudicated. The Veteran's treatment records suggest that the symptoms of the Veteran's heart disability have worsened since his October 2019 VA examination, which served as primary basis for his current disability rating. Notably, VA treatment records show that in June 2020 the Veteran reported to the emergency room for a racing heartbeat. VA treatment records also show that he underwent a cardiac catheterization in August 2020. As the record suggests that the Veteran's disability may have worsened, he should be afforded a new VA examination to assess the current extent and severity of his heart condition. Since this matter is being remanded, the Veteran's claims folder should also be updated with any recent VA treatment records. The matters are REMANDED for the following action: 1. Obtain the Veteran's updated VA treatment records dated from March 2021 to the present and associate them with the claims folder. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected valvular heart disease with cardiac murmur. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. J. Komperda Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. VanValkenburg, 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.