Citation Nr: 22013347 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 18-26 222 DATE: March 9, 2022 ORDER Entitlement to a disability rating greater than 10 percent prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 14, 2021, and to a disability rating greater than 60 percent thereafter, for coronary artery disease, status-post bypass surgery, is denied. FINDINGS OF FACT 1. The record evidence shows that prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, the Veteran's service-connected coronary artery disease, status-post bypass surgery, is manifested by, at worst, a history of documented myocardial infarction resulting in continuous medication required for control. 2. The record evidence shows that, effective November 15, 2021, the Veteran's service-connected coronary artery disease, status-post bypass surgery, is manifested by, at worst, a history of documented myocardial infarction resulting in a left ventricle ejection fraction of 45 percent and an interview-based metabolic equivalents (METs) of 3-5 resulting in dyspnea on exertion, fatigue, and angina. CONCLUSION OF LAW The criteria for a disability rating greater than 10 percent prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, and a disability rating greater than 60 percent thereafter, for coronary artery disease, status-post bypass surgery have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code (DC) 7006 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service from July 1969 to February 1971, including in combat in the Republic of Vietnam. This appeal has a long procedural history. It comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). A videoconference Board hearing was held in May 2021 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. In July 2021, the Board remanded the currently appealed claim to the Agency of Original Jurisdiction (AOJ) for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed that the AOJ obtain updated treatment records for the Veteran and schedule him for examination to determine the current nature and severity of his service-connected coronary artery disease, status-post bypass surgery. Additional records subsequently were associated with the claims file. And the requested examination occurred in November 2021. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In a December 2021 rating decision, the AOJ assigned a 100 percent rating effective January 2, 2019, a 10 percent rating effective May 1, 2019, a 100 percent rating effective November 3, 2019, a 10 percent rating effective March 1, 2020, and a 60 percent rating effective November 25, 2021, for the Veteran's service-connected coronary artery disease, status-post bypass surgery. Thus, the Board has recharacterized this claim as stated above. The Veteran appointed his current service representative to represent him before VA by filing a completed VA Form 21-22 at the AOJ in February 2022. The Board is not persuaded that the evidence supports granting the Veteran's claim of entitlement to a disability rating greater than 10 percent prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, and to a disability rating greater than 60 percent thereafter, for coronary artery disease, status-post bypass surgery. The Veteran essentially contends that this disability is more disabling than currently evaluated during each of the time periods at issue in this appeal. The record evidence does not support his assertions. It shows instead that, prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, the service-connected coronary artery disease, status-post bypass surgery is manifested by, at worst, a history of documented myocardial infarction resulting in continuous medication required for control (i.e., a 10 percent rating under DC 7006). See 38 C.F.R. § 4.104, DC 7006. For example, private cardiac testing in February 2012 showed a METs level of 11.30 and a left ventricular ejection fraction (LVEF) of 60 percent. His stress echocardiogram was normal with no evidence of inducible ischemia. On VA ischemic heart disease Disability Benefits Questionnaire (DBQ) in August 2013, it was noted that the Veteran's treatment plan for his heart disease included taking continuous medication. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran had a myocardial infarction in 2007 which was treated with coronary bypass surgery. He did not have congestive heart failure. His METs level was 11.30 documented in February 2012. His current LVEF was 55 percent. There was no evidence of cardiac hypertrophy or dilatation. The Veteran's stress echocardiogram in February 2012 was normal with no evidence of inducible ischemia. The diagnosis was arteriosclerotic heart disease. On private outpatient treatment later in August 2013, it was noted that the Veteran was doing well and had no interval symptoms of angina, congestive heart failure, or transient ischemic attack (TIA). Physical examination showed a regular heart rate and rhythm. The diagnoses included coronary artery disease/coronary artery bypass graft (CABG) which was stable and currently asymptomatic and carotid stenosis status-post right carotid endarterectomy which was currently asymptomatic. In March 2014, it was noted that the Veteran "has fairly aggressive vascular disease." A history of coronary artery bypass surgery in 2007 and right carotid endarterectomy in July 2009 was noted. Physical examination showed a regular heart rate and rhythm. The diagnoses included coronary artery disease with bypass surgery with a note that the Veteran was doing well, a normal stress echocardiogram in February 2012, and carotid artery disease with prior right carotid endarterectomy with acceptable carotid Dopplers. In September 2014, it was noted that the Veteran was status-post bypass surgery and doing well with no angina, congestive heart failure, or TIA. Physical examination showed a regular heart rate and rhythm. The diagnoses included coronary artery disease/coronary artery bypass graft (CABG) which was stable and carotid stenosis, status-post right carotid endarterectomy which was currently asymptomatic. In April 2015, the Veteran reported that he was walking on a treadmill for 30 minutes without chest pain or shortness of breath. Pe a regular heart rate and rhythm. The diagnoses included coronary artery disease with bypass surgery with a note that the Veteran was doing well and carotid artery disease with prior right carotid endarterectomy. In September 2015, it was noted that the Vet was doing well without symptoms of angina, congestive heart failure, or TIA. He played golf several days per week during golfing season and walked on a treadmill in the winter. Physical examination showed a regular heart rate and rhythm. The diagnoses included coronary artery disease/coronary artery bypass graft (CABG) which was stable. In April 2016, the Veteran's medical history was unchanged. Physical examination showed a regular heart rate and rhythm. The Veteran's normal stress echocardiogram in February 2012 was noted. The diagnoses included coronary artery disease with bypass surgery in 2007 with a note that the Veteran was doing well and carotid artery disease with prior right endarterectomy. In March 2020, it was noted that there was no recurrence of angina. The Veteran reported walking on a treadmill 3 times a week for 1.5 miles in 30 minutes. "He does get lightheaded when he stands up too quickly." There was no syncope, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, or edema. Physical examination showed a regular heart rate and rhythm and no edema. The diagnoses included coronary artery disease with a note that the Veteran was "doing well without angina or signs of heart failure." The private cardiologist recommended that he stay on continuous medication. In September 2020, it was noted that the Veteran was doing well since his most recent cardiac procedure on November 4, 2019. "He continues to do well without chest pain or shortness of breath. He is push mowing his yard and playing golf frequently without issues." Physical examination showed a regular heart rate and rhythm and no edema. The diagnoses included coronary artery disease without angina or signs of heart failure. In March 2021, the Veteran's medical history was noted. "He denies any unusual tightness, heaviness, palpitations, or shortness of breath with exertion...He has not had any classical angina. He is exercising by walking on his treadmill daily without limitation." Physical examination showed a regular heart rate and rhythm and a right carotid endarterectomy scar. The diagnoses included coronary artery disease involving coronary bypass graft of native heart without angina pectoris which was stable. Contrary to the Veteran's lay assertions, the record evidence shows that, prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, the service-connected coronary artery disease, status-post bypass surgery is manifested by, at worst, a history of documented myocardial infarction resulting in continuous medication required for control (i.e., a 10 percent rating under DC 7006). Id. The Board acknowledges that the Veteran experienced myocardial infarctions on January 3, 2019, and on November 3, 2019; temporary total (100 percent) ratings already are in effect for 3 months following each of these myocardial infarctions. Id. Following each of these cardiac events, the Veteran's service-connected coronary artery disease, status-post bypass surgery again required, at most, continuous medication for control. His voluminous private outpatient treatment records document that his coronary artery disease was treated successfully following surgery with continuous medication. This disability repeatedly was stable when he was seen as an outpatient between his myocardial infarctions and after each of these myocardial infarctions occurred. It appears that the Veteran successfully completed his surgical recovery following each of these myocardial infarctions and his service-connected coronary artery disease, status-post bypass surgery, returned to the baseline requirement of continuous medication for control. Id. There is no indication that, prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, the service-connected coronary artery disease, status-post bypass surgery is manifested by a history of documented myocardial infarction resulting in a workload of between 5 and 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatations on EKG, echocardiogram, or x ray as is required for a 30 percent rating under DC 7006. Id. His private treating cardiologist repeatedly concluded that his coronary artery disease was without angina. And he repeatedly denied experiencing dyspnea, fatigue, or syncope on outpatient treatment visits. Although he reported experiencing lightheadedness in March 2020, the private treating cardiologist apparently concluded that this was the result of the Veteran taking metoprolol and advised him to stop taking this medication. The Veteran otherwise has not identified or submitted any evidence demonstrating his entitlement to a disability rating greater than 10 percent prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, for his service-connected coronary artery disease, status-post bypass surgery. Thus, the Board finds that the criteria for a disability rating greater than 10 percent prior to January 2, 2019, from May 1, 2019, to November 2, 2019, and from March 1, 2020, to November 15, 2021, for coronary artery disease, status-post bypass surgery, have not been met. The Veteran also is not entitled to a disability rating greater than 60 percent effective November 15, 2021, for his service-connected coronary artery disease, status-post bypass surgery. The Board acknowledges that VA heart conditions DBQ on November 15, 2021, showed that the symptomatology attributable to this disability had worsened and supported the assignment of a 60 percent rating effective on that date under DC 7006. Id. At this examination, the Veteran's medical history of 2 myocardial infarctions (or heart attacks) was noted. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. Continuous medication was required for control of the Veteran's heart conditions. He had tricuspid regurgitation. His coronary artery bypass surgery in 2007 was noted. Physical examination showed a regular heart rate and rhythm, a systolic murmur, clear lungs to auscultation, normal peripheral pulses, and trace peripheral edema of the bilateral lower extremities. There was no evidence of cardiac hypertrophy or dilatation. His echocardiogram was normal. His ECG showed lateral ischemia. A chest x-ray showed a torturous appearing aorta and prior coronary artery bypass graft (CABG). Interview-based METs testing showed 3-5 METs resulting in dyspnea on exertion, fatigue, and angina. The Veteran's LVEF was 45 percent. He had not had congestive heart failure. The diagnoses were acute, subacute, or old myocardial infarction, unstable angina, arteriosclerotic heart disease (coronary artery disease), valvular heart disease, and CABG. The findings at this examination of 3-5 METs and an LVEF of 45 percent supported the assignment of a higher 60 percent rating effective November 25, 2021, under DC 7006. Id. There is no indication, however, that the Veteran experienced a history of documented myocardial infarction resulting in congestive heart failure, a workload of less than 3 METs resulted in dyspnea on exertion, fatigue, angina, dizziness, or syncope, or an LVEF of less than 30 percent as a result of his service-connected coronary artery disease, status-post bypass surgery, such that a disability rating greater than 60 percent effective November 25, 2021, is warranted. Id. He otherwise has not identified or submitted any evidence demonstrating his entitlement to a disability rating greater than 60 percent effective November 25, 2021, for his service-connected coronary artery disease, status-post bypass surgery. Thus, the Board finds that the criteria for a disability rating greater than 60 percent effective November 25, 2021, for coronary artery disease, status-post bypass surgery, have not been met. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael T. Osborne, 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.