Citation Nr: 22018587 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 14-38 289 DATE: March 29, 2022 REMANDED An initial increased rating in excess of 30 percent from February 7, 2013, until August 30, 2021, and in excess of 60 percent from August 30, 2021, for service-connected coronary artery disease status post myocardial infarction (hereinafter "coronary artery disease") is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1969 to July 1971. This matter originally came before the Board of Veterans' Appeals (Board) from a November 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. This matter has previously been remanded by the Board multiple times for further development, most recently in May 2021. This matter is again before the Board. An initial increased rating in excess of 30 percent from February 7, 2013, until August 30, 2021, and in excess of 60 percent from August 30, 2021, for service-connected coronary artery disease is remanded. The Veteran believes that a higher rating for service-connected coronary artery disease is warranted. VA examinations for coronary artery disease took place in 2013, 2020, and 2021. See October 2013 C&P Exam; March 2020 C&P Exam; October 2021 C&P Exam. The Board notes that, among other things, the 2013 VA examination found fatigue and angina at a METs level greater than seven to ten and found no evidence of cardiac hypertrophy or dilatation. Among other problems, the Board finds that these VA examinations did not consider/were unable to consider all of the relevant evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, among other evidence, the VA examinations did not consider/were unable to consider a January 2013 private examination showing dyspnea at a METs level between one and three and showing evidence of cardiac hypertrophy or dilatation, the Veteran's report that the heart problem had continued to worsen since 2011, and medical records showing a heart stent in 2013. See February 2013 DBQ; March 2020 C&P Exam; August 2021 Medical Treatment Record. Additionally, the 2021 VA examination did not provide an opinion of what employment limitations the Veteran had due to the Veteran's other service-connected disabilities as required by the Board's 2021 remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); May 2021 BVA Decision. Finally, none of the VA examinations provided an opinion as to whether the Veteran's reported headaches were related to or aggravated by his service-connected coronary artery disease. As such, the current medical evidence of record is insufficient to determine whether a separate rating is warranted for the Veteran's headaches. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Therefore, a remand is needed for a VA examination which covers the entire appeal period. The matter is REMANDED for the following action: 1. Update VA and private treatment records. VA treatment records appear current up to June 2021. 2. Schedule an appropriate VA examination to determine the nature and severity of the Veteran's coronary artery disease status post myocardial infarction disability throughout the entire appeal period (i.e., since February 2013). All signs and symptoms necessary for evaluating the Veteran's service-connected coronary artery disease status post myocardial infarction disability throughout the entire appeal period should be reported. This should also include the impact that the disability may have on the Veteran's headaches. The claims file and a copy of this Remand should be made available to and should be reviewed by the examiner. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should also report the impact that each of the Veteran's service-connected disabilities would have had on the Veteran's ability to secure and follow a substantially gainful occupation throughout the appeal period. After a review of the record on appeal and an examination of the Veteran, the examiner is asked to provide the following opinions: (A) Is it approximately at least as likely as not (approximately a 50 percent probability or greater) that at any point during the appeal period prior to August 30, 2021, the Veteran's service-connected coronary artery disease status post myocardial infarction disability resulted in a workload of greater than three METs but not greater than five METs resulting in dyspnea, fatigue, angina, dizziness, or syncope? If yes, for which periods of time? (B) Is it approximately at least as likely as not (i.e., approximately a 50 percent probability or greater) that at any point during the appeal period, the Veteran's service-connected coronary artery disease status post myocardial infarction disability resulted in a workload of three METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope? If yes, for which periods of time? (C) Is it approximately at least as likely as not (i.e., approximately a 50 percent probability or greater) that at any point during the appeal period since November 14, 2021, the Veteran's service-connected coronary artery disease status post myocardial infarction disability resulted in a workload of three METs or less resulting in heart failure symptoms (which include but are not limited to breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope)? If yes, for which periods of time? (D) Identify all disabilities related to the Veteran's service-connected coronary artery disease status post myocardial infarction disability, existing at any point during the pendency of the appeal (i.e., since February 2013), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (E) The Veteran is also claiming that his service-connected coronary artery disease status post myocardial infarction disability affects his headaches. Identify all disabilities related to this complaint during the appeal period. (F) For each identified disability, is it approximately at least as likely as not (i.e., approximately a 50 percent probability or greater) that the disability is related to or aggravated by the Veteran's service-connected coronary artery disease status post myocardial infarction disability? For aggravation, state whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. In addition to the other relevant evidence of record, the examiner is asked to consider the following information with a caution that this list is not a substitute for a review of the record: (1) The Veteran's reports. See April 2021 Appellate Brief; June 2019 Appellate Brief; October 2014 Form 9; February 2014 NOD. (2) A medical record from 2021 showing that the Veteran's heart disability had worsened over the years. See October 2021 C&P Exam. (3) Medical records from 2013 and 2014 showing that headaches were coming, that the Veteran had a myocardial infarction in 2011, and that "sl NTG" had given the Veteran a significant headache in the past. See September 2015 Medical Treatment Record. (4) Medical records showing a report of dyspnea from going up a flight of stairs. Further information is provided. See July 2014 Medical Treatment Record. (5) The 2013 private examination showing dyspnea at a METs level between one and three and evidence of cardiac hypertrophy or dilatation. See February 2013 DBQ. (6) All other relevant lay and medical evidence. A complete and clear rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community's medical knowledge or due to the limits of the examiner's medical knowledge. 3. Readjudicate the issue on appeal. The AOJ should consider separate ratings, if warranted by the evidence of record. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Dougan, 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.