Citation Nr: 25002997 Decision Date: 03/03/25 Archive Date: 03/03/25 DOCKET NO. 20-16 041A DATE: March 3, 2025 ORDER Entitlement to a compensable rating prior to November 14, 2021, for atrial fibrillation is denied. Entitlement to a rating in excess of 10 percent from November 14, 2021, for atrial fibrillation is denied. FINDINGS OF FACT 1. For the period prior to November 14, 2021, the Veteran's atrial fibrillation did not manifest as permanent atrial fibrillation (lone atrial fibrillation), as one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor, or as more than four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. 2. For the period from November 14, 2021, the Veteran's atrial fibrillation did not manifest as paroxysmal atrial fibrillation or other supraventricular tachycardia with more than four episodes per year documented by ECG or Holter monitor, or as supraventricular tachycardia confirmed by ECG with five or more treatment interventions per year. CONCLUSIONS OF LAW 1. The criteria for a compensable rating prior to November 14, 2021, for atrial fibrillation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.31, 4.104, Diagnostic Code 7010. 2. The criteria for a rating in excess of 10 percent from November 14, 2021, for atrial fibrillation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7010. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2022, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge of the Board. A transcript of the hearing is of record. This matter was most recently before the Board in December 2023, at which time the claim was remanded for the agency of original jurisdiction (AOJ) to notify the Veteran of VA's inability to obtain private records from Dr. A.W. in accordance with 38 C.F.R. § 3.159(e)(1) and to obtain outstanding VA treatment records, including community care records and those scanned into VistA imaging. The record reflects that in October 2024, the AOJ sent the letter to the Veteran as directed by the Board. The record also reflects that VA treatment records including community care records and VistA imaging scanned documents were associated with the claims file in December 2023. Additional VA treatment records were associated with the claims file in May 2024, June 2024, July 2024, August 2024, October 2024, December 2024, and January 2025. Accordingly, the Board finds that there has been substantial compliance with the Board's prior remand directives and thus, no further action in this regard is warranted. See Stegall v. West, 11 Vet. App. 268 (1998) In a January 2025 rating decision, the AOJ granted a 10 percent rating for atrial fibrillation effective November 14, 2021. However, as this grant does not represent a total grant of benefits sought on appeal, the claim for an increased rating remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The Board notes that in February 2025, after the issuance of the January 2025 supplemental statement of the case and the return of the matter to the Board, additional VA treatment records were associated with the claims file. However, the records are either not pertinent to the claim or duplicative of evidence already considered by the AOJ. As such, the Veteran is not prejudiced by the Board's adjudication of this appeal. 1. Entitlement to a compensable rating prior to November 14, 2021, for atrial fibrillation. 2. Entitlement to a rating in excess of 10 percent from November 14, 2021, for atrial fibrillation. The Veteran is seeking a higher rating for his atrial fibrillation. He generally contends that a February 2018 private heart conditions disability benefits questionnaire supports the assignment of a higher rating. Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ Part 4. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In cases where an assigned disability rating has been challenged or appealed, it is possible for a Veteran to receive a staged rating. A staged rating is an award of separate percentage evaluations for separate periods, based on the facts found during the appeal period. Fenderson v. West, 12 Vet. App. 119, 126-28 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (in determining the present level of a disability for any increased evaluation claim, the Board must consider staged ratings). The Veteran's atrial fibrillation is evaluated under Diagnostic Code 7010 for supraventricular tachycardia. Effective November 14, 2021, VA amended the rating criteria for ratings pertaining to the cardiovascular system under 38 C.F.R. § 4.104, to include Diagnostic Code 7010. 86 Fed. Reg. 54089 (Sep. 30, 2021). This amended regulation applies to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after November 14, 2021. Claims pending prior to the effective date will be considered under both the pre- and post-amendment rating criteria, and whichever is more favorable to the Veteran will be applied. However, the Board may not apply the post-amendment rating criteria to a period prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Conversely, the Board is not precluded from applying the pre-amendment rating criteria to a period on or after the effective date of the post-amendment rating criteria so long as it was in effect during the pendency of the appeal. Prior to November 14, 2021, under Diagnostic Code 7010, a 10 percent rating was warranted for evidence of permanent atrial fibrillation (lone atrial fibrillation), or one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. 38 C.F.R. § 4.104. A maximum 30 percent rating was assigned for evidence of paroxysmal atrial fibrillation or other supraventricular tachycardia with more than four episodes per year documented by ECG or Holter monitor. Id. As Diagnostic Code 7010 does not provide rating criteria for a noncompensable rating, a noncompensable rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. Effective November 14, 2021, a 10 percent rating under Diagnostic Code 7010 is warranted with supraventricular tachycardia confirmed by ECG, with one to four treatment interventions per year; or, confirmed by ECG with either continuous use of oral medications to control or use of vagal maneuvers to control. A maximum 30 percent rating is warranted when supraventricular tachycardia is confirmed by ECG, with five or more treatment interventions per year. 38 C.F.R. § 4.104. Note (1) indicates that examples of supraventricular tachycardia include, but are not limited to: atrial fibrillation, atrial flutter, sinus tachycardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. Note (2) indicates that for the purposes of this Diagnostic Code, a treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. By way of history, an October 2017 rating decision granted service connection for atrial fibrillation with a noncompensable evaluation effective July 13, 2017. In April 2018, the Veteran filed a VA Form 21-526EZ seeking a higher rating for his atrial fibrillation, and in the June 2018 rating decision on appeal, the AOJ continued the noncompensable evaluation for atrial fibrillation. Turning to the evidence of record, an October 2017 VA heart disabilities examination reported diagnoses of acute, subacute, or old myocardial infarction, coronary artery disease, and atrial fibrillation. The Veteran's heart disabilities required continuous medication including Plavix, Aspirin, Lisinopril, and Atorvastatin. The examiner reported that the Veteran had intermittent (paroxysmal) fibrillations. He also had intermittent atrial flutters that had occurred on more than 4 episodes in the past 12 months, and these episodes were documented by hospital records that showed a consultation report. In April 2018, the Veteran submitted a copy of a heart conditions disability benefits questionnaire (DBQ) completed by a private doctor, Dr. A.W. in February 2018. Dr. A.W. reported diagnoses of coronary artery disease and atrial fibrillation. His heart disability required continuous medications, specifically Acetylsalicylic acid, Clopidogrel Bisulfate, Metoprolol, Atorvastatin, and Lisinopril. Dr. A.W. indicated that the Veteran had intermittent atrial fibrillation with more than 4 episodes in the past 12 months that were documented with EKG and reported that the Veteran underwent an EKG in January 2018 which showed atrial fibrillation. In May 2018, the Veteran was afforded a VA heart examination, which documented diagnoses of acute, subacute, or old myocardial infarction, coronary artery disease, and atrial fibrillation. He took continuous medication, including Zetia, Metoprolol, Atorvastatin, Lisinopril, Plavix, and Aspirin for his coronary artery disease. The examiner reported he had intermittent atrial fibrillation with zero episodes in the past 12 months which were documented by EKG. An EKG conducted in conjunction with the examination showed sinus rhythm with sinus arrhythmia. A November 2020 private treatment record noted that an electrocardiogram showed sinus rhythm with premature atrial contractions (PACs), old inferior wall myocardial infarction, and intraventricular conduction delay (IVCD). A March 2021 VA treatment record noted that an EKG showed sinus bradycardia with PACs. The interpretation was that there were no significant symptoms or ECG changes diagnostic of ischemia. A September 2022 VA treatment record noted that an EKG was "ok." An October 2022 VA pre-operative evaluation note for an unrelated surgery to the Veteran's foot documented that no EKG was needed if within a year with no new issues, no shortness of breath, and no chest pains. The note stated that the questions were verbalized to the Veteran by the writer with the Veteran stating no new issues as of this date. During his October 2022 Board hearing, the Veteran testified that he underwent an EKG the prior week. He asserted that he experienced atrial fibrillation on average about twice a year. He further testified that he thought he had been taking medication for the atrial fibrillation, and he did not have a pacemaker or defibrillator implanted. In January 2023, the Board remanded the claim. The Board noted that the February 2018 private heart conditions DBQ completed by Dr. A.W. indicated that the Veteran had intermittent atrial fibrillation with more than four episodes in the past 12 months documented by EKG; however, the only reported EKG on the DBQ was a January 2018 EKG that showed atrial fibrillation. Notably, the January 2018 EKG was not included with the February 2018 heart conditions DBQ and was not included in the record. Moreover, no additional documentation of episodes of atrial fibrillation within one year of the February 2018 DBQ were submitted by the Veteran or included in the record. The Board also noted that the May 2018 VA examination reported that the Veteran had atrial fibrillation with zero episodes in the past 12 months documented with an EKG and that the May 2018 VA examination did not reference the February 2018 private DBQ. The Board pointed out that if Dr. A.W.'s February 2018 statement that the Veteran had intermittent atrial fibrillation with more than four episodes in the past 12 months documented by EKG was supported by documented evidence, a higher rating for the Veteran's atrial fibrillation may be warranted under Diagnostic Code 7010. See 38 C.F.R. § 4.104. The Board determined that remand was necessary to determine whether Dr. A.W.'s statement was supported by documented evidence, as Dr. A.W. referenced only a single EKG performed in January 2018 when he completed the February 2018 DBQ. Thus, it was unclear if his statement regarding the frequency of the Veteran's episodes of atrial fibrillation was made in error. The matter was remanded for the AOJ to undertake appropriate development to determine whether Dr. A.W.'s statement in the February 2018 DBQ that the Veteran had intermittent atrial fibrillation with more than four episodes in the past 12 months documented by EKG was supported by documented evidence; to obtain the documentation of any EKGs performed, including the January 2018 EKG reported by Dr. A.W. on the February 2018 DBQ; and to contact the Veteran and request that he provide or authorize the release of records from Dr. A.W., as well as any other private treatment records (including EKGs), not already of record, that are relevant to his claim. The Board directed that if, after making reasonable efforts to obtain non-VA records the AOJ is unable to secure the same, the AOJ must notify the Veteran and (a) identify the specific records the AOJ is unable to obtain; (b) briefly explain the efforts that the AOJ made to obtain those records; (c) describe any further action to be taken by the AOJ with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Board directed that the Veteran must then be given an opportunity to respond. In February 2023, the AOJ sent the Veteran a letter requesting he complete and return the enclosed authorization forms to allow VA to obtain his private treatment records and advising that he may want to obtain and send VA the records himself, if possible. The letter advised the Veteran that private treatment records were needed to determine whether Dr. A.W.'s statement in the February 2018 DBQ was supported by documented evidence and that the documentation of any EKGs performed was needed, including the January 2018 EKG reported by Dr. A.W. on the February 2018 DBQ to have shown atrial fibrillation. In response, the Veteran provided a completed VA Form 21-4142 as well as a VA Form 21-4142a that did not list the names of any providers or facilities. This form was rejected in February 2023 due to "incomplete PHP information." The AOJ subsequently sent the Veteran a second letter requesting he complete and return the enclosed authorization forms to allow VA to obtain his records from Dr. A.W. as well as any other private treatment records regarding his heart disabilities. The Veteran was advised that if he preferred, he could secure the treatment records himself and submit them to VA. In response, the Veteran submitted a completed VA Form 21-4142 and a completed VA Form 21-4142a authorizing VA to obtain private treatment records from Dr. N.E. The Veteran's private treatment records were received from Dr. N.E. and associated with the claims file in March 2023. In March 2023, the Veteran submitted an additional completed VA Form 21-4142 and another VA Form 21-4142a that did not list the names of any providers or facilities. This form was rejected due to "incomplete PHP information." In a March 2023 phone call with VA, the Veteran advised that in response to the February 2023 letter requesting medical records from Dr. A.W., he only saw Dr. A.W. for a C&P examination and those results should be in his records already. He also advised he did not recall this provider. In May 2023, VA attempted to contact Dr. A.W. to undertake appropriate development to determine whether his statement on the February 2018 DBQ that the Veteran had intermittent atrial fibrillation with more than four episodes in the last 12 months documented by EKG was supported by documented evidence. VA attempted to call Dr. A.W. twice at the phone number he listed on the February 2018 DBQ. However, after two rings each time VA called, the call ended with a busy signal. Subsequently, the AOJ sent the Veteran another letter requesting he complete the enclosed authorization forms to allow VA to obtain his records from Dr. A.W. The Veteran was again advised that he may want to obtain and send VA the records himself. In August 2023, the Veteran provided a completed VA Form 21-4142 and a completed VA Form 21-4142a authorizing VA to obtain private treatment records from Dr. A.W. He also submitted a statement indicating that he had been unable to connect with Dr. A.W. He stated that he tried to trace from the phone number attached but no investigation had turned up Dr. A.W.'s current address or phone number. In an August 2023 letter, the AOJ advised the Veteran that they had requested copies of his private medical records from Dr. A.W. Approximately one week later, the AOJ called a phone number they found online for Dr. A.W. but the number was out of service. See August 2023 Report of Contact. They also called a hospital which was located at the address listed on the VA Form 21-4142a, but they were advised that the hospital did not have Dr. A.W. on staff. Additional research was conducted, but they were unable to locate alternative contact information for Dr. A.W. Thus, the AOJ closed out the request as the PHP information was invalid. However, the AOJ failed to notify the Veteran that they were unable to obtain the records in accordance with the January 2023 remand directives and in accordance with 38 C.F.R. § 3.159(e)(1). In September 2023, the Veteran was afforded a VA heart disability examination, and diagnoses of coronary artery disease, status post percutaneous coronary intervention, status post myocardial infarction, and atrial fibrillation were noted. The Veteran took continuous medication for his heart disabilities, including Atorvastatin and Ezetimibe for hyperlipidemia. He also took Metoprolol daily but was unsure which diagnosis he took the medication for. The examiner reported that the Veteran had atrial fibrillation that required continuous use of oral medications to control. The examiner did not report any treatment intervention for the past year. An ECG performed in conjunction with the examination showed sinus arrhythmia and possible myocardial infarction of indeterminate age. In a medical opinion, the examiner was asked to report how many treatment interventions the Veteran has had for atrial fibrillation since July 2017 to the present. The examiner stated that in May 2018 the Veteran was diagnosed with atrial fibrillation, myocardial infarction, and coronary artery disease and EKG results from May 2018 noted sinus rhythm with sinus arrhythmia. The examiner stated that no hospitalizations were noted, and the percutaneous coronary intervention was noted as done in 2005 and 3 stents placed. A March 2021 EKG showed sinus bradycardia (heart rate 53 beats per minute) with PACs, and the interpretation was that there were no significant symptoms or ECG changes diagnostic of ischemia. April 2021 records showed an EKG that indicated sinus bradycardia with PACs, and the September 2023 VA examination showed that the Veteran reported taking Metoprolol daily and an ECG that was done and showed sinus rhythm with marked sinus arrythmia and possible inferior myocardial infarction of indeterminate age. The examiner stated that the Veteran was taking Metoprolol daily to control the atrial fibrillation and had multiple treatments between 2017 to the present as listed above. In October 2023, an addendum opinion was obtained. The examiner explained that a review of the records provided in association with the exam did not contain any EKG tracings since 2017 showing atrial fibrillation. The examiner stated that the only evidence of atrial fibrillation since 2017 was a heart conditions DBQ completed by Dr. A.W. in 2018 which documented interpretation of atrial fibrillation on an EKG tracing from January 2018 and the referenced EKG tracing was not included in the records. As such, the examiner explained that they could not affirm or refute the validity of that interpretation. The examiner stated that Dr. A.W. indicated the Veteran had four or more episodes per year of atrial fibrillation and it was unclear how that determination was made as there was no objective evidence in the records provided to substantiate the report. The examiner explained that what could be stated was there was no other evidence in the records provided of an EKG documenting atrial fibrillation beyond the single reference on the February 2018 DBQ from Dr. A.W. which did not include the tracing reportedly documenting the finding. The examiner said that it was noted that a cardiology consult accomplished in April 2021 confirmed coronary artery disease with prior stent placement but did not include atrial fibrillation on the list of cardiac diagnoses. Concerning the number of interventions per year, the examiner stated that prior DBQs indicated Metoprolol had been given for the diagnosis of atrial fibrillation. However, the evidence of record indicated that Metoprolol predated the atrial fibrillation as documented in the records, and the Veteran also had a concomitant diagnosis of coronary artery disease with prior stent placement. The examiner stated that Metoprolol was commonly prescribed for this, and the records were unclear as to which diagnosis for which the Veteran was taking the medication. The examiner said that the benefit of the doubt was given to the Veteran in this regard, however, there was no evidence in the records provided of any other intervention for atrial fibrillation since 2017. In December 2023, the Board remanded the claim for the AOJ to notify the Veteran of VA's inability to obtain his records from Dr. A.W. pursuant to 38 C.F.R. § 3.159(e)(1) and to obtain the Veteran's outstanding VA treatment records, including community care records and records uploaded into VistA imaging, and associate the records with the claims file. In October 2024, the AOJ sent the Veteran a letter advising him of VA's inability to obtain his records from Dr. A.W. and requested the Veteran submit the records if they were in his possession. The letter advised the Veteran that several steps had been made to try to obtain the treatment records to include asking the Veteran to submit the records, asking him to submit authorization forms to release the records, VA staff completing telephone development with him in an attempt to obtain the records, and VA staff making attempts to complete telephone development directly with the medical provider in an attempt to obtain the records. The Veteran was advised that he was ultimately responsible for providing the evidence and he was encouraged to submit any information or evidence as soon as he could. The letter advised the Veteran that if they did not hear from him, a decision may be made on his claim after 30 days. In a November 2024 letter, the AOJ again advised the Veteran of VA's inability to obtain his records from Dr. A.W. The Veteran was asked to complete and return the enclosed authorization forms and advised that he may want to obtain and send the records himself. He was encouraged to submit any information or evidence as soon as he could, and he was advised that if they did not hear from him, a decision may be made on his claim after 30 days. In December 2024, the Veteran was afforded a VA heart disabilities examination, and the examiner reported diagnoses of acute, subacute, or old myocardial infarction, coronary artery disease, and atrial fibrillation. The examiner indicated that the Veteran's atrial fibrillation required continuous use of oral medications to control. No other treatment interventions were noted. An ECG performed in conjunction with the examination showed sinus rhythm with PACs and inferior infarction of undetermined age. The examiner reported that the Veteran had intermittent arrhythmia with episodes documented per the February 2018 DBQ completed by Dr. A.W. In January 2025, the AOJ issued a rating decision granting a 10 percent evaluation for atrial fibrillation from November 14, 2021. The AOJ also issued a supplemental statement of the case (SSOC) denying a compensable rating for atrial fibrillation prior to November 14, 2021, and denying a rating in excess of 10 percent for atrial fibrillation from November 14, 2021. The SSOC was issued more than 30 days after the October 2024 and November 2024 letters were sent to the Veteran. After reviewing the evidence of record, the Board finds that higher ratings are not warranted. First, for the period prior to November 14, 2021, a compensable evaluation for atrial fibrillation is not warranted. In this case, the evidence is persuasively against finding that his atrial fibrillation manifested as one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. In this regard, the October 2017 VA examination showed intermittent fibrillations but did not document any episodes in the prior year and intermittent atrial flutters that had occurred on more than 4 episodes in the prior 12 months. However, the examiner indicated that the episodes of atrial flutters were documented by a hospital record that showed a consultation report, not by ECG or Holter monitor. In addition, the May 2018 VA examination documented that he had intermittent atrial fibrillation with zero episodes in the past 12 months which were documented by EKG. Additionally, the evidence of record does not support that he had permanent atrial fibrillation, as the VA examinations indicated that he had intermittent atrial fibrillation. The Board acknowledges that the February 2018 private heart conditions DBQ completed by Dr. A.W. reported that the Veteran had intermittent atrial fibrillation with more than 4 episodes in the past 12 months that were documented with EKG and that he underwent an EKG in January 2018 which showed atrial fibrillation. However, the Board affords this DBQ no probative weight as the findings of this DBQ are not otherwise supported by the record. As described in great detail above, the AOJ undertook substantial effort to attempt to seek clarification and determine whether Dr. A.W.'s statement that the Veteran had intermittent atrial fibrillation with more than 4 episodes in the prior 12 months documented by EKG was supported by documented evidence. See Savage v. Shinseki, 24 Vet. App. 259 (2011). However, after numerous attempts, VA was unable to contact Dr. A.W. to obtain clarification, supporting evidence, or the referenced January 2018 EKG. The Veteran has also not provided a copy of the referenced January 2018 EKG or documentation supporting the findings of the private DBQ. As VA conducted reasonable efforts to obtain information from Dr. A.W. to clarify the findings of the private DBQ in order to substantiate the Veteran's claim for an increased rating and notified the Veteran of VA's inability to obtain records from Dr. A.W. in accordance with 38 C.F.R. § 3.159(e)(1), the Board finds that VA's duty to assist in this regard has been fulfilled. The Board affords great probative weight to the October 2023 VA addendum opinion as it was based on a thorough review of the record and contains adequate rationale. The examiner indicated that the record did not contain any EKG tracings since 2017 showing atrial fibrillation, other than the February 2018 private DBQ. The examiner noted that Dr. A.W. indicated the Veteran had four or more episodes per year of atrial fibrillation and explained it was unclear how that determination was made as there was no objective evidence in the records provided to substantiate the report. The examiner stated that there was no other evidence in the records provided of an EKG documenting atrial fibrillation beyond the single reference on the February 2018 DBQ from Dr. A.W. which did not include the tracing reportedly documenting the finding. The Board acknowledges the Veteran's Board hearing testimony that he experienced atrial fibrillation on average about twice a year. However, the record does not support the Veteran's statement and as such, the Board affords this statement little probative weight. The Board affords more probative weight to the October 2023 VA addendum opinion, which found that based on a thorough review of the evidence, the record did not contain any EKG tracings since 2017 showing atrial fibrillation, other than the February 2018 private DBQ which the Board has afforded no probative weight. In light of the above, the Board finds that a compensable rating for atrial fibrillation prior to November 14, 2021, is not warranted. Second, for the period from November 14, 2021, a rating in excess of 10 percent for atrial fibrillation is not warranted under the old or new rating criteria. As the two criteria consider different factors, and one is not necessarily more restrictive than the other, both the old and new criteria will be considered by the Board. In considering the old rating criteria, the evidence in this case does not support finding that the Veteran experienced paroxysmal atrial fibrillation or other supraventricular tachycardia with more than four episodes per year documented by ECG or Holter monitor. Here, the October 2023 VA examiner explained that the record did not contain any EKG tracings since 2017 showing atrial fibrillation, other than the February 2018 private DBQ, and as explained above, the Board affords the February 2018 private DBQ no probative weight. Additionally, the evidence does not support a higher 30 percent rating under the new rating criteria, as the record does not establish that he experienced supraventricular tachycardia confirmed by ECG with five or more treatment interventions per year. In this regard, neither the September 2023 VA heart examination nor the December 2024 VA heart examination indicated that his atrial fibrillation required treatment interventions. The Board has considered the September 2023 VA examiner's finding in the medical opinion that the Veteran had multiple "treatments" between 2017 to the present. While the record and the opinion document that the Veteran underwent multiple EKGs and took Metoprolol daily, these treatments are not considered "treatment interventions" under Diagnostic Code 7010, as a treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. Moreover, the examiner did not document on the examination report that the Veteran had underwent intravenous pharmacological adjustment, cardioversion, or ablation for symptom relief. Additionally, the October 2023 examiner explained that other than the Veteran taking Metoprolol, there was no evidence in the records provided of any other intervention for atrial fibrillation since 2017. As such, the evidence does not support that he had supraventricular tachycardia confirmed by ECG with five or more treatment interventions per year and a higher 30 percent rating is not warranted. As a final matter, the Board notes that the Veteran is separately service connected for coronary artery disease under Diagnostic Code 7005, which is rated under the General Rating Formula for Diseases of the Heart. The General Rating Formula for Diseases of the Heart contemplates heart failure symptoms such as breathlessness, fatigue, and palpitations, and as such, the Veteran is already compensated for such symptoms. Moreover, the November 14, 2021, amendments to 38 C.F.R. § 4.104 expressly declined to incorporate symptoms of extreme fatigue, hypotension, shortness of breath, dizziness, and chest pain under Diagnostic Code 7010, which specifically addresses supraventricular tachycardia. See 86 Fed. Reg. 54091-92 (Sept. 30, 2021). In sum, the Board finds that a compensable rating prior to November 14, 2021, and a rating in excess of 10 percent from November 14, 2021, for atrial fibrillation are not warranted. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the evidence is persuasively against the claims and the positive and negative evidence is not nearly in balance, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Accordingly, the claims are denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Bruce, 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.