ISCHEMIC HEART DISEASE

COLLEEN M. GLASER-ALLEN · 2025 · Case ID: 25001716

MIXED

Summary

The veteran, who served in the United States Air Force from September 1968 to November 1976, appeals the denial of an increased disability rating for his service-connected ischemic heart disease (IHD) and the remand of his claim for a skin condition. The veteran's IHD is currently rated at 30 percent. The Board reviewed the case under both pre- and post-November 14, 2021, rating criteria for IHD. Under the pre-amendment criteria, a 30 percent rating is assigned for a workload of 5.1-7.0 METs with symptoms, or cardiac hypertrophy/dilatation. A 60 percent rating requires a workload of 3.1-5.0 METs with symptoms, or left ventricular dysfunction with an ejection fraction of 30-50 percent. A 100 percent rating requires a workload of 3.0 METs or less with symptoms, or left ventricular dysfunction with an ejection fraction below 30 percent. Post-amendment criteria also use METs levels and heart failure symptoms. The Board considered VA examinations from May 2022 and May 2024, along with private medical evidence. The May 2022 exam indicated a METs level of greater than 5, but less than 7, with symptoms, and an ejection fraction of 55-60 percent. The May 2024 exam noted fatigue with activity, cardiac hypertrophy and dilatation, and a METs level of greater than 5, but less than 7. The Board found the echocardiogram, which showed hypertrophy and dilatation, to be the gold standard for evaluating cardiac function. The Board concluded that the veteran's condition did not meet the criteria for a 60 percent or 100 percent rating under either set of criteria, and therefore denied the increased rating for IHD. The Board remanded the skin condition claim because the VA examiner failed to complete a required Scars/Disfigurement DBQ, preventing the Board from determining if a higher rating was warranted.

Rationale

Evidence did not meet criteria for 60% or 100% rating; METs level and ejection fraction did not meet higher rating thresholds; Echocardiogram considered gold standard for IHD evaluation

Service Branch

AIR FORCE

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

7005

Docket No.

18-06 238

Full Decision Text

Citation Nr: 25001716
Decision Date: 02/05/25 Archive Date: 02/05/25

DOCKET NO. 18-06 238
DATE: February 5, 2025

ORDER

Entitlement to a disability rating higher than 30 percent for service-connected ischemic heart disease (IHD) is denied.

REMANDED

Entitlement to a compensable disability rating for a service-connected skin condition, to include dermatitis and psoriasis, prior to May 5, 2022, and higher than 10 percent thereafter, is remanded.

FINDING OF FACT

The Veteran's service-connected IHD has been manifested by continuous medication, a workload of greater than 5 METs (metabolic equivalents) but not greater than 7 METs that results in dyspnea, fatigue, dizziness, and left ventricular dysfunction with an ejection fraction of more than 50 percent.

CONCLUSION OF LAW

The criteria are not met for a disability rating higher than 30 percent for service-connected IHD. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.104, Diagnostic Code 7005.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Air Force from September 1968 to November 1976. He is a recipient of the Air Force Commendation Medal and Vietnam Service Medal, among other awards and decorations.

These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2015 and June 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO).

Most recently, in April 2024, the Board remanded the Veteran's claims to obtain updated VA examinations reassessing the current severity of his service-connected IHD and skin condition. Regarding the Veteran's increasing rating claim for IHD, the examination report provides the necessary information, so the additional development directed to occur on remand has been accomplished. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, as will be discussed, additional development is necessary prior to adjudication of the Veteran's increased rating claim for a skin condition.

1. Entitlement to a disability rating higher than 30 percent for service-connected ischemic heart disease (IHD)

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability is considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.7 provides that, 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. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107; 38 C.F.R. § 4.3.

As alluded, to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). But where service connection already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed (even up to one year prior) until a final decision is made. Therefore, separate ratings can be assigned for separate periods of time based on the facts found a practice known as "staged" ratings. This practice is employed irrespective of whether an initial or established rating. Fenderson v. West, 12 Vet. App. 119 (1999) (initial rating); Hart
is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed (even up to one year prior) until a final decision is made. Therefore, separate ratings can be assigned for separate periods of time based on the facts found a practice known as "staged" ratings. This practice is employed irrespective of whether an initial or established rating. Fenderson v. West, 12 Vet. App. 119 (1999) (initial rating); Hart v. Mansfield, 21 Vet. App. 505 (2007) (established rating).

The Veteran's IHD is currently rated 30 percent disabling under the General Rating Formula for Diseases of the Heart, 38 C.F.R. § 4.104, Diagnostic Code 7005.

Effective November 14, 2021, VA amended the rating criteria for arteriosclerotic heart disease (coronary artery disease) under 38 C.F.R. § 4.104, Diagnostic Code 7005. 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 (AOJ) on or after November 14, 2021, such as the claim currently under appeal.

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 38 C.F.R. § 4.104, Diagnostic Code 7005, a 30 percent rating is warranted where a workload of greater than 5.0 METs but not greater than 7.0 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted where there is more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3.0 METs but not greater than 5.0 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 where there is chronic congestive heart failure, or; a workload of 3.0 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent.

Under the pre-amendment rating criteria, one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id.

For the purposes of a 60 percent evaluation, the pre-amendment rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380.

For the purposes of a 100 percent evaluation, the pre-amendment rating criteria do not
such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id.

For the purposes of a 100 percent evaluation, the pre-amendment rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382.

Effective November 14, 2021, under 38 C.F.R. § 4.104, Diagnostic Code 7005, IHD is rated in accordance with the General Rating Formula for Diseases of the Heart. A 30 percent rating is warranted where a workload of 5.1-7.0 METs results in heart failure symptoms, or where there is cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging). A 60 percent rating is warranted where a workload of 3.1-5.0 METs results in heart failure symptoms. A 100 percent rating is warranted where a workload of 3.0 METs or less results in heart failure symptoms.

Under the post-amendment rating criteria, one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms may be used. Id.

For purposes of the General Rating Formula for Diseases of the Heart, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. 38 C.F.R. § 4.104, Note (3).

During the pendency of this appeal, the principal medical evidence material to the Veteran's increased rating claim is contained in the reports of VA IHD examinations in May 2022 and May 2024, VA medical opinions obtained in January 2023, March 2023, and May 2024, as well as an October 2014 echocardiogram and a November 2014 Disability Benefits Questionnaire (DBQ) completed by a private nurse practitioner. The remainder of the medical treatment records contain no evidence materially inconsistent with the findings of those examinations as they relate to the severity of the Veteran's service-connected IHD.

The findings of the October 2014 echocardiogram showed that the Veteran required continuous medication, and demonstrated left ventricular dysfunction with an ejection fraction of 60 percent. Following a review of the evidence from the October 2014 echocardiogram, private nurse practitioner, A.C., also noted that the Veteran exhibited dyspnea and fatigue, with interview-based METs testing assessed at greater than 5, but less than 7 METs. See November 2014 A.C. DBQ.

Shortly thereafter, in his January 2015 notice of disagreement (NOD), the Veteran stated that he experienced shortness of breath, low stamina, and was easily fatigued. He subsequently testified at the August 2021 hearing that a few weeks prior to the hearing, his cardiologist wanted him to undergo a stress test on a treadmill, but, because he had not been vaccinated against COVID-19, the technicians would not allow him to do a treadmill test. Rather, a chemical stress test was recommended. The Veteran and his representative therefore argued that a chemical stress test did not provide a true assessment of the Veteran's cardiac disability and that his disability has worsened in severity over the prior years. As a result, the Board remanded his claim in December 2021 to obtain a thorough VA examination with a treadmill stress test to determine the severity of his service-connected IHD.

He subsequently underwent the requested VA examination in May 2022, at which time it was noted that the Veteran experienced fatigue and weakness
wanted him to undergo a stress test on a treadmill, but, because he had not been vaccinated against COVID-19, the technicians would not allow him to do a treadmill test. Rather, a chemical stress test was recommended. The Veteran and his representative therefore argued that a chemical stress test did not provide a true assessment of the Veteran's cardiac disability and that his disability has worsened in severity over the prior years. As a result, the Board remanded his claim in December 2021 to obtain a thorough VA examination with a treadmill stress test to determine the severity of his service-connected IHD.

He subsequently underwent the requested VA examination in May 2022, at which time it was noted that the Veteran experienced fatigue and weakness. He continued to require several medications to control his condition. The examination report reflects EKG with normal results, chest X-ray with normal results, and echocardiogram with normal results, with left ventricular dysfunction with an ejection fraction of 55 to 60 percent. The VA examiner documented that the Veteran's previous exercise stress test reflected his current cardiac condition, and conducted an interview-based METs test. During activity, the Veteran reported breathlessness, fatigue, and dizziness. For estimated METs level due solely to the cardiac condition, the examiner noted greater than 5, but less than 7 METs. The VA examiner noted that the Veteran became fatigued with minimal activities and had shortness of breath at the time of the examination. In response to the Board's remand directive requiring a treadmill test, the VA examiner clarified that one was not provided during the May 2022 VA examination because the facility did not have access to a treadmill. See March 2023 VA Addendum Medical Opinion.

In April 2024, the Board again remanded the Veteran's claim to provide him with a VA examination to determine the current severity of his IHD. The Board directed that if the Veteran was not able to undergo a treadmill stress test of his heart, the examiner should address the Veteran's assertions that other stress test methods do not provide as accurate depictions of the severity of a cardiac disability as the treadmill stress test, and explain the significance, if any, of the different methods of stress testing in arriving at accurate measurements of METs or ejection fraction.

The Veteran was provided with this VA examination in May 2024. During the examination, he reported becoming fatigued quickly with activity that was punctuated by frequent rest. The VA examiner noted that an earlier January 2024 chemical stress test was normal. Echocardiogram revealed cardiac hypertrophy and dilatation. The examiner opined that the Veteran's METs level limitation was due solely to his heart condition and interview-based METs testing revealed fatigue and greater than 5, but less than 7 METs.

The May 2024 VA examiner further explained that echocardiogram is the gold standard for evaluating cardiac function, contrary to the assertions of the Veteran and his representative. While exercise stress tests measure cardiac capacity for exercise by measuring threshold for ischemia, echocardiogram evaluates valves, wall motion, and wall thickness, and therefore measures all causes of valvular dysfunction including coronary artery disease, volume overload, and hypertrophy. It is therefore a more accurate representation of the severity of the Veteran's IHD.

In deciding this appeal, the Board has also considered the Veteran's lay statements in support of it. He is competent to report observations about the severity of his symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, and 1376-77 (Fed. Cir. 2007). The Board finds these lay statements to be credible and consistent with the ratings assigned. To the extent he argues his symptomatology is more severe, his statements must be weighed against the other evidence of the record, including the medical evidence. And, here, the specific examination findings of trained health care professionals and documented medical treatment records are of greater probative weight than the more general lay assertions that higher ratings are warranted. Some consideration of whether higher ratings are warranted involves using the results of objective clinical measurements so these determinations do not rely on mere subjective lay testimony alone.

Based upon the foregoing, the Board finds that the Veteran's currently assigned 30 percent disability rating is appropriate under both the old and new rating criteria. At no time during the period on appeal, has the Veteran demonstrated a workload of 3.1-5.0 METs resulting in heart failure symptoms, or one episode of acute congestive heart failure in the past year, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent that would warrant a 60 percent rating. Therefore, the Board finds that the claim for an increased rating higher than 30 percent
consideration of whether higher ratings are warranted involves using the results of objective clinical measurements so these determinations do not rely on mere subjective lay testimony alone.

Based upon the foregoing, the Board finds that the Veteran's currently assigned 30 percent disability rating is appropriate under both the old and new rating criteria. At no time during the period on appeal, has the Veteran demonstrated a workload of 3.1-5.0 METs resulting in heart failure symptoms, or one episode of acute congestive heart failure in the past year, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent that would warrant a 60 percent rating. Therefore, the Board finds that the claim for an increased rating higher than 30 percent for service-connected IHD must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7. This is not a situation where the evidence for versus against this claim is in "approximate" (meaning nearly equal) balance, i.e., relative equipoise, so there is no reasonable doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

REASONS FOR REMAND

1. Entitlement to a compensable disability rating for a service-connected skin condition, to include dermatitis and psoriasis, prior to May 5, 2022, and higher than 10 percent thereafter, is remanded.

Regarding the Veteran's claim for entitlement to a compensable disability rating for a service-connected skin condition prior to May 5, 2022, and higher than 10 percent thereafter, the Board finds that remand is warranted to obtain a VA examination. During the Veteran's most recent May 2022 VA examination, the examining clinician noted that the Veteran's dermatitis and psoriasis cause scarring, or disfigurement of the head, face, or neck. Although the examination itself directed, "If 'Yes', complete the Scars/Disfigurement DBQ," that referenced DBQ (examination) was not completed.

The Veteran's skin condition is currently rated under Diagnostic Code 7806. See 38 C.F.R. § § 4.118. The General Rating Formula for the Skin provides that a disability may be alternatively rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), or scars (Diagnostic Codes 7801-7805), depending on the predominant disability.

The Skin Diseases DBQ does not call for detailed evaluations of scarring, as it anticipates that the companion Scars/Disfigurement examination would be completed. The VA examiner was on notice that a Scars/Disfigurement examination was necessary but failed to complete one.

Without a comprehensive examination of the scars, the Board does not have sufficient evidence to determine whether the skin condition warrants a higher rating. Remand is therefore required.

The matter is REMANDED for the following action:

Schedule the Veteran for appropriate examination of the Veteran's scars related to his service-connected skin condition. The examination report should include a review of the Veteran's file and past clinical history, with particular attention to the severity of present symptomatology, as well as any significant pertinent interval medical history since his VA examination in May 2022. A Scars/Disfigurement DBQ should be completed.

The examiner should describe all symptomatology attributable to the Veteran's skin condition and determine whether the Veteran has associated facial and/or neck scarring, to include whether his skin condition manifests any of the eight characteristics of disfigurement. Specifically, to the extent possible the examiner should measure the scarring caused by his skin condition and indicate 1) whether the scars are superficial or deep (i.e., associated with underlying soft tissue damage); or 2) whether the scars are painful or unstable (i.e., demonstrating frequent loss of epidermal covering/skin over the scar), or tender to palpation.

The clinician is reminded that the Veteran is competent to report his pain. Layno v. Brown, 6 Vet. App. 465, 469 (1994).

Colleen M. Glaser-Allen

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Mukherjee, C.

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.

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