Citation Nr: 0531554 Decision Date: 11/21/05 Archive Date: 11/30/05 DOCKET NO. 03-05 145A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been received to reopen the previously denied claim for entitlement to service connection for a sinus condition, more recently alleged to be the result of exposure to Agent Orange or to asbestos. 2. Entitlement to service connection for coronary artery disease. 3. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 4. Entitlement to service connection for asthma. 5. Entitlement to service connection for chronic bronchitis. 6. Entitlement to an initial rating in excess of 30 percent for bilateral hearing loss. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Fetty, Counsel INTRODUCTION The veteran served on active duty from September 1968 to April 1970. This appeal arises before the Board of Veterans' Appeals (Board) from a rating decision rendered in July 2002 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Although the rating decision also included denial of service connection for skin cancer, the veteran did not include that issue in his substantive appeal. The Board will therefore not address the issue of entitlement to service connection for skin cancer. Since the final March 1981 Board decision that denied entitlement to service connection for sinusitis, the veteran has alleged that sinusitis was caused by exposure to either asbestos or Agent Orange. These are new theories of entitlement to a previously denied service connection claim. Where a new law establishes entitlement, a previously denied claim can become a new claim. Spencer v. Brown, 4 Vet. App. 283 (1993), aff'd 17 F.3d. 368 (Fed. Cir. 1994). However, because no new law establishes entitlement to service connection for sinusitis as a result of exposure to herbicide or to asbestos, these two new theories of entitlement do not amount to new claims. See also Ashford v. Brown, 10 Vet. App. 120, 123 (1997) ("notwithstanding the nomenclature and varied etiology attributed to his disability, [the appellant's lung condition], by any name, remains the same; it is 'inextricably intertwined' with his previous claim [for service connection] for a lung disorder"). Thus, new and material evidence will be required to reopen the claim; however, the issue has been recharacterized, as shown on page 1. See Spencer v. Brown, 4 Vet. App. 283 (1993), aff'd 17 F.3d. 368 (Fed. Cir. 1994). In August 2003 correspondence, the veteran indicated that he no longer wanted a hearing on appeal; thus, his hearing request is deemed withdrawn. 38 C.F.R. § 20.704 (2005). In an August 2004 decision, the Board reopened the veteran's claim seeking entitlement to service connection for bilateral hearing loss and remanded the issues of service connection for hearing loss, coronary artery disease, COPD, asthma, and chronic bronchitis in order to obtain additional evidence. In January 2005, the undersigned granted a motion for advancement on the docket for medical reasons. The veteran's claims for an initial higher rating for hearing loss and entitlement to service connection for asthma and for chronic bronchitis are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The VA has fulfilled its notice and duty to assist to the appellant by obtaining and fully developing all relevant evidence necessary for the equitable disposition of the issues addressed in this decision. 2. In a March 1981 decision, the Board denied entitlement to service connection for a sinus condition. 3. Evidence received since the March 1981 Board decision does not raise a reasonable possibility of substantiating the claim. 4. The veteran is presumed to have been exposed to herbicide agents while serving in the Republic of Vietnam during the Vietnam War era. 5. It is as likely as not that the veteran was exposed to asbestos in Vietnam. 6. Coronary artery disease arose many years after active military service. 7. Competent evidence of a link between coronary artery disease and active service or exposure to herbicide agents, or exposure to asbestos has not been submitted. 8. Competent evidence links COPD to asbestos exposure. CONCLUSIONS OF LAW 1. The March 1981 Board decision, which denied entitlement to service connection for a sinus condition, is final. 38 U.S.C.A. § 7104(b) (West 2002); 38 C.F.R. § 20.1100 (2005). 2. New and material evidence has not been received to warrant reopening the previously and finally denied service connection claim and the claim is not reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2005). 3. Coronary artery disease was not incurred during active service and may not be presumed to have been incurred in active military service. 38 U.S.C.A. §§ 1110, 1111, 1112, 5103, 5103A, 5107 (West 2002 & 2005); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2005). 4. Resolving all reasonable doubt in favor of the veteran, COPD was incurred during active service. 38 U.S.C.A. §§ 1110, 1111, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2005). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA redefined VA's duty to assist and enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp 2005); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)) (2005). Under the VCAA, VA has a duty to tell a claimant what evidence is needed to substantiate a claim, what evidence the claimant is responsible for obtaining and what evidence VA will undertake to obtain. 38 U.S.C.A. § 5103(a) (West 2002). VA has also undertaken to tell claimants to submit relevant evidence in their possession. 38 C.F.R. § 3.159(b) (2005). VA has made required efforts to notify the veteran of the information and evidence needed to substantiate his claims. The RO provided a rating decision, a statement of the case, and VCAA notice letters sent in July 2002 and August 2004. These documents provided notice of the law and governing regulations as well as the reasons for the determination made regarding his claims. They thereby served to tell him of the evidence needed to substantiate the claims. The VCAA letters also told the veteran what evidence he was responsible for obtaining, and what evidence VA would undertake to obtain. VA has met its duty to assist in obtaining any relevant evidence available to substantiate the claims. A VA examination report with nexus opinion is associated with the claims file. All identified evidence has been accounted for to the extent possible. 38 U.S.C.A. § 5103A(b)-(d) (West 2002 & Supp. 2005). The record shows that VA provided required notice prior to the initial adverse decision on his claim as stressed in Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). In Short Bear v. Nicholson, No. 03-2145 (U.S. Vet. App. Aug. 31, 2005), the Court determined that only VA's failure to point out what evidence is needed to substantiate the claim would be unfairly prejudicial to the veteran. New and Material Evidence In March 1981, the Board denied service connection for a sinus condition. In June 2002, the veteran essentially requested that the claim be reopened. As such, the application to reopen was received subsequent to August 29, 2001, the effective date of the amended version of 38 C.F.R. § 3.156(a). Therefore, the amended provisions apply. See 38 C.F.R. § 3.156(a) (2005). The pertinent evidence of file at the time of the March 1981 Board decision consists of service medical records (SMRs), service personnel documents, private medical records, the veteran's claims, and some lay witness statements, briefly summarized below. The SMRs reflect that the veteran was sound at entry and that he had not had a sinus complaint prior to active service. During active service in 1968, he first complained of sinus trouble, head colds, and headaches. These complaints continued in 1969 (the 1981 Board decision notes that these complaints are consistent with sinus disability). The SMRs include an April 1970 separation examination report; however, there is no report of medical history on which the veteran might have reported lingering sinus problems. The veteran's DD Form 214 reflects that he served in the Marine Corps as a mortar man receiving the Vietnam Service Medal (VSM) with device and the Vietnam Campaign Medal (VCM) with device. In March 1980, the veteran requested service connection for sinus problems and reported that the disorder began in 1969. In May 1980, George Sands, D.O., report having treated the veteran for sinusitis at various times from 1977 to 1980. In September 1980, various lay witnesses indicated that the veteran had a sinus problem after returning from Vietnam. Based on this evidence, the Board found that no competent evidence linked a current sinus disorder with sinus complaints during active service. Unless the Chairman of the Board orders reconsideration, all decisions of the Board are final on the date stamped on the face of the decision. 38 C.F.R. § 20.1100; see also 38 U.S.C.A. § 7103(a); Hayslip v. Principi, 364 F.3d 1321, 1326 (Fed. Cir. 2004). Because the Chairman did not order reconsideration of the Board's March 1981 decision, it is final. With respect to a claim that has been finally disallowed, the law and regulations provide that if new and material evidence has been presented or secured, the claim may be reopened and the former disposition reviewed. 38 U.S.C.A. § 5108. Pursuant to 38 C.F.R. § 3.156(a) (2005): A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can neither be cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. In determining whether the evidence is new and material, the credibility of the newly presented evidence is presumed. Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curiam) (holding that the "presumption of credibility" doctrine continues to be binding precedent). The Board is required to consider all of the evidence received since the last disallowance, in this case, since the Board decision dated in March 1981. Hickson v. West, 12 Vet. App. 247, 251 (1999). The evidence received by VA since the Board's March 1981 decision includes a June 1997 VA general medical examination report, an October 2004 VA medical opinion, private medical records, additional service records, photographs taken in Vietnam, lay witness statements, and statements of the veteran. Some of the medical evidence, both VA and private, addresses the presence or absence of a current sinus disorder. While private records dated in 1997 show treatment for recurrent sinusitis, a June 1997 VA general medical examination report reflects no current sinus problem. More recently dated VA outpatient treatment reports do reflect sinusitis. Because none of these medical reports tends to link sinusitis with active service, however, they do not raise a reasonable possibility of substantiating the claim. Therefore, this evidence is not new and material evidence. In October 2004, a VA physician reviewed the claims files, examined the veteran's sinuses, and determined that it is "less likely" that current sinusitis is related to active service, including claimed asbestos exposure. Because the medical opinion does not tend to link sinusitis with active service, it does not raise a reasonable possibility of substantiating the claim. Therefore, this evidence is not new and material evidence. The additional service personnel records reflect such information as dates and locations of the veteran's various military assignments. Because the veteran's DD Form 214, which was previously considered, reflects service in Vietnam, the additional information concerning his assignments is merely cumulative. Moreover, because none of this evidence tends to link sinusitis with active service, it does not raise a reasonable possibility of substantiating the claim. Therefore, this evidence is not new and material evidence. Photos were submitted that allegedly show asbestos exposure in Vietnam. These do not tend to support service connection for sinusitis, because the October 2004 VA physician determine it "less likely" that any current sinusitis is related to asbestos. The photos are not new and material evidence because they do not raise a reasonable possibility of substantiating the claim. Lay witnesses have reported that the veteran had obvious sinus problems after he returned from Vietnam. Because this evidence is cumulative of earlier considered lay witness statements, it is not new and material. The veteran himself has continued to claim that sinusitis began in active service. This evidence is also cumulative of earlier considered evidence and cannot therefore be new and material evidence. The veteran has claimed that exposure to herbicides might have caused sinusitis. Because he served in Vietnam during 1968 and 1969, VA will assume that he was exposed to an herbicide, such as Agent Orange. He has not submitted any competent evidence tending to relate sinusitis to herbicide exposure, however, and VA regulation has not provided for presumptive service connection for sinusitis. See 38 C.F.R. § 3.309(e). Thus, alleging that an herbicide caused sinusitis does not by itself raise a reasonable possibility of substantiating the claim. Therefore, this new contention is not new and material evidence. Finally, the veteran has claimed that sinusitis is the result of exposure to asbestos. Even assuming arguendo that he was exposed to asbestos during active service (as required by Justus, supra), the October 2004 VA medical opinion found asbestos "less likely" to have caused sinusitis. He has not submitted any competent evidence tending to relate sinusitis to asbestos exposure. Thus, claiming that asbestos exposure caused sinusitis does not raise a reasonable possibility of substantiating the claim where there is competent medical evidence to the contrary. Therefore, even if asbestos exposure is conceded, is not new and material evidence because it does not raise a reasonable possibility of substantiating the claim. Because none of the evidence submitted since March 1981 raises a reasonable possibility of substantiating the claim, it is not new and material evidence. The Board therefore must deny the application to reopen a claim of entitlement to service connection for a sinus condition. Service Connection Background The veteran's SMRs reflect complaint of colds and respiratory disorders at various times. A reddened pharynx was noted in December 1968, but the chest was clear. The ears, nose, and throat were within normal limits in January 1969, although the veteran complained of a headache, cough, and sore throat for two weeks. A separation examination report is negative for any claimed disorder. No report of medical history accompanies the separation medical examination report, however. A 1997 VA general medical examination report contains a diagnosis of arteriosclerotic heart disease. In June 2002, the veteran claimed entitlement to service connection for two heart attacks, asthma, and chronic bronchitis. He reported that chronic bronchitis began in January 1995, that heart attacks occurred in August 1996 and July 1997, and that asthma began in March 1998. In his application for service connection, he reported that he was exposed to herbicides and that he was not exposed to asbestos or to radiation. He believed that his health problems had been caused by exposure to Agent Orange. The veteran has submitted numerous private treatment reports reflecting coronary artery disease and myocardial infarction in the later 1990s. The RO has obtained VA outpatient treatment report showing treatment for various health problems at various times during the 1990s. In July 2002, the veteran submitted personnel records reflecting that he served in Vietnam from approximately May 26, 1969, to March 25, 1970. He served as a mortar man and as a guard. He received familiarization training with the M- 16 and M-60 on August 26, 1969, at Chu Lai. He was promoted to Lance Corporal on November 13, 1969. In his September 2002 notice of disagreement, the veteran reported that he was exposed to asbestos in the building in which he lived while in Vietnam. He submitted a photo of a building. In January 2003, the RO sent the veteran a letter requesting that he provide more information concerning asbestos exposure. The veteran replied, stating that he was exposed at Chu Lai, Vietnam. He reported that asbestos was found in various buildings there, including his residence. He recalled seeing asbestos dust that appeared to sparkle. In his reply, the veteran also reported that after active service, he worked as a tree surgeon and then as a seafood worker. He claimed that asbestos might be related to coronary artery disease, to COPD, to asthma, and to bronchitis. He said that he first received treatment for these disorders after active service, but that the private physician who provided that treatment had passed away and no record was available. He stated that more recent private medical records are the only relevant private records that exist. He submitted photos of various buildings at Chu Lai and a hand-drawn sketch of Chu Lai Air Base. He reported that at least 100 hootches (hutches) at Chu Lai had been constructed with asbestos. The veteran submitted private medical reports that reflect treatment for bronchitis and other claimed conditions in the early 2000s. None of these reports tends to relate any claimed condition to active service or to asbestos or an herbicide agent. After obtaining additional VA outpatient treatment reports (which do not tend to relate a claimed condition to active service, to asbestos, or to a herbicide agent), in March 2003 the RO denied entitlement to service connection for coronary artery disease, COPD, asthma, chronic bronchitis, and for a sinus condition, claimed due to asbestos. In August 2004, the Board remanded the case to the AMC for a VA examination. Following the remand, the AMC received additional VA outpatient treatment reports that do not tend to link any claimed disorder to active military service. The veteran underwent VA examination in October 2004. The physician reviewed the claims files and noted that coronary artery disease arose in the 1990s, long after active military service. Likewise, COPD arose in the early 1990s. The veteran quit tobacco in 1997. The veteran reported chronic coughing with yellow phlegm. The physician noted that it would be difficult to ascertain whether the phlegm came from the lungs, or from the sinuses. Likewise, shortness of breath and dyspnea on exertion could be due to congestive heart failure, or to COPD. X-rays showed "chronic changes in the lower lung fields that are not further described in the report." Concerning respiratory symptoms, the physician opined as follows: It is as likely as not that the patient's active service exposure to asbestos can be causing some of his respiratory symptoms as asbestos is known to cause interstitial lung disease and the patient does have some impairment of his diffusing capacity of lung for carbon monoxide and restrictive airflow disease in his PFTs. Concerning coronary artery disease, the physician concluded: Patient currently exhibits Class III New York Heart Association heart failure symptoms and Class II to III angina. The patient had ischemic cardiomyopathy with ejection fraction of approximately 20 percent. It is less likely that the patient's cardiac condition is as a result of his active service-related exposure to asbestos. Again, it is difficult to ascertain whether patient's limitation in his activity are due to cardiac or his pulmonary condition. Analysis Exposure to herbicides According to 38 C.F.R. § 3.307 (a) (6) (iii), a veteran who served in Vietnam during the requisite period shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that period. Thus, exposure to herbicides must be presumed, because there is no affirmative evidence to the contrary. Exposure to asbestos The veteran has alleged exposure to asbestos during service in Vietnam. He has also claimed that he had no pre-service or post-service exposure to asbestos. There is no specific regulation concerning the development of a case where there is alleged exposure to asbestos, nor is there any presumption available to the veteran. However, the United States Court of Appeals for Veterans Claims (CAVC) has noted that the Board must follow certain steps in adjudicating asbestos cases, including determining whether exposure has occurred. In McGinty v. Brown, 4 Vet. App. 428, 432-33 (1993), the CAVC vacated and remanded a Board decision which had not addressed relevant considerations included in a VA circular on asbestos-related diseases. Similarly, in Ennis v. Brown, 4 Vet. App. 523, 527 (1993), the CAVC vacated and remanded a Board decision which had failed to analyze an asbestos- related claim in light of considerations discussed in Department of Veterans Benefits (DVB) Circular 21-88-8. See also Nolen v. West, 12 Vet. App. 347, 351 (1999); VAOPGCPREC 6-2000. However, the Board notes that DVB 21-88-8 was rescinded by VBA Manual M21-1, Part VI, Change 3, September 21, 1992 and its provision are incorporated into VBA Manual M21-1, Part VI. Paragraph 7.21a of VBA Manual M21-1, Part VI, provides that asbestos fibers, when inhaled or swallowed, can produce fibrosis and tumors of the larynx, pharynx, lungs, gastrointestinal tract, and urogenital system. They can produce pleural effusions and pleural plaques. Persons with asbestos exposure have increased incidence of bronchial, lung, pharyngolaryngeal, gastrointestinal, and urogenital cancer. The risk of bronchial cancer is increased in current cigarette smokers who have asbestos exposure. About 50 percent of those with asbestosis will eventually develop lung cancer. Paragraph 7.21b of VBA Manual M21-1, Part VI, provides that certain occupations such as work in shipyards, insulation work, demolition of old buildings, and installation of military equipment involve exposure to asbestos. Significantly, the latent period between exposure and the development of disease varies from 10 to 45 or more years, and significant exposure may occur in as brief a period as a month or two, even for an indirect bystander. Paragraph 7.21c of VBA Manual M21-1, Part VI, provides that a clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Symptoms and signs might include dyspnea on exertion, rales over the lower lobes, pulmonary function test impairment, and emphysema. Paragraph 7.21d.(1) of VBA Manual M21-1, Part VI, provides: When considering VA compensation claims, rating specialists must determine whether or not military records demonstrate evidence of asbestos exposure in service. Rating specialists must also assure that development is accomplished to determine whether or not there is preservice and/or post- service evidence of occupational or other asbestos exposure. A determination must then be made as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information noted above. VAOPGCPREC 4-2000 includes the following guidance: The determinative issues in an asbestos-related claim would generally include a medical diagnosis and medical causation. For example, the asbestos- related diseases referenced in paragraph 7.21 of VBA Manual M21-1, Part VI, such as asbestosis, pleural effusions and fibrosis, pleural plaques, and mesothelioma of pleura or peritoneum, must first be medically diagnosed and then shown to be medically related to in-service exposure to asbestos. See Nolen, 12 Vet. App. at 351 (finding no medical-nexus evidence between the veteran's asbestosis and his service exposure). Therefore, although a claimant may provide competent evidence of a current disability and of in-service exposure to asbestos, the claimant would still need to present competent medical evidence of a nexus relating the current disability to in-service exposure to asbestos. Id. As set forth above, the first sentence in paragraph 7.21d. (1) requires a determination as to "whether or not military records demonstrate evidence of asbestos exposure in service." In the present case, military records do not demonstrate evidence of asbestos exposure. The fact that the veteran served in Vietnam, where perhaps asbestos was used in construction, is simply an assertion of the veteran. However, as noted above, in VAOPGCPREC 4-2000, VA's General Counsel suggested that a claimant may provide competent evidence of in-service exposure to asbestos. Thus, the Board will resolve any remaining doubt in favor of the veteran and find that the veteran has provided competent evidence of exposure to asbestos. Analysis Service connection will be awarded for disability resulting from injury or disease incurred in or aggravated by active service (wartime or peacetime). 38 U.S.C.A. §§ 1110; 1131; 38 C.F.R. § 3.303(a). "Direct" service connection may be established for a current disability when the evidence shows affirmatively that the disability resulted from injury or disease incurred (or aggravated) during active service. Id. "Direct" service connection may be granted for any disease not diagnosed initially until after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Each disabling condition shown by SMRs, or for which the veteran seeks service connection, must be considered on the basis of the places, types, and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence. 38 C.F.R. § 3.303(a). There is no requirement that a disorder must be "chronic" as a condition precedent to direct service connection under 38 C.F.R. § 3.303; however, "chronic diseases" as defined at 38 C.F.R. § 3.307 and 3.309 are accorded special consideration for service connection. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and certain chronic diseases, such as cardiovascular-renal disease (including involvement of arteriosclerosis and organic heart disease), become manifest to a degree of 10 percent within one year from the date of termination of such service, such diseases shall be presumed to have been incurred in service, even though there is no evidence of such diseases during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Once the evidence has been assembled, the Board assesses the credibility and weight to be given to the evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) and cases cited therein. When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the CAVC held that a veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Coronary Artery Disease In this case, coronary artery disease arose decades after active service, according to clinical records. There is no competent medical evidence tending to relate coronary artery disease to active service or to exposure to herbicides or asbestos. None of VA's guidance discussed above mentions that asbestos carries an increased risk of coronary artery disease. Moreover, coronary artery disease is not a disease for which presumptive service connection is available for exposure to herbicides. The sole medical opinion addressing the etiology of the veteran's coronary artery disease argues against service connection. Where the determinative issue involves a question of causation, as here, only individuals possessing specialized training and knowledge are competent to render an opinion. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The veteran does not possess any specialized training and it is not contended otherwise. Thus, any claim he may have made regarding the cause of coronary artery disease cannot be afforded any weight. After considering all the evidence of record, the Board finds that the preponderance of the evidence it is against the claim of service connection for coronary artery disease. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107 (West 2002); Gilbert, supra. The claim of entitlement to service connection for coronary artery disease is therefore denied. COPD In its August 2004 REMAND, the Board asked the physician to determine the nature, extent, and etiology of any manifested respiratory disability, to include COPD, asthma, and chronic bronchitis. The Board also asked the physician to provide diagnoses for any manifested respiratory pathologies identified, and to provide an opinion concerning the etiology of any such disorder. Reviewing the October 2004 compensation and pension examination report, it appears that the physician has specifically addressed only one respiratory ailment, COPD, as manifested by mild obstructive airflow disease measured on spirometry. Neither asthma or chronic bronchitis are mentioned, except as reported history supplied by the veteran. Concerning the etiology of COPD, however, the VA physician gave an "at least as likely as not" nexus opinion. Because there is no medical evidence to controvert this opinion, the Board finds that this opinion is sufficient to place the evidence in at least relative equipoise on this issue. Giving the veteran the benefit of the doubt, the Board will grant entitlement to service connection for COPD. ORDER New and material evidence not having been received, the claim of entitlement to service connection for a sinus condition is denied. Service connection for coronary artery disease is denied. Service connection for COPD is granted. REMAND In a June 2005 decision, VA's Appeals Management Center (AMC) granted service connection for bilateral hearing loss and assigned a 30 percent rating. In July 2005, the veteran submitted a notice of disagreement (NOD) with the 30 percent rating. A statement of the case (SOC) was not issued on this claim. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). This issue will be returned to the Board after issuance of the SOC only if perfected by the filing of a timely substantive appeal. According to 38 C.F.R. § 4.2, if a report does not contain sufficient detail, it must be returned as inadequate for evaluation purposes. In its August 2004 REMAND, the Board asked the physician to determine the nature, extent, and etiology of any manifested respiratory disability, to include COPD, asthma, and chronic bronchitis. The October 2004 examination report focuses on one respiratory disorder only, that of COPD, and mentions only a history of asthma and chronic bronchitis. It is unclear whether asthma and/or bronchitis are currently shown. Thus, clarification of the diagnosis is requested. Accordingly, further appellate consideration will be deferred and the case is REMANDED for the following: 1. Return the October 2004 examination report and the claims files to the examiner. If that physician is not available, a qualified substitute may be used. The physician is asked to clarify whether the current diagnosis includes either asthma or bronchitis. If the answer is yes, the physician is asked to offer an opinion addressing whether it is at least as likely as not (50 percent or greater probability) that asthma and/or bronchitis is/are related to exposure to asbestos during active service. The veteran may be re-examined if necessary. The physician should offer a complete rationale for any conclusion in a legible report. If any question cannot be answered, the physician should state the reason. 2. After the development requested above has been completed to the extent possible, the AMC should readjudicate the claim for service connection for asthma and bronchitis. If the benefits sought remain denied, the veteran and his representative should be furnished a supplemental statement of the case and given an opportunity to respond. 3. The AMC should provide the veteran a statement of the case as to the issue of entitlement to a higher initial rating for bilateral hearing loss. The veteran should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of this issue to the Board. 38 C.F.R. §§ 20.200, 20.202, and 20.302(b). If a timely substantive appeal is not filed, the claim should not be certified to the Board. If so, subject to current procedures, the case should be returned to the Board for further consideration, if appropriate. The veteran need take no further action until he is so informed. He has the right to submit additional evidence and argument on the matter that the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2005). ______________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs