Citation Nr: 1020008 Decision Date: 06/01/10 Archive Date: 06/10/10 DOCKET NO. 07-05 504 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Whether new and material evidence has been received to reopen the Veteran's claim for service connection for idiopathic pulmonary fibrosis. 2. Entitlement to service connection for idiopathic pulmonary fibrosis, also claimed as lung scaring disease, to include as due to exposure to herbicides. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to April 1971. He served in the Republic of Vietnam from April 1970 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In September 2007, the Veteran and his spouse testified during a hearing before a Decision Review Officer (DRO) at the RO. A transcript of the hearing is of record. In October 2009, the Veteran twice submitted additional evidence, including the report of February 2009 surgery for a cardiopulmonary bypass for bilateral lung transplant, the report of a lung biopsy, a photograph of the type of helicopter the Veteran flew in Vietnam rigged for spraying Agent Orange, and a copy of an October 2009 letter from Dr. E.B.G. noting the possibility that the Veteran's exposure to dust and Agent Orange while a helicopter pilot in Vietnam might be factors, if not the primary factor, in the development of his lung disease. In two October 2009 briefs, the veteran's representative waived initial RO consideration of this new evidence. The Board accepts this additional evidence for inclusion in the record. See 38 C.F.R. § 20.800 (2009). In December 2009, the Board unsuccessfully attempted to obtain the opinion of an independent medical expert, but in view of the decision reached herein moving forward with the claim will not cause any prejudice to the Veteran. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A September 2004 rating decision, which denied service connection for idiopathic pulmonary fibrosis, is final. 2. The evidence associated with the claims file subsequent to the September 2004 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for idiopathic pulmonary fibrosis and raises a reasonable possibility of substantiating the claim. 3. The Veteran had active service in the Republic of Vietnam during the period from April 1970 to April 1971; exposure to Agent Orange is accordingly presumed. 4. Resolving all doubt in the Veteran's favor, idiopathic pulmonary fibrosis is likely related to service. CONCLUSIONS OF LAW 1. Evidence received since the final September 2004 rating decision, which denied service connection for idiopathic pulmonary fibrosis, is new and material and the Veteran's claim for that benefit is reopened. 38 U.S.C.A. §§ 5103, 5103A, 5104, 5107, 5108, 7105 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.104(a), 3.156, 3.159, 20.1103 (2009). 2. The criteria for service connection for idiopathic pulmonary fibrosis, also claimed as lung scaring disease, to include as due to exposure to herbicides, are met. 38 U.S.C.A. § 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). (CONTINUED ON NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA) are codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) and interpreted by the United States Court of Appeals for Veterans Claims (the Court). (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006)). Given the determinations reached in this decision, the Board is satisfied that adequate development has taken place and that there is a sound evidentiary basis for both reopening the Veteran's claim and resolution of this service connection claim for idiopathic pulmonary fibrosis at present without detriment to the due process rights of the Veteran. New and Material Evidence - Laws and Regulations The Veteran seeks service connection for idiopathic pulmonary fibrosis. The RO previously considered and denied a claim for idiopathic pulmonary fibrosis in a September 2004 rating decision. The Veteran did not timely appeal this decision and as such, it has become final. 38 U.S.C.A. § 7103(a); 38 C.F.R. §§ 20.302, 20.1103. The submission of "new and material" evidence is a jurisdictional prerequisite to the Board's review of such an attempt to reopen a claim. Absent the submission of evidence that is sufficient to reopen the claim, the Board's analysis must cease. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996); McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). Therefore, the Board will undertake a de novo review of the new and material evidence issue. As a general rule, a claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to a claim that is final. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. When a claimant seeks to reopen a final decision, the first inquiry is whether the evidence obtained after the last disallowance is "new and material." Under 38 C.F.R. § 3.156(a), new evidence means evidence not previously submitted to agency decision makers. Material evidence means 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 be neither 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. 38 C.F.R. § 3.156(a). Initially, it is noted that the evidence to be reviewed for sufficiency to reopen a claim is the evidence submitted since the most recent final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273 (1996). When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). In order for evidence to be sufficient to reopen a previously denied claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). Furthermore, "material evidence" could be "some new evidence [that] may well contribute to a more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability, even where it will not eventually convince the Board to alter its rating decision." Hodge v. West, 155 F. 3d 1356, 1363 (Fed. Cir. 1998). If it is determined that new and material evidence has been submitted, the claim must be reopened. The VA may then proceed to the merits of the claim on the basis of all of the evidence of record. Pulmonary Fibrosis The claim for service connection for idiopathic pulmonary fibrosis was initially denied in the September 2004 rating decision as there was no evidence any currently diagnosed pulmonary fibrosis was incurred in or caused by the Veteran's period of military service. At the time of the September 2004 rating decision the evidence of record consisted of service treatment records and private treatment records from Respiratory Services in Arizona, Cigna HealthCare of Arizona, Barnes Jewish Hospital in St. Louis, Washington University School of Medicine in St. Louis, and the Vanderbilt University Medical Center in Tennessee, all dated from 2001 to 2004. Subsequently associated with the claims file were: the Veteran's military personnel file; the September 2006 report of the Veteran's August 2006 VA Agent Orange Registry examination by Dr. J.W.W.; a September 2006 private letter from Dr. L.H.L.; various articles on pulmonary fibrosis reprinted off the Internet; approximately a dozen lay statements from the Veteran's brother and others; additional private medical records; VA outpatient treatment records dated in August 2006 and June 2007; the transcript of a RO hearing in September 2007; the reports of a VA examination in June 2008 and a VA medical opinion in July 2008; the December 2008 advisory medical opinion from the Chief of VA's Public Health and Environmental Hazards office; the report of an advisory opinion from the VA's Director of the Compensation and Pension Service dated in January 2009; an October 2009 private letter from Dr. E.B.G.; and copies of written submissions from the Veteran and his representative. The evidence submitted subsequent to the September 2004 rating decision is new, in that it was not previously of record and is also material. As noted above, the claim was initially denied as there was no medical evidence of a chronic pulmonary fibrosis disability related to the Veteran's period of active service. Subsequent to the final September 2004 decision, the September 2006 letter from the Agent Orange Registry examination indicated that results revealed Agent Orange caused pulmonary fibrosis and lung scarring disease; the June 2008 VA examiner found that the Veteran's pulmonary fibrosis was at least as likely as not caused by exposure to environmental dust, fumes and toxins the Veteran was exposed to during service; and the VA examiner opined later in July 2008 that he was unable to find another specific cause of the Veteran's pulmonary condition and the National Academy of Sciences lack of proof linking the condition to those factors did not exclude the possibility of what other environmental dust or toxins the Veteran could have been exposed to in an environment shown by photographic evidence to be extremely polluted. Presumed credible, the additional evidence received since the September 2004 rating decision reflects that the Veteran has been diagnosed with idiopathic pulmonary fibrosis linked to his period of active service in Vietnam. See Kent v. Nicholson, 20 Vet. App. 1, 10 (2006) (finding that "the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied"). Therefore, the evidence submitted since the final September 2004 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. Accordingly, the Board finds that the claim for service connection for idiopathic pulmonary fibrosis is reopened. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2009). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). Section 1116(a) of Title 38 provides presumptive service connection on the basis of herbicide exposure for specified diseases manifested to a degree of 10 percent within a specified period in a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. The following diseases are associated with herbicide exposure for the purposes of the presumption: chloracne or other acneform disease consistent with chloracne, Type II diabetes mellitus, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and certain soft- tissue sarcomas. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. § 3.309(e). It also provides presumptive service connection on the basis of herbicide exposure for each additional disease that the Secretary determines in regulations prescribed under this section warrants a presumption of service connection by reason of having a positive association with exposure to an herbicide agent, and that becomes manifest within the period (if any) prescribed in such regulations in a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. Whenever the Secretary determines, on the basis of sound medical and scientific evidence, that a positive association exists between (A) the exposure of humans to an herbicide agent, and (B) the occurrence of a disease in humans, the Secretary shall prescribe regulations providing that a presumption of service connection is warranted for that disease for the purposes of this section. 38 U.S.C.A. § 1116(b)(1). In making determinations for the purpose of this subsection, the Secretary shall take into account (A) reports received by the Secretary from the National Academy of Sciences under section 3 of the Agent Orange Act of 1991, and (B) all other sound medical and scientific information and analyses available to the Secretary. In evaluating any study for the purpose of making such determinations, the Secretary shall take into consideration whether the results are statistically significant, are capable of replication, and withstand peer review. 38 U.S.C.A. § 1116(b)(2). An association between the occurrence of a disease in humans and exposure to an herbicide agent shall be considered to be positive for the purposes of this section if the credible evidence for the association is equal to or outweighs the credible evidence against the association. 38 U.S.C.A. § 1116(b)(3). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has also held that when a claimed disorder is not included as a presumptive disorder direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Generally, in order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The Federal Circuit has held that a veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Factual Background and Analysis The issue before the Board is entitlement to service connection for idiopathic pulmonary fibrosis. Specifically, the Veteran alleges that his pulmonary fibrosis was caused by herbicides, dust, chemicals, fumes and other toxins which he was exposed to during his service in Vietnam from April 1970 until April 1971. As he served on land in Vietnam he is presumed to have been exposed to herbicidal agents. The Board notes that the service connection disability the Veteran seeks is not a condition recognized by VA to be presumptively linked to herbicidal agents; however, the Veteran still may be entitled to benefits if he can prove a direct link between his exposure to herbicides and his currently diagnosed condition. Service treatment records are negative for any treatment or diagnosis of pulmonary fibrosis or abnormalities of the lungs and chest but for a June 1970 record showing treatment for an upper respiratory infection with early otitis and bronchitis. The Veteran was diagnosed with pulmonary fibrosis in approximately September 2001. He underwent a bilateral lung transplant in February 2009 and a subsequent biopsy reflects a Grade A3, B0 cellular rejection of the transplant. Many of the records noted an unknown, or idiopathic, cause of the pulmonary fibrosis. Early records, such as a November 2001 private record from L.H.L., M.D., suggested the Veteran's severe gastroesophageal reflux might be causing the pulmonary problems. A June 2003 private record from A.M., M.D., noted a diagnosis of exclusion relating the Veteran likely had rheumatoid disease with pulmonary fibrosis. The Veteran underwent an examination for the Agent Orange Registry in August 2006. The September 2006 letter from the environmental physician indicated that results of the examination and laboratory tests revealed Agent Orange caused pulmonary fibrosis and lung scarring disease. No further rationale was provided for this conclusion. In a November 2006 signed statement, the Veteran related that he was a helicopter pilot in Vietnam whose main function was to fly logistics or supply and combat assaults. He said that he flew hundreds of sorties into heavily sprayed landing zones and also sprayed Agent Orange in Vietnam. Numerous Internet articles were attached to his statement indicating possible causes of idiopathic pulmonary interstitial fibrosis included exposure of inhaled environmental and occupational pollutants; rheumatoid arthritis and cigarette smoking also were noted as possible precursors of the disease. Nine lay statements received in November 2006 are found in the claims file and testify that the Veteran was very sick in 2001 and that he lost his job to the side effects of Interferon injections. A buddy statement from R.W.B. received in September 2007 revealed that he had flown with the Veteran on a near daily basis for 10 months in Vietnam as crew chief. He wrote that during the dry season and even at other times during landings and take-offs the dust was so severe that they almost always had a dangerous brown out situation. Long after the helicopter left the landing zone, the crew would still be coughing and choking from the dust for quite some time. He also testified that every area that they were sent into at some point in time before they arrived had been heavily sprayed with Agent Orange and other defoliants. The Veteran's brother submitted a statement in September 2007 that related the Veteran experienced shortness of breath in 1981 when he played racquetball and that the Veteran could not go on ski trips to Colorado due to the altitude. When they lived together in 1984 and both worked out at a gym, the Veteran had difficulty running after workouts due to shortness of breath and eventually stopped running at all. His brother wrote that the only difference in their backgrounds and environments was the Veteran's service in Vietnam. The Veteran was afforded a VA examination in June 2008 to specifically assess whether or not there was any relationship between the Veteran's current interstitial pulmonary fibrosis and exposure to herbicides, dust and toxic agents during service. The examiner reviewed the claims files, studies, and pulmonary function tests and examined the Veteran. He concluded that based upon his 21-year experience of caring for pulmonary fibrosis patients, an active involvement in research and updated information of published literature, the Veteran's pulmonary fibrosis was at least as likely as not caused by exposure to environmental dust, fumes and toxins. The examiner clarified it was not possible to say it was most likely caused by dust exposure because they have been unable to specifically identify the amount of dust exposure and specific chemicals or toxins that were involved during that one year in Vietnam. The examiner concluded there was a possibility that the pulmonary fibrosis was totally unrelated to service and could have happened even if he never went to Vietnam; however, in the Veteran's case, given the intensity, severity and frequency of exposure and the lack of protective device usage, the examiner felt it was at least as likely as not caused by the exposure. The RO requested an addendum to further develop the rationale for the opinion. In July 2008, the examiner indicated that it would be impossible to provide the exact names of the toxins or combinations of toxins the Veteran was exposed to nearly 40 years prior when no air sample or chemical analysis has been provided for review. The examiner further noted the Veteran denied post service exposure to toxins, fumes and dust and indicated he worked indoors in banking and finance. The examiner explained the claims file did not provide proof of the Veteran working in an environment that would expose him to chemicals or toxins. The examiner also indicated the Veteran went to service at age 18 or 19 and was in Vietnam for one year. He had medical documentation that he became short of breath about two years after returning from work. He indicated that the idiopathic pulmonary fibrosis or pulmonary fibrosis under discussion did not begin at such a young age, but rather was typical of patients in their 50s or 60s and increases as people age. The examiner indicated that with the onset of the illness at such a young age, it would be extremely unlikely to be called idiopathic pulmonary fibrosis. The examiner further noted he was unable to find another specific cause of the condition. The examiner noted that the National Academy of Sciences did not exclude the possibility of what other environmental dust or toxins the Veteran could have been exposed to in an environment that was shown by photographic evidence to be extremely polluted. The examiner also cited to objective evidence published in various literature, that the Veteran submitted in the claim, as supporting the possibility of a link. As there was no other likely explanation and the Veteran submitted documentation of the environment where he worked and the lack of protective devices to shield him from chemicals, it was the examiner's best opinion that the Veteran most likely developed pulmonary fibrosis due to exposure to unidentified toxins, chemicals and fumes that he was exposed to during service. The examiner noted there was not another external agent during the Veteran's lifetime with the same intensity or severity of exposure that could be identified from the medical records. Without resorting to speculation the examiner could not be more specific but he held that given the absence of other significant exposure history of toxins, fumes and gas the Veteran has more likely that not developed pulmonary fibrosis related to unidentified, unquantifiable and undetermined quantity of exposure to chemicals, dust and fumes that he was exposed to in Vietnam. Given the complexity of the case, the RO solicited an advisory opinion from the Director of Compensation and Pension Services. VA's Chief Public Health and Environmental Hazards Officer responded in December 2008. He indicated that even assuming the Veteran was exposed to herbicides used in Vietnam, including Agent Orange, or to the dioxin some were contaminated with, it would be difficult to ascribe the Veteran's pulmonary fibrosis to such exposure. The Chief Officer cited to the National Academy of Sciences (NAS) 2006 update "Veterans and Agent Orange" which concluded there was "inadequate or insufficient evidence to determine the association" between herbicide exposure and respiratory diseases. The evidence was drawn from scientific evidence available from occupational, environmental and Veteran studies in which subjects were exposed to herbicides and herbicide contaminants including dioxin. The Chief Officer indicated that VA gives a lot of weight to the NAS findings and, therefore, while it was possible that pulmonary fibrosis could be related to herbicide exposure, it could not be clearly stated that the likelihood met the legal standard required by VA of "at least as likely as not." The Chief Officer further noted that while it was likely a helicopter pilot would experience dust exposure as part of the job, there was no medical or scientific literature that he was aware of supporting a connection between the occupational exposures and the pulmonary fibrosis. VA's Director of Compensation and Pension provided an advisory opinion in January 2009. The Director also cited the NAS study that concluded there was inadequate or insufficient evidence to determine the association between herbicide exposure and respiratory disease. He explained that VA gave a lot of weight to NAS findings and, therefore, while it was possible there could be a relationship between pulmonary fibrosis and herbicides or other environmental exposure to dust, chemical fumes, and toxins, this did not meet the required legal standard of "at least as likely as not." The claims file also contains a record of the Veteran's private surgery in February 2009 for a cardiopulmonary bypass for bilateral lung transplant. It notes a diagnosis of end- stage lung disease secondary to pulmonary fibrosis with moderate pulmonary hypertension. In correspondence dated in October 2009, Dr. E.B.G. noted the possibility that the Veteran's exposure to dust and Agent Orange while a helicopter pilot in Vietnam might be factors, if not the primary factor, in the development of his lung disease. Based upon a review of all the evidence of record, the Board finds that the evidence is at an approximate balance and the appeal will be allowed. The Veteran's service records indicate that he served in Vietnam from April 1970 to April 1971, and received the Vietnam Service Medal and the Vietnam Campaign Medal among other service badges and medals. Thus, the Veteran is presumed to have been exposed to herbicide agents. See 38 C.F.R. § 3.307(a)(6)(iii). However, none of the medical evidence of record indicates that the Veteran has been diagnosed with any pulmonary or lung disorder subject to presumptive service connection on the basis of herbicide exposure. Pulmonary fibrosis is not listed among the diseases and conditions which the Secretary has approved for presumptive service connection based on exposure to Agent Orange. See 38 C.F.R. § 3.309(e). Without the presumption, a claimant can still establish service connection for disability due to Agent Orange exposure with proof of direct causation. Combee, 34 F.3d at 1042. With respect to whether service connection is warranted on a direct basis, the Board notes that the Veteran's service treatment records are negative for any care or treatment of pulmonary fibrosis. Post-service, there is no indication of a diagnosis of a pulmonary fibrosis disorder until approximately 2001. Records from Vanderbilt University Medical Center in 2001 and 2002 show a diagnosis of interstitial lung disease or pulmonary fibrosis. Subsequent medical records show idiopathic pulmonary fibrosis in February 2003. As noted above, the Veteran underwent a lung transplant in February 2009 with a preoperative and postoperative diagnosis of end-stage lung disease secondary to pulmonary fibrosis with moderate pulmonary hypertension. After reviewing the medical evidence of record, the Board finds that the preponderance of the evidence is, at the very least, in equipoise as to whether the Veteran's current idiopathic pulmonary fibrosis is the result of exposure to herbicides and other toxins during his service in Vietnam. The VA examiner provided a detailed rationale with specific facts from the Veteran's case including his age at the onset of symptoms, his work history, and the severity of exposure, including as exposure as depicted in photographic evidence. While the examiner has an impressive 21-year history in the field, he cited generally to "research" but did not provide any further clarification as to what current research he examined that would support his findings. On the other hand, two officials from VA cited the well-regarded National Academy of Sciences publication. Furthermore, as noted by the RO there has been no further discussion concerning the involvement of the rheumatoid arthritis or gastroesophageal reflux disease, which were initially cited as possible causes. There can be no doubt that further medical inquiry could be undertaken with a view towards additional development of the claim. However, the Board finds that the VA examiner's opinions in June 2008 and July 2008 are sufficient to provide proof of a nexus, or relationship, between the Veteran's currently diagnosed pulmonary fibrosis and his period of active service in Vietnam. Therefore, the Veteran has a medical opinion linking diagnosed pulmonary fibrosis to service. In addition, the Board notes that the VA examiner's opinions are buttressed by the written view of Dr. E.B.G. noted above. Under the law, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Thus, giving the Veteran the benefit of the doubt as the law requires, the Board finds service connection is warranted for the Veteran's idiopathic pulmonary fibrosis. As the Board finds that the Veteran has provided evidence of all three elements required for a grant of service connection for idiopathic pulmonary fibrosis, the claim for service connection for idiopathic pulmonary fibrosis is granted. ORDER Entitlement to service connection for idiopathic pulmonary fibrosis, also claimed as lung scaring, to include as due to exposure to herbicides, is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs