Citation Nr: 1323112 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 10-46 171 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to a disability rating in excess of 30 percent for service-connected bronchiectasis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from November 1955 to April 1956 and from March 1959 to March 1963. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Veteran testified before the undersigned Veterans Law Judge at a March 2012 videoconference hearing, and a transcript of this hearing is of record. In April 2012, the Veteran submitted additional evidence, but waived RO review. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The record does not demonstrate that the Veteran's bronchiectasis results in incapacitating episodes of infection of four to six weeks total duration per year, or near continuous findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis requiring almost continuous antibiotic use. 2. The Veteran's severe obstructive ventilatory impairment on pulmonary function tests is more likely than not related to his extensive smoking history and possible occupational exposure to respiratory irritants, rather than his service-connected bronchiectasis or right middle lobe lobectomy. CONCLUSION OF LAW The criteria for entitlement to a disability rating in excess of 30 percent for service-connected bronchiectasis have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. § 4.1, 4.2, 4.7, 4.10, 4.97, Diagnostic Codes 6600-660, 6844 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R., Part 4 (2012). 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 must be 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. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then-current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. The Veteran's service-connected bronchiectasis is current rated as 30 percent disabling under Diagnostic Code 6601, which rates bronchiectasis. He asserts that his disability is more severe than reflected by the current assigned 30 percent evaluation. Additionally, the Veteran contends that he should be rated under Diagnostic Code 6844 or 6845 for residuals of a January 1957 right middle lobe lobectomy he underwent to treat his bronchiectasis. Diagnostic Code 6601 states that a 10 percent rating is warranted for symptoms of an intermittent productive cough with acute infection requiring a course of antibiotics at least twice a year. A 30 percent rating is warranted for incapacitating episodes of infection of two to four weeks total duration per year, or daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year. A 60 percent rating is warranted for incapacitating episodes of infection of four to six weeks total duration per year, or near continuous findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis requiring antibiotic use almost continuously. Incapacitating episodes are defined as episodes requiring bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Code 6601. Diagnostic Code 6601 also provides that bronchiectasis may be rated according to pulmonary impairment, as for chronic bronchitis, under Diagnostic Code 6600. Under this diagnostic code, a 10 percent rating is warranted if the Forced Expiratory Volume in one second (FEV-1) is 71 to 80 percent of predicted value, the ratio of FEV-1/Forced Vital Capacity (FVC) is 71 to 80 percent, or Diffusion Capacity of the Lung for Carbon Monoxide by Single Breath Method [DLCO (SB)] is 66 to 80 percent predicted. A 30 percent rating is warranted if FEV-1 is 56 to 70 percent of predicted value, or FEV-1/FVC is 56 to 70 percent, or if DLCO (SB) is 56 to 65 percent predicted. A 60 percent rating is warranted if FEV-1 is 40- to 55-percent predicted, when FEV-1/FVC is 40 to 55 percent, when DLCO (SB) of 40- to 55-percent predicted, or when there is maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent disability rating is warranted if FEV-1 is less than 40 percent of predicted value, FEV-1/FVC is less than 40 percent, DLCO (SB) is less than 40-percent predicted, maximum exercise capacity is less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by Echo or cardiac catheterization,), episode(s) of acute respiratory failure, requires outpatient oxygen therapy. The rating criteria for Diagnostic Code 6604, for chronic obstructive pulmonary disease; for Diagnostic Code 6844, for post-surgical residuals; and Diagnostic Code 6845, for chronic pleural effusion or fibrosis are identical to those of Diagnostic Code 6600. 38 C.F.R. § 4.97. VA evaluates pulmonary function test (PFT) results based on post-bronchodilation results. See 61 Fed. Reg. 46720 (Sept. 5, 1996). In so deciding, VA noted that The American Lung Association /American Thoracic Society Component Committee on Disability Criteria has recommended testing for pulmonary function after optimum therapy based upon reasoning that the results of such tests reflect the best possible functioning of an individual and were the figures used as the standard basis of comparison of pulmonary function. It was also noted that using post-bronchodilation results would assure consistent evaluations. Id. at 46,723. When PFTs are not consistent with clinical findings, evaluation should generally be based on the PFTs. Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes with some exceptions; when evaluating based on PFTs. Post-bronchodilator results are to be used unless they are poorer than the pre-bronchodilator results; then the pre-bronchodilator values should be used for rating purposes. When the results of different PFTs (FEV-1, FVC, etc.) are disparate, the test result that the examiner states most accurately reflects the level of disability should be used for evaluation, and if the FEV-1 and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV-1/FVC ratio should not be assigned. See 71 Fed. Reg. 52457-10 (Sept. 6, 2006). The Veteran was originally granted entitlement to service connection for bronchiectasis in a May 1977 Board decision and was assigned an initial 30 percent disability rating under Diagnostic Code 6601. He filed his current increased rating claim in July 2009. As part of his claim, the Veteran submitted PFT results from Lake Hospital System dated March 2009. These tests showed that FVC was mildly reduced and FEV1 and FEV1/FVC were severely reduced. The Veteran was diagnosed with severe obstructive lung disease with significant air trapping demonstrating incomplete lung volumes. He was suspected to be suffering from a fixed obstructive lung disease process, such as chronic bronchitis or emphysema. A June 2009 chest x-ray from Lake Hospital System showed mild bronchiectasis, post-inflammatory scarring of the right lower lobes, chronic obstructive lung disease, and a 9mm non-calcified module in the right lower lobe. The Veteran was afforded a VA examination in August 2009. The Veteran reported that he was first diagnosed with bronchiectasis in 1957 and underwent a right middle lobectomy. He also reported being hospitalized six or seven years ago, but did not know his diagnosis. The Veteran complained of dyspnea on exertion and "off and on" cough productive of yellowish mucus. He denied fever, chills, drenching night sweats, weight loss, gas, or hemoptysis. He reported no history of pulmonary embolism, respiratory failure, or chronic pulmonary embolism. On physical examination, there was no evidence of pulmonary hypertension, right ventricular hypertrophy, cor pulmonale, or CHF. The Veteran had a high-pitched rhonchi in the left lung. The right lung was without rales or rhonchi. An August 2009 chest x-ray showed chronic obstructive pulmonary disease (COPD) with evidence of acute pulmonary process and mild cardiomegaly. The Veteran was diagnosed with severe COPD, status post right middle lobectomy for bronchiectasis. VA outpatient treatment records show that the Veteran had a long history of tobacco abuse, with the Veteran reporting a forty year history of smoking a pack a day. He reported that he continued to smoke approximately half a pack a day. A November 2010 PFT showed FEV-1 of 39 percent predicted and FEV1/FVC of 62 percent predicted. In June 2011, the Veteran was afforded another VA examination. The Veteran reported that post-service, he worked in a factory as a machinist, with no personal protective equipment. The examiner noted that the Veteran's claims file included notations that the Veteran smoked a pack and a half a day for forty years, but that the Veteran verbally reported smoking one pack per day for forty years. The Veteran denied fever except when ill or hemoptysis. He reported daytime fatigue, clear sputum with a cough on a regular basis, but no purulent sputum requiring prolonged antibiotic treatment. On examination, the Veteran's lungs were clear to auscultate bilaterally, without audible wheezes, rales, or rhonchi. He had a well-healed right thoracotomy scar. There was no evidence of pulmonary hypertension, right ventricular hypertrophy, cor pulmonale, or CHF. The Veteran had no history of pulmonary embolism or respiratory failure. A chest x-ray showed heart size within normal limits with a cardiac pacemaker present. There was marked hyperexpansion of the lungs, but no acute infiltrate, mass, or pleural effusion. A pulmonary function test showed FEV-1 36 percent predicted and FEV-1/FVC 61 percent predicted. The Veteran was diagnosed with severe COPD and bronchiectasis, status post right middle lobectomy. In a July 2011 addendum, the VA examiner noted that there is no documentation of further episodes of bronchiectasis, no prolonged antibiotic treatments, no use of expectorants, no postural/bronchial drainage procedures, and no further surgery. She opined that due to the Veteran's extensive smoking history and possible occupational exposure to respiratory irritants, the severe obstructive ventilatory impairment noted on the pulmonary function tests is more likely than not related to those factors, rather than his remote history of bronchiectasis and lung resection. However, she noted that impossible to determine without resorting to speculation exactly how much impairment is caused by his multiple pulmonary disabilities. In August 2011, the Veteran submitted a written statement in which he argued the his obstructive lung disease was due to his service-connected bronchiectasis and reduced lung capacity due to his right middle lobe resection. This letter was signed by T.D., a respiratory therapist, who indicated that the Veteran's statements were consistent with his professional opinion. However, it is unclear whether T.D. has ever actually treated the Veteran or even reviewed his medical records before rendering his "opinion." It appears that the only documents he has reviewed are the VA examination reports, the rating decision, the statement of the case, and the supplemental statement of the case. In November 2011, the Veteran was hospitalized at Hillcrest Hospital for an exacerbation of COPD. His diagnoses included chronic obstructive pulmonary disease exacerbation, primary emphysematous lung disease, and history of bronchiectasis with resection of the right middle lobe. PFT administered during his hospitalization were consistent with previous findings. In March 2012, the Veteran testified at a videoconference hearing, the Veteran claimed that he requires multiple medications to treat his lung disease, including Prednisone and oxygen therapy. Based on all the above evidence, the Board finds that entitlement to a disability rating in excess of 30 percent cannot be awarded under Diagnostic Code 6601. There is no evidence of record that the Veteran's service-connected bronchiectasis results in incapacitating episodes of infection of more than four weeks total duration or near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously. Ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 cannot be combined with each other. See 38 C.F.R. § 4.96 (a). Therefore, the Veteran cannot be awarded a separate disability rating under another diagnostic code, such as Diagnostic Code 6844, which rates post-surgical residuals. However, the Board has considered whether rating the Veteran under a diagnostic code other than Diagnostic Code 6601 could afford the Veteran a higher disability rating. Multiple pulmonary function tests during the period on appeal show that the Veteran's FEV-1 is less than 40 percent. Under Diagnostic Code 6844, the Veteran could be assigned a total disability rating based, if the these test results can be attributed to the Veteran's service-connected disability. However, in July 2011, a VA examiner determined that it is more likely than not that the Veteran's severe obstructive ventilatory impairment is due to his extensive smoking history, as well possible occupational exposure to respiratory irritants. While the Board has considered that T.D., a respiratory therapist, has endorsed the Veteran's claim that his current respiratory problems are due to his service-connected disability, the Board finds that this opinion has limited probative value. In cases such as this, where there are conflicting statements or opinions from medical professionals, it is within the Board's province to weigh the probative value of those opinions. In Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the U.S. Court of Appeals for Veterans Claims (Court) stated: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . . So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Greater weight may be placed on one examiner's opinion over another depending on factors such as reasoning employed by the examiners and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, the thoroughness and detail of a medical opinion are among the factors for assessing the probative value of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, it appears that T.D. reviewed only a very limited number of records before offering his support for the Veteran's claim and did not review the Veteran's claims folder or medical records. The Board finds that this failure significantly undermines the probative value of any opinion offered by T.D. since these records are relevant to the Veteran's claim. The Board notes that in July 1977, around the time the Veteran was granted service connection for bronchiectasis, PFT results showed only minimal airway obstruction. Additionally, a June 2009 chest x-ray showed mild bronchiectasis. As the July 2011 VA medical opinion is based on a review of all the evidence of record and is most consistent with the evidence of record, the Boards finds that it has greater probative value the any opinion offered by T.D.. Furthermore, to the extent that the Veteran himself has offered an opinion concerning the etiology of his current respiratory problems, he has not demonstrated that he has any knowledge or training in determining the etiology of such conditions. In other words, he is a layman, not a medical expert. The Board recognizes that there is no bright line rule that laypersons are not competent to offer etiology opinions. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (rejecting the view that competent medical evidence is necessarily required when the determinative issue is medical diagnosis or etiology). Evidence, however, must be competent evidence in order to be weighed by the Board. Whether a layperson is competent to provide an opinion as to the etiology of a condition depends on the facts of the particular case. In Davidson, the Federal Circuit drew support from Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) for support for its holding. Id. In a footnote in Jandreau, the Federal Circuit addressed whether a layperson could provide evidence regarding a diagnosis of a condition and explained that "[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran seeks to offer etiology opinions rather than provide diagnoses, the reasoning expressed in Jandreau is applicable. The Board finds that the question of whether the Veteran currently has COPD due to his service connected bronchiectasis and right middle lobe lobectomy is too complex to be addressed by a layperson. This connection or etiology is not amenable to observation alone. Rather it is common knowledge that such relationships are the subject of extensive research by scientific and medical professionals. Hence, the Veteran's opinion of the etiology of his current disability is not competent evidence and is entitled to low probative weight. In conclusion, the Board finds that rating the Veteran under a diagnostic code that rates disabilities of the lungs based on the results of PFT, such as Diagnostic Code 6600 or 6844 is not appropriate, as his current impaired respiratory impairment has been attributed to his nonservice-connected tobacco abuse. The Veteran is most appropriately rated under Diagnostic Code 6601, which specifically rates bronchiectasis. Under this diagnostic code, a higher disability evaluation is not warranted for any period on appeal. Finally, the Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The criteria for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that the schedular rating criteria reasonably reflect the Veteran's disability levels and symptomatology. The Veteran's reported difficulties are not so exceptional or unusual a disability picture as to render impractical application of regular schedular standards. Therefore, no referral for extraschedular consideration is required and no further analysis is in order. For all the above reasons, entitlement to a disability rating in excess of 30 percent is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board notes that in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the Court clarified VA's notice obligations in increased rating claims. The Federal Circuit recently reversed the Court's decision in Vazquez-Flores, finding that VA is not required to tailor § 5103(a) notice to individual Veterans or to notify them that they may present evidence showing the effect that worsening of a service-connected disability has on their employment and daily life for proper claims adjudication. For an increased rating claim, section § 5103(a) now requires that the Secretary notify claimants generally that, to substantiate a claim, they must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd sub. nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (holding that notice specific to individual Veterans is no longer required in increased compensation claims). Here, the VCAA duty to notify was satisfied by a letter sent to the Veteran in August 2009. This letter informed the Veteran of what evidence is required to substantiate his claim, as well as of VA and the Veteran's respective duties for obtaining evidence. The Veteran was also informed of how VA assigns disability ratings and effective dates. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, as well as VA treatment records. The Veteran submitted private treatment records and was provided an opportunity to set forth his contentions during the March 2012 videoconference hearing before the undersigned Veterans Law Judge. In this regard, the Board notes that in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that there are two duties imposed by 38 C.F.R. § 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked are not impacted by the Veteran's receipt of letter that complies with VA's duty to notify. In this case, during the Board hearing, testimony was elicited regarding the elements that were lacking to substantiate the claim and the Veteran and his representative demonstrated actual knowledge of this information. The representative's questions specifically elicited responses designed to show that the Veteran's understood the criteria necessary to substantiate his claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). Further, a review of the record also reveals no assertion, by the Veteran or his representative, that VA or the undersigned failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any other prejudice in the conduct of the Board hearing. Accordingly, the Veteran is not shown to be prejudiced on this basis. The appellant was afforded a VA medical examination in August 2009 and June 2011, with an addendum medical opinion in July 2011. These examinations are based upon review of the claims folder, and thoroughly discuss the nature and severity of the Veteran's disability as well as the functional impairments resulting therefrom. These examination reports are adequate for rating purposes. See 38 C.F.R. § 4.2. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to a disability rating in excess of 30 percent for service-connected bronchiectasis is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs