Citation Nr: 1334935 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 10-28 015 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for tuberculosis. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1983 to December 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision, which was decided by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, and issued by the RO in Detroit, Michigan. The rating decision declined to reopen the Veteran's claim for service connection for tuberculosis, which had last been denied in May 1989. The Board reopened the claim and remanded the case to the agency of original jurisdiction (AOJ) for further development in November 2012. The AOJ has returned the claim to the Board for further appellate review and, as discussed further herein, the Board finds that the AOJ substantially complied with the remand orders such that no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's appeal, which has also been reviewed by the Board. This virtual file contains VA treatment records that were not contained in the paper claims file, but were reviewed and considered by the AOJ in a March 2013 supplemental statement of the case (SSOC). After the issuance of the March 2013 SSOC, the Veteran submitted additional evidence with a waiver of the agency of original jurisdiction's (AOJ) consideration. 38 C.F.R. § 20.1304(c) (2013). Therefore, the Board may properly consider the newly received evidence. The Board observes that, in a December 2008 statement, the Veteran requested VA "look at the side effects of INH" (a treatment he was prescribed in service) and stated that he was seeking compensation for those side effects which he identified as tinnitus and "pain in the abdominal and kidney areas." Although the Veteran has been granted service connection for tinnitus, the file reflects no development of a claim for service connection for disability manifesting as abdominal and kidney pain. As this claim has been raised by the record, but has not been adjudicated by the AOJ, the Board does not have jurisdiction over it and REFERS it to the AOJ for appropriate action. FINDING OF FACT The Veteran has not had active or inactive tuberculosis at any time during the appeal period. CONCLUSION OF LAW The criteria for the establishment of service connection for tuberculosis have not been met. 38 U.S.C.A. §§ 1101, 1112, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, June 2008 and September 2008 letters, sent prior to the initial unfavorable November 2009 rating decision, advised the Veteran of the evidence and information necessary to reopen and substantiate his claim for service connection as well as his and VA's respective responsibilities in obtaining such evidence and information. Such letters also informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records as well as VA and private treatment records have been obtained and considered. The Board notes that, in January 2013, the Veteran reported that he was willing to complete an authorization to allow his private treatment providers to release his records to VA. However, he stated that he had not done so because he had already obtained his available private treatment notes and provided them to VA. Additionally, an April 2013 SSOC Notice Response form, which accompanied the submission of additional evidence, reflects that, while the Veteran checked the paragraph indicating that he had additional evidence to submit and would do so in the next 30 days, he further stated that he had submitted all of his evidence in connection with such document. Furthermore, no additional evidence was submitted subsequent to the receipt of the April 2013 SSOC Notice Response from. Therefore, the Board finds that neither the Veteran nor his representative has identified any additional, outstanding records. Additionally, the Veteran was afforded VA tuberculosis examinations in September 2008 and March 2013. The Board finds that these VA examinations, which reflect that the examiners reviewed the claims file in addition to interviewing and examining the Veteran, are adequate to decide the issue. The ultimate opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and reflect rationales relying on, and citing to, the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met. The Board remanded this case in November 2012 in order for the AOJ to afford the Veteran a new examination, obtain additional VA treatment records, and assist him in gathering additional private medical evidence. The record reflects that the Veteran was afforded an examination in March 2013. Additional VA records have been associated with the claims file and, as discussed above, although the AOJ mailed the Veteran authorization forms that would allow VA to obtain additional private records on his behalf, he chose to submit copies of such records himself and has indicated that no additional pertinent private records remain outstanding. The AOJ also issued a March 2013 SSOC reflecting readjudication of the claim. Therefore, the Board finds that the prior remand directives have been substantially complied with such that no further action is necessary in this regard. See D'Aries, supra. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis The Veteran contends that he experienced active tuberculosis in service and currently has inactive tuberculosis. Therefore, he alleges that service connection for such disorder is warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Although active tuberculosis is recognized as a chronic disease under 38 C.F.R. § 3.309(a), the Veteran contends that he has inactive tuberculosis and, as detailed below, the most probative evidence of record reflects that he has not experienced active tuberculosis. As such, the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable. Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet.App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's service treatment records reflect that his respiratory system was evaluated as normal, and a chest x-ray was within normal limits, at the time of his enlistment in December 1983. In March 1988, he underwent a routine PPD (purified protein derivative) test that was positive. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1498, 1962 (30th ed. 2003) (purified protein derivative examination is used to test for exposure to Mycobacterium tuberculosis). Although service records reflect that subsequent chest x-ray and liver function tests were normal, the Veteran was prescribed a course of INH therapy. Treatment notes refer to the INH therapy as prophylactic in nature and an August 1988 examination reflects a normal chest x-ray and normal respiratory system. On a contemporaneous self report of medical history, the Veteran denied shortness of breath and stated that he was "in good health," but endorsed tuberculosis. A January 1989 post-service VA treatment note reflects that the Veteran reported having a positive PPD that was treated prophylactically and inquired as to whether any follow-up care was necessary. Upon examination, his chest was clear, but the physician ordered a chest x-ray and continued the Veteran's prophylactic treatment. The report of the chest radiograph conducted at that time reflects that there was "no evidence of cardiopulmonary abnormality." In February 1989, the Veteran was afforded a VA examination. The examiner noted his history of a positive PPD test result and prophylactic treatment. Although observing that chest x-rays were within normal limits, the examiner stated under the diagnosis section of the report: "T.B. prob diag as PPD +." In April 1989, the Veteran reported for follow-up and was noted to be in no acute distress with a clear chest. He was later diagnosed with pharyngitis in November 1990 after complaining of occasional cough with phlegm. In June 1992, he was treated for an upper respiratory infection, but the treating physician noted that his chest was clear. He also reported for treatment of cough in October 1994 and was diagnosed with pharyngitis. He was prescribed an inhaler. The following month, he reported that his cough was resolving, but the inhaler did not seem to help. A March 1995 note refers to an occasional cough. The Veteran was again prescribed an inhaler in August 1997 due to complaints of cough. An October 1997 note refers to resolved pharyngitis. In October 2003, the Veteran reported to VA for general treatment. The note reflects that he reported contracting tuberculosis while he was in service and stationed in Turkey. The treating clinician advised that the majority of tuberculosis lesions remain inactive after treatment, but indicated that x-ray was appropriate follow up. The subsequent December 2003 x-ray shows "no focal opacity or infiltrate" and the radiologist interpreted the results as showing "no active disease." The Veteran received another general evaluation in November 2007. Chest x-ray at that time was also within normal limits. In July 2008, he reported for follow-up at VA and inquired as to whether or not he should have another PPD test. The clinician informed him that annual chest x-rays were considered optimal for monitoring and observed that his last x-ray in 2007 was normal. VA afforded the Veteran another tuberculosis examination in September 2008. He informed the examiner that he was diagnosed with tuberculosis while on active duty and experienced a cough and some shortness of breath as residual. A chest x-ray showed "no active pulmonary disease," but the results of pulmonary function testing indicated asthma. The examiner diagnosed "no active pulmonary disease" and asthma. However, the examiner also answered "tuberculosis" to the following examination query: "problem associated with this diagnosis." In December 2008, the Veteran submitted two Internet articles. One article discussed side effects of INH therapy (such as tinnitus and pain in some parts of the body) and the other stated that, if "the body's immune system becomes weakened, [] the TB bacteria [can] break through the scar tissue and can cause active disease." A copy of an August 2010 letter written by a private physician states that the Veteran had been infected with tuberculosis while on active duty, was treated with INH therapy, and, afterwards, his tuberculosis was "pretty much under control and dormant." Based on that history, the physician opined that the Veteran currently had inactive tuberculosis. Treatment notes from that physician stated that chest x-rays of the Veteran revealed "a small amount of scar tissue diffusely throughout the lung, but no actual infiltrates or any signs of active TB." An August 2010 note diagnoses reactive airway disease and states that the treating physician "believe[s] that this is mild intermittent asthma only that is probably more exercise-induced than anything else." In September 2010 the Veteran saw another private treatment provider seeking "2nd opinion on 'inactive TB.'" The note reflects that he complained of occasional dyspnea and reported exposure to tuberculosis in 1988 that was treated with one year of INH therapy. The note also reflects that x-ray revealed a small nodule on the left side of the chest. The diagnosis was asthma and tuberculosis based on "hx of TB in 1988." The Veteran submitted two other research articles in October 2010. One article was titled "Endobronchial tuberculosis simulating bronchial asthma" and indicated that symptoms of bronchial asthma may, in some cases, actually be manifestations of endobronchial tuberculosis. The second article discussed interrelationship between asthma and tuberculosis, noting that asthma was not a "disease entity" and that some patients with asthma had underlying tuberculosis. The Veteran has also submitted multiple lay statements in support of his claim. A September 2010 statement by B.W. states that she witnessed two occasions of the Veteran experiencing shortness of breath. A January 2013 statement by L.V. notes that the Veteran appeared to be "gasping for air" after some physical exertion. The Veteran has also authored his own opinions as to the causes of any current respiratory problems - attributing all to tuberculosis and diagnosing himself with inactive diagnosis due to a "mild case of [active] tuberculosis" in service. In June 2012, the Veteran reported for general VA treatment and denied any respiratory complaints. He was afforded another VA examination in March 2013 and the examiner noted review of the entire claims file to include the service treatment records. The examiner ordered a chest x-ray that was normal. The examiner also observed the history of normal chest x-rays from 1988 to 2010 when private x-ray showed "suggestion of minimal infiltrate or scarring in the left lower lung medially," but indicated that the "rest of the lung fields and costophrenic angles are clear." Based on the recorded medical history and his own evaluation of the Veteran, the examiner determined that the Veteran had a positive PPD test without ever having active tuberculosis disease. The examiner specifically addressed the private physician's 2010 diagnosis of inactive tuberculosis, observing that diagnosis was rendered based on a history provided by the Veteran rather than on review of the medical record. The examiner again explained that the medical evidence did not show that the Veteran had ever experienced active tuberculosis and, as such, he could not have inactive tuberculosis. Subsequent VA treatment notes reflect that the Veteran was informed by letter that his VA examination results showed a normal chest (upon x-ray), but pulmonary function testing that indicated asthma. In April 2013, the Veteran submitted an additional Internet article that discusses tuberculosis, generally, and specifically observes that "if you have a positive PPD it does not mean that you have Tuberculosis." The Veteran has contended that he is entitled to service connection for inactive tuberculosis because he allegedly experienced active tuberculosis while on active duty. However, the Board finds below that the probative evidence is against the claim and service connection is not warranted. Generally, competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). In contrast, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions such as the diagnosis of an internal respiratory disease process. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Veteran's service treatment records reflect that he experienced a positive PPD during service, which, as noted in those records and as subsequently observed by multiple clinicians, indicates exposure to tuberculosis. The Veteran has contended that he was not just exposed to tuberculosis, but also experienced the active form of that disease while he was serving on active duty. However, he has not shown that he possesses any medical training or expertise that would make him competent to render such a diagnosis. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). As such, the Veteran's own opinion is non-probative evidence. See Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Moreover, contemporaneous records show no such medical diagnosis and instead reflect that chest x-ray and liver function tests were normal and he was treated only prophylactically, rather than for active infection. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than subsequently reported history). The Veteran's lay assertions lose credibility and persuasiveness in light of the other evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed.Cir. 1996) (per curiam) (table); (the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant). Consequently, the Board finds the Veteran's statements that he experienced active tuberculosis in service not credible as they are inconsistent with the service treatment records specifically indicating the contrary. Id. In reference to the competent medical evidence of record, the Board again notes that some providers have indicated that the Veteran did experience active tuberculosis in the past, but others have opined that he did not. In this regard, there are conflicting medical opinions of record, i.e. the February 1989 examiner noted tuberculosis as a 'probable' diagnosis due to a positive PPD test, the September 2008 VA examiner identified tuberculosis as a 'problem associated with' the diagnosis of no active pulmonary disease, a private physician diagnosed inactive tuberculosis in August 2010, a private physician diagnosed tuberculosis based on a history of treatment of TB in 1988, and the March 2013 examiner diagnosed no history of active or inactive disease. When faced with conflicting medical opinions, the Board must weigh the credibility and probative value of each of the opinions, and, in so doing, the Board may favor one medical opinion over the others. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Initially, the Board will assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. Here, only the September 2008 and March 2013 VA examiners reviewed the claims file, but review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran, as the Veteran's private physician, or through a factually accurate medical history reported by a Veteran. Id. at 303-04. Second, the Board will consider whether or not the medical expert provided a fully articulated opinion. Id. An equivocal medical opinion or one that is expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Finally, the Board considers whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez, supra; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Here, the 2013 VA examiner was aware of pertinent case facts via review of the case file and interview and examination of the Veteran. Although the 2008 examiner also indicated review of the case file, the only summary of medical history in the resulting report appears to be the examiner's notation of the Veteran's account of his medical history, including his self-reported in-service diagnosis. Similarly, although the private physicians were familiar with the Veteran through treatment, their respective August 2010 and September 2010 records also state that the Veteran was diagnosed with tuberculosis while in service, i.e., 1988. Such statements are not accurate as service records only reflect diagnosis of exposure to tuberculosis, rather than any active disease process. The Court has held that the Board may reject a medical opinion that is based on facts provided by the Veteran that have been found to be inaccurate or because other facts present in the record contradict the facts provided by the Veteran that formed the basis for the opinion. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). Further, although the 1989 and 2008 VA examiners indicated that the Veteran may have been diagnosed with tuberculosis, rather than simply exposed to tuberculosis, their opinions were not definitive or specific - respectively using the term 'probable' and stating that tuberculosis was a problem associated with the Veteran's "no active pulmonary disease," but not actually diagnosing tuberculosis. In this regard, medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. 38 C.F.R. § 3.102; see also Warren v. Brown, 6 Vet. App. 4, 6 (1993); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (a generic statement about the possibility of a link is too general and inconclusive); Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993), (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship); Morris v. West, 13 Vet. App. 94, 97 (1999) (a diagnosis that the appellant was "possibly" suffering from schizophrenia was deemed speculative). In contrast, the 2013 VA examiner reviewed service treatment records and all the prior opinions as well as interviewed and examined the Veteran. The 2013 examiner's opinion also definitively stated that the Veteran had never experienced active tuberculosis. The examiner specifically addressed the prior opinion diagnosing inactive tuberculosis and explained that diagnosis cannot be rendered without evidence of prior active tuberculosis. Unlike the prior (1998 and 2008) VA examiners, the 2013 examiner chronologically detailed the Veteran's medical history and explained that the number of normal radiographs and liver function tests contraindicated diagnosis of active tuberculosis. The 2013 examiner provided the most detailed analysis of the record as well as the most thorough rationale. See Nieves-Rodriguez, supra; Stefl, supra. For these reasons, the Board finds the opinion of the 2013 VA examiner most probative (Evans, 12 Vet. App. at 30) and thus determinative on the question of etiology. The Board has considered the lay statements authored by B.W. and L.V. and submitted by the Veteran, but finds them not relevant to the question of service connection. Specifically, both statements reflect lay observations of the Veteran's shortness of breath, but do not provide any competent evidence as to the underlying cause thereof. The Board has also considered the Veteran's submissions of medical literature regarding tuberculosis, INH therapy, and asthma since medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). In this regard, the Board notes that treatise evidence must "not simply provide speculative generic statements not relevant to the Veteran's claim." Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, "standing alone," must discuss "generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Id. (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (medical treatise evidence must demonstrate connection between service incurrence and present injury or condition); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (generic statement about the possibility of a link between chest trauma and restrictive lung disease is too general and inconclusive); Mattern v. West, 12 Vet. App. 222, 227 (1999) (generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive (quoting Sacks, supra)). In this case, the Board finds that the research submitted by the Veteran is general in nature. As described above, the other research articles submitted by the Veteran either discuss, generally, the tuberculosis disease process, identify side effects of INH therapy (which is not pertinent here), or discuss the possibility of an etiological relationship between asthma and tuberculosis. The examiner's conclusions demonstrate that the research does not warrant a grant of service connection - not only did the examiner explain the tuberculosis disease process in specific reference to the Veteran's medical history, but he specifically addressed tuberculosis in the context of the Veteran's currently diagnosed asthma and explained that because the Veteran had "never had active TB [] no nexus with his asthma can be established." Because the VA examiner's opinions are specific to the Veteran's case, they are entitled to greater probative value than the submitted general research. Wallin, supra; Sacks, supra. Furthermore, while the Veteran has cited to another Board decision in his April 2013 statement, he is advised that such decision is not precedential and, therefore, non-binding on the Board. In this regard, the Board notes that each decision issued is specific to the individual Veteran and involve separate facts. Therefore, the Board finds that the Veteran has not had active or inactive tuberculosis at any time during the appeal period, or prior to the filing of his claim. See McClain, supra; Romanowsky, supra. Finally, in regard to the Veteran's contention, as expressed in the May 2013 informal hearing presentation, that he is entitled to service connection for tuberculosis solely because he had a positive PPD test while on active duty, the Board notes that such a test result is not, by itself, considered a disability for which service connection can be granted. A laboratory finding does not ultimately constitute a disability in and of itself, absent a separate diagnosis. See 61 Fed. Reg. 20440, 20445 (May 7, 1996) (regarding cholesterol testing). As Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability, there can be no valid claim solely on the basis of the positive PPD test. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine, but the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. As such, that doctrine is not applicable in the instant appeal, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for tuberculosis is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs