Citation Nr: 1335869 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 08-09 910A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a heart disability. 2. Entitlement to service connection for erectile dysfunction. 3. Entitlement to a compensable evaluation for pleural thickening with a history of pneumonia and a positive tuberculin reaction. REPRESENTATION Appellant represented by: Marine Corps League ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The Veteran served on active duty from May 1959 to September 1979, to include service in Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal from August 2007, September 2008 and February 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran was scheduled for a travel Board hearing in June 2010. The Veteran elected to cancel the hearing and has expressed no intention to reschedule it. In March 2011, the Board (in pertinent part) reopened the claims for service connection for a heart disability and erectile dysfunction, and remanded these claims along with the claim for a compensable evaluation for pleural thickening with a history of pneumonia and a positive tuberculin reaction for further development. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the appellant's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The Veteran had service in the Republic of Vietnam during the Vietnam era and therefore exposure to herbicides including Agent Orange is presumed. 2. There is no competent and credible evidence the Veteran has had ischemic heart disease, that a heart disability had its onset in service or within one year of service discharge, that any current heart disability is related to his active military service, including to his presumed herbicide exposure in Vietnam. 3. There is no competent and credible evidence that the Veteran's current heart disability was caused or aggravated by a service-connected disability. 4. There is no competent and credible evidence the Veteran's erectile dysfunction had its onset in service or is related to his active military service, including to his presumed herbicide exposure in Vietnam. 5. There is no competent and credible evidence that the Veteran's current erectile dysfunction was caused or aggravated by a service-connected disability. 6. The evidence of record does not establish the Veteran has experienced active tuberculosis at any point during the period on appeal. 7. Throughout the period of the appeal, the competent and credible evidence of record demonstrates that the Veteran's diminished respiratory capacity is unrelated to the service-connected pleural thickening with a history of pneumonia and a positive tuberculin reaction; rather, diminished respiratory capacity is entirely related to smoking. CONCLUSIONS OF LAW 1. A heart disability was not incurred in or aggravated by the Veteran's military service, and may not be presumed to have been incurred in service, including from herbicide exposure in Vietnam; and is not secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1131, 1137, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. Erectile dysfunction was not incurred in or aggravated by the Veteran's military service, and may not be presumed to have been incurred in service, including from herbicide exposure in Vietnam; and is not secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2013). 3. The criteria for a compensable rating for pleural thickening with a history of pneumonia and a positive tuberculin reaction have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.31, 4.97, Diagnostic Codes 6731 and 6840-6845 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159, provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Court further held that VA failed to demonstrate that "lack of such a pre-AOJ-decision notice was not prejudicial to the appellant, see 38 U.S.C. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that '[i]n making the determinations under [section 7261(a)], the Court shall...take due account of the rule of prejudicial error')." The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). By correspondence on numerous occasions, including dated in August 2006, July 2007, May 2008, August 2008, May 2009 and August 2011, the Veteran was informed of the evidence and information necessary to substantiate his claims, the information required of the Veteran to enable VA to obtain evidence in support of the claim, the assistance that VA would provide to obtain evidence and information in support of the claim, and the evidence that should be submitted if there was no desire for VA to obtain such evidence. Notice regarding the assignment of a disability rating and effective date in the event of an award of VA benefits was included as well. In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims. See January 2013 Supplemental Statement of the Case. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). Furthermore, the Board observes that the Veteran has demonstrated actual knowledge and understanding of the type of evidence which can substantiate his claims in his written arguments. Therefore, no prejudice accrues to him in the matter of notice. The Board also finds that VA's has satisfied its duties to assist the Veteran in the development of his claims. His service treatment records (STRs) and post-service (VA and private) medical records have been obtained. In addition, relevant Social Security Administration disability records are associated with the claims file. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. In addition, the Board finds that no additional development for medical opinions or examinations is necessary. In this regard, the Veteran has been afforded the appropriate VA examinations to determine the etiology of his claimed heart disability and erectile dysfunction, as well as the current severity of his service-connected pleural thickening with a history of pneumonia and a positive tuberculin reaction. As directed by the March 2011 Board remand, VA examinations were provided in April 2011 so as to ascertain whether any currently-diagnosed heart disability and erectile dysfunction are etiologically-related to service. A VA examination was provided in September 2012 to ascertain the current severity of the Veteran's pleural thickening with a history of pneumonia and a positive tuberculin reaction . The examinations included the requested opinions and, as discussed below, are supported by reasons and bases. Accordingly, the Board finds that there has been substantial compliance with its remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Evidentiary development is complete. As VA's duties to notify and assist are met, the Board will address the merits of the claims. II. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303(a), 3.304. 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). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). The United States Court of Appeals for the Federal Circuit (Federal Circuit) recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board notes that cardiovascular-renal disease is listed as a chronic disability under 38 C.F.R. § 3.309(a); therefore this disability may be subject to service connection based on continuity of symptomatology. Moreover, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as cardiovascular-renal disease, may be presumed to have been incurred in service if manifest to a compensable degree within one year after discharge from service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Applicable regulations provide that a Veteran who served on active duty in Vietnam during the Vietnam era is presumed to have been exposed to Agent Orange or similar herbicide. 38 C.F.R. § 3.307(a)(1)(6)(iii). Here, the Board finds the Veteran is presumed to have been exposed to herbicides, since his DD Form 214 confirms he served in the Republic of Vietnam during the Vietnam War. 38 C.F.R. § 3.307(a)(6)(iii). Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era will be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). The presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). During the course of this appeal, on October 13, 2009, in accordance with authority provided in 38 U.S.C. § 1116, the Secretary of VA announced his decision to establish presumptions of service connection, based upon exposure to herbicides used in the Republic of Vietnam during the Vietnam era, for three new conditions: ischemic heart disease, Parkinson's disease, and B cell leukemias. On March 25, 2010, the Secretary published in the Federal Register a proposed rule that would amend 38 C.F.R. § 3.309(e) to establish a presumption of service connection for ischemic heart disease, Parkinson's disease, and B cell leukemias based upon exposure to herbicides used in the Republic of Vietnam during the Vietnam era. 75 Fed. Reg. 14,391. On August 31, 2010, the Secretary published in the Federal Register a final rule amending 38 C.F.R. § 3.309(e) to establish such presumptions. 75 Fed. Reg. 53,202. The final rule was effective August 31, 2010. In the proposed rule, which was ultimately adopted, VA noted that, according to Harrison's Principles of Internal Medicine (Harrison's Online, Chapter 237, Ischemic Heart Disease, 2008), IHD [ischemic heart disease] is a condition in which there is an inadequate supply of blood and oxygen to a portion of the myocardium; it typically occurs when there is an imbalance between myocardial oxygen supply and demand. Therefore, for purposes of the regulation, the term ''IHD'' [ischemic heart disease] includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. Because the term refers only to heart disease, it does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke. 75 Fed. Reg. 14,391, 14,393 (March 25, 2010). Service connection also may be granted on a secondary basis for disability that is proximately due, the result of, or aggravated by service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). 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 Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Heart Disability STRs are negative for any complaints or findings related to a heart disability. The April 1979 separation examination report shows that clinical evaluation of the heart was normal and that the Veteran denied having any heart trouble. A December 1980 VA examination report indicates that the Veteran had no history of dyspnea, angina, or palpitation of the heart. On physical examination, the heart was not enlarged and no murmurs were heard. Private medical records reflect that nicotine dependence was diagnosed in 1999. Records from the Social Security Administration reflect that the Veteran was determined to be disabled from January 2002 due to primary diagnosis of peripheral neuropathy with a secondary diagnosis of cardiomyopathy. Private treatment records note that in March 2002, the Veteran was hospitalized for symptoms of rapid heartbeat, chest pain and tightness, and shortness of breath. Diagnoses of new onset of atrial fibrillation and congestive heart failure with an ejection fraction of 20% were made. Cardiac catheterization revealed normal arteries. A CT scan of the chest was done in May 2002 pursuant to the Veteran's heart failure, described as "without significant coronary artery disease." A CT scan revealed emphysema. A May 2003 cardiac catheterization revealed normal arteries. A private medical record dated in February 2007 reflects that diabetes had been recently diagnosed. A March 2008 private medical report reflects that the Veteran was seen for consultation relating to his atrial fibrillation. The report indicated that he had no coronary artery disease. The assessments included atrial fibrillation. A May 2009 VA Agent Orange examination report notes diagnoses of emphysema and "CAHD." VA records include a May 2009 entry indicating that the Veteran's diagnosed conditions included PVD/CAD (peripheral vascular disease/coronary artery disease). A September 2009 VA treatment record notes that the Veteran's medical history included coronary arthrosclerosis. A September 2010 VA heart examination report notes that examination revealed a diagnosis of coronary artery disease, status post-coronary stent placement. The claims file was not reviewed in conjunction with this examination and no etiology opinion was provided. An April 2011 VA examination report notes that the VA examiner examined the Veteran and reviewed the claims file, and opined that the Veteran does not have a heart disability that meets the definition of ischemic heart disease under 38 C.F.R. § 3.309(e). In support of this opinion, the examiner noted that the Veteran had two normal cardiac catheterizations and a normal dobutiamine stress test; his symptoms are not typical of ischemic heart disease. Rather, he has atrial fibrillation. The examiner also opined that the Veteran's current heart disability, atrial fibrillation, did not have its onset in service or within the first post-service year, or is casually related to service. The examiner noted that there is no objective evidence of any heart condition in service; the first such evidence is in 2002; 23 years after service. The examiner also opined that this disability is not etiologically related to a service-connected disorder by virtue of causation or aggravation. He explained medical records show no objective evidence that the Veteran's service-connected diabetes, respiratory condition, skin conditions, or audio conditions have aggravated his atrial fibrillation. The examiner noted that the Veteran's heart disability is in good control. In particular, the examiner noted that the Veteran's atrial fibrillation had its onset prior to his diabetes. After careful consideration, service connection for a heart condition is not warranted. The Veteran's post-service treatment records and examination reports show a current heart disability, recently diagnosed as atrial fibrillation. The Veteran's currently diagnosed heart disability is not on the list of diseases associated with herbicide exposure for purposes of the presumption. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. § 3.309(e). To emphasize, the Veteran does not have a diagnosis for ischemic heart disease or any related heart disability that might qualify for presumptive service connection. See 38 C.F.R. § 3.309(e). The Board acknowledges coronary artery disease was suspected in the past; however, the April 2011 VA examiner noted that testing, to include a stress test and catheterization, has shown he does not have this condition. Indeed, there is no indication of any current heart condition in which there is an inadequate supply of blood and oxygen to a portion of the myocardium, as required for ischemic heart disease. See 75 Fed. Reg. 14,391, 14,393 (March 25, 2010). The criteria for presumptive service connection for ischemic heart disease on the basis of herbicide exposure have not been satisfied. The Veteran is competent, even as a layman, to comment on any symptoms within his five senses, such as having experienced shortness of breath and chest pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran is not competent, however, to ascribe these symptoms to a particular diagnosis for a chronic heart disability. Certain disabilities, including ischemic heart disease (which is not shown here), are medically complex in nature and simply not readily amenable to lay diagnosis or probative opinion on etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). The Board finds the Veteran is not competent to self-diagnose his heart disability, particularly with regards to identifying the existence of ischemic heart disease. As regards secondary service connection, the April 2011 VA examiner opined against the possibility that the Veteran's heart disability is proximately due to or the result of a service-connected disability, to include diabetes, by virtue of causation or aggravation. In particular, the examiner reasoned the Veteran's heart disability was diagnosed prior to his symptoms, objective findings and diagnosis of diabetes mellitus. There is no medical opinion to the contrary. The Board next turns to consideration of possible entitlement to service connection for the heart disability on a direct-incurrence basis, but finds the claim lacking in this respect as well. There is no objective indication of in-service incurrence of any heart condition. The Veteran's STRs are completely unremarkable for any complaint, treatment, or clinical diagnosis of a heart disorder during his active duty military service, as noted above. The record also fails to show by objective evaluation that he manifested any cardiovascular disease to a degree of 10 percent by September 1980 (within the first year following his active duty service discharge, in September 1979). In this regard, a December 1980 VA examination report notes no history, complaints, or findings related to a hear disability. The first recorded diagnosis of any heart-related disability is not reported until approximately 2002, approximately 22 years after service. Although it is presumed that the Veteran was exposed to a toxic herbicide while in the Republic of Vietnam, there still has to be some competent and credible evidence that his current heart disability is attributable to that exposure. Here, there is no medical opinion etiologically linking his current heart disability to his military service, including as due to his presumed exposure to herbicides. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). The Board finds medical evidence is needed to establish both secondary and direct service connection in the instant case, since the Veteran's heart disability is not the type of condition that is readily amenable to mere lay probative comment regarding its etiology, given its inherent medical complexity. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). There is no indication that the Veteran is competent to attribute his heart-related symptoms to his service-connected disabilities, either for the notion that this disability is causally related to or aggravated by his service-connected disabilities. Likewise, there is no indication that the Veteran is competent to attribute his heart-related symptoms to his military service, to include herbicide exposure therein. These are inherently complex medical determinations that require specialized medical expertise. The Board finds the Veteran's lay statements regarding secondary and direct service connection for his current heart disability are not competent. Erectile Dysfunction STRs reflect that on separation examination of April 1979, the prostate was normal to palpation and that cystic lesions on the scrotum and hyperpigmented flat lesions were present on the penal shaft. However, erectile dysfunction was never diagnosed during service. A December 1980 VA examination report notes the presence of multiple small sebaceous cysts in the scrotum, but is negative for any complaints, findings or diagnosis relating to erectile dysfunction. Outpatient treatment records dated in 2001 note that the Veteran was taking Viagra. A March 2004 private medical record lists the Veteran's historical and active medical problems to include impotence of organic origin. An October 2005 private medical report states that the results of a neurophysiological study indicated that the Veteran had not had an erection for 4 years. A March 2006 private medical record documents the Veteran's complaints of erectile dysfunction, indicating that the onset of this condition was one year previously. Organic erectile dysfunction was diagnosed and it was noted that the condition might be related to neuropathy. A February 2007 private medical record reflects that diabetes had been recently diagnosed. In a June 2010 statement, Dr. C. indicated that the Veteran has erectile dysfunction which may be related to diabetes mellitus. An April 2011 VA examination report notes that the examiner reviewed the claims file and examined the Veteran. The Veteran reported a history of complete erectile dysfunction since 2001. The examiner opined that the Veteran's erectile dysfunction is not due to and has not been permanently aggravated by service-connected diabetes mellitus or any other service connected disabilities. The examiner noted that erectile dysfunction had its onset before the onset of diabetes. Moreover, there is no support in the medical literature that any of the Veteran's other service-connected disabilities (skin disabilities, hearing loss, tinnitus, lung disability) would cause or place an individual at risk for erectile dysfunction. Regarding the etiology of the Veteran's erectile dysfunction, as noted above, the Veteran's STRs are silent for any diagnosis of this disability. The first medical evidence of such disability is in 2001, more than 21 years after service. Such a long interval of time between service separation and the earliest documentation of the disease is, of itself, a factor weighing against a finding of service connection. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The evidence of record does not include any medical opinion that the Veteran's current erectile dysfunction is related to his active service. Nor does the Veteran so contend. (Regarding the June 2010 opinion from Dr. C, the Board notes that medical opinions that are speculative, general, or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993).) The Veteran maintains that his erectile dysfunction was caused or aggravated by his service-connected diabetes mellitus. However, the April 2011 VA medical opinion (as noted above) is clearly against this claim. The Board finds this opinion to be persuasive because it is based on a review of the Veteran's pertinent history. Notably, the VA examiner specified reasons for her conclusion, as noted above. There is no competent medical opinion of record to the contrary. With regard to the Veteran's contentions, the Board is aware that lay statements may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). As to the question of secondary service connection, this is a matter concerning medical causation rather than continuity of observable symptomatology. A layperson is generally not capable of opining on matters requiring medical training or knowledge, such as whether one disability has the effect of causing or worsening another. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In any event, the Veteran's own lay opinion is of very limited probative value, far less so than the aforementioned medical opinion. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Conclusion In arriving at the decision to deny the service connection claims, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As such, the claims are denied. III. Increased Rating Claim Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Court has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As a layperson the Veteran is only competent to report observable symptoms--not clinical findings which are applied to VA's Schedule for Rating Disabilities. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The service-connected pleural thickening with a history of pneumonia and a positive tuberculin reaction has been rated under the criteria of 38 C.F.R. § 4.97 for Diseases of the Lungs and Pleura - Tuberculosis. That section distinguishes between ratings for pulmonary tuberculosis entitled on August 19, 1968 (Diagnostic Codes 6701 through 6724) and those ratings initially rated after August 19, 1968 (Diagnostic Codes 6730 through 6732). In this case, the Veteran was entitled to compensation for tuberculosis effective October 1, 1979. Accordingly, Diagnostic Codes 6730 through 6732 apply. Under Diagnostic Code 6731, depending on the specific findings, the residuals are to be rated as interstitial lung disease (Diagnostic Codes 6825 through 6833), restrictive lung disease (Diagnostic Codes 6840 through 6847), or, when obstructive lung disease is the major residual, as chronic bronchitis (Diagnostic Code 6600). In this case, the Veteran has been diagnosed with restrictive lung disease. The General Rating Formula for Restrictive Lung Disease for diseases, Diagnostic Codes 6840-6845, provide for a 10 percent rating for chronic pleural effusion or fibrosis with FEV-1 of 71 to 80 percent predicted, or FEV-1/FVC of 71 to 80 percent, or DLCO (SB) of 66 to 80 percent predicted. A 30 percent rating is warranted where pulmonary function tests (PFTs) show any of the following: FEV-1 of 56 to 70 percent predicted, FEV-1/FVC of 56 to 70 percent; or DLCO (SB) 56 to 65 percent of predicted. 38 C.F.R. § 4.97, Diagnostic Codes 6840-6845. The provisions of 38 C.F.R. § 4.31 also indicate that a zero percent evaluation will be assigned when the symptomatology required for a compensable rating is not shown. See 38 C.F.R. § 4.31. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales, supra (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran is in receipt of service connection and a noncompensable rating for pleural thickening with a history of pneumonia and a positive tuberculin reaction. The instant claim for increased rating was received in February 2007. An April 2007 VA examination report notes the Veteran's history of smoking from the age of 18 until he stopped some two and half months ago (49 years). On examination, the Veteran complained of moderate to severe dyspnea on exertion. He was able to walk 100 yards before shortness of breath required him to stop. X-ray studies revealed pleural thickening. The Veteran underwent pulmonary function tests, which revealed mild restrictive defect (reduced FVC and TLC) but normal diffusion capacity (110%) and no obstructive defects (normal FEV1/FVC ratio). The examiner essentially opined that current evidence of mild restrictive ventilatory dysfunction was attributed to the Veteran's smoking history and not to his in-service pneumonia and positive tuberculin reaction, which had resolved. Outpatient treatment records dated from 2007 to 2011 note the Veteran's only occasional complaints of wheezing, coughing and shortness of breath. On many occasions he denied these symptoms. An April 2011 VA examination report notes that the claims file was reviewed and the Veteran was examined. The examiner stated that pulmonary function tests revealed mild restrictive defect with decreased DLCO. The examiner opined that these findings were not related to the Veteran's service-connected disability. In a September 2012 VA examination report, the VA examiner reported that the Veteran's pulmonary function tests were normal at separation. The examiner stated that the Veteran's service-connected lung conditions (pleural thickening and treated PPD (positive tuberculosis skin test), are not conditions that worsen over time. Any current pulmonary function tests abnormality, any pulmonary function tests abnormality that onset after two years post-separation, is due to a pulmonary/lung condition other than the service-connected disability. The examiner noted that the Veteran has continued to smoke cigarettes, and has had pneumonia since active duty service. The medical evidence herein does not establish impairment due to service-connected disability that would merit a compensable rating. The probative medical opinion reveals that the Veteran's limited respiratory function is attributable to nonservice-connected causes, to include smoking, not to the service-connected disability that is under consideration. Under the law governing claims for increase in disability compensation, those manifestations of nonservice-connected disabilities are not to be used in establishing the evaluation of a service-connected disability. 38 C.F.R. § 4.14. See also, Mittleider v. West, 11 Vet. App. 181, 182 (1998) (VA must be able to clinically distinguish by competent medical opinion, the extent of symptoms that are attributable to service-related causes from those that are not). Where it is not possible to separate the effects of service-connected and nonservice-connected conditions, all symptoms will generally be attributed to the service-connected disability. Mittleider, 11 Vet. App. at 182; 38 C.F.R. § 3.102. In the present case, the most recent 2012 VA examiner determined that there are no residuals from the Veteran's inactive tuberculosis and in-service pneumonia. She also determined that the limitations on the Veteran's daily activities are due to other causes, such as the effects of a long history of smoking. This determination was based on both a physical examination and review of the claims file. No medical opinion to the contrary has been presented. The Board has considered whether staged ratings are appropriate. The competent medical evidence of record shows that the service-connected disability has not fluctuated materially during the course of this appeal. As such, a staged rating is not warranted. See Hart, supra. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim. Entitlement to a compensable schedular rating for pleural thickening with a history of pneumonia and a positive tuberculin reaction is denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations (and lack thereof) of the Veteran's service-connected lung disability are contemplated by the schedular criteria and the assigned schedular evaluation is adequate, as discussed above. The rating criteria provide for a higher rating for additional or more severe symptoms than currently shown by the evidence. Hence, as the schedular rating reasonably describes the Veteran's disability picture, referral for extra-schedular consideration is not warranted. [Continued on Next Page] ORDER Service connection for a heart disability is denied. Service connection for erectile dysfunction is denied. A compensable evaluation for pleural thickening with a history of pneumonia and a positive tuberculin reaction is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs