Citation Nr: 1338971 Decision Date: 11/26/13 Archive Date: 12/06/13 DOCKET NO. 08-34 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for a lung disability, including as secondary to service-connected coronary artery disease (CAD), status post myocardial infarction. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1965 to December 1967, including service in the Republic of Vietnam. His awards and decorations include the Purple Heart Medal and the Combat Infantryman Badge. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, which denied the benefit sought on appeal. The Veteran testified at a hearing before an RO Decision Review Officer (DRO) in March 2009. A transcript of that hearing is of record. In March 2011, the Board remanded the Veteran's claim on appeal for further evidentiary development. Although the Veteran initiated an appeal with respect to the denial of a claim of entitlement to service connection for Agent Orange exposure, he subsequently indicated his desire to withdraw the appeal in a March 2009 statement. Accordingly, the Board dismissed his claim with respect to that issue in the March 2011 decision. FINDINGS OF FACT 1. Service connection is in effect for CAD, status post myocardial infarction. 2. The competent evidence shows that the Veteran's current lung disability was caused by his service-connected CAD, status post myocardial infarction. CONCLUSION OF LAW The criteria for entitlement to service connection for a lung disability as secondary to service-connected CAD, status post myocardial infarction have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board grants entitlement to service connection for a lung disability as secondary to the Veteran's service-connected heart disability. As this represents a complete grant of the benefits sought on appeal with respect to this service connection claim, no further notice or assistance is required under the Veterans Claims Assistance Act of 2000. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). I. Governing Law and Regulations Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). To establish service connection, generally the evidence must show (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310(a) (2013). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the non-service-connected disease or injury. See Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). Thus, there must be (1) competent evidence of a current disability; (2) evidence of a service-connected disability; and, (3) medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 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). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A 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 for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or 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). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also 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."). 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. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). II. Analysis Although the Veteran initially indicated that he was seeking service connection for a lung condition due to asbestos exposure, the record appears to discount such asbestos exposure. Discussion of the merits of the Veteran's claimed asbestos exposure and consideration of his service connection claim on a direct basis, however, is rendered unnecessary due to the Board's favorable finding regarding service connection for his claimed lung disability on a secondary basis. Turning then to the issue of service connection for a lung disability on a secondary basis, the Board notes at the outset that service connection was awarded for CAD, status post myocardial infarction in a December 2010 rating decision. With respect to the current disability requirement for service connection for a lung disability, an incidental chest X-ray taken in October 2007 showed multiple lung conditions, including pleural thickening and calcification in the lung cavity. A probable correlation to a history of tuberculosis (TB) was noted. A subsequent October 2007 CT scan showed calcified and noncalcified pleural plaque formation, and basilar pleural thickening. Upper lobe predominant emphysema and bibasilar scarring/atelectasis were also noted. The impression was that the pleural plaque formations were compatible with asbestos related disease. Subsequently, during a December 2007 VA pulmonary consultation the Veteran presented with self-described bronchitis. He reported having quit smoking four years earlier and he denied any known asbestos exposure. Pulmonary function testing (PFT), however, showed moderate to severe restrictive physiology; although the Veteran had indicated that he was asymptomatic. An April 2008 PET/CT scan revealed a number of pulmonary lesions. A right pleural biopsy was subsequently performed in May 2008; however, the biopsy yielded negative results for malignancy or granuloma. Based on the foregoing evidence, the Board finds that the current disability requirement for service connection for a lung disability has been met. See Walker, Wallin, supra. The Board is finally left to consider whether there is a nexus between the Veteran's current lung disability and his service-connected heart disability. At this juncture, the Board notes that the Veteran underwent a coronary angiography and four vessel coronary artery bypass graft (CABG) surgery, as treatment for his now service-connected CAD, in August 2004. The evidence of record reflects a thorough investigation into the etiology of the Veteran's discovered lung disability. A May 2009 VA pulmonary fellow/resident outpatient note discussed the findings of multiple pulmonary lesions. The report concluded that the etiology of the Veteran's pleural/medistinal lesions was not clear, and that the only positive element in his history was heavy smoking. The report noted that pleural lesions were most consistent with a pleural inflammatory process, and that apart from asbestos exposure, pleural thickening may be caused by TB, thoracic surgery, trauma, or drug reactions. The conclusion reached in the report was that if the Veteran was not really exposed to asbestos or a fibrosing drug, his history of CABG was the next most probable cause for the pleural lesions. In a subsequent September 2009 pulmonary fellow report, a different pulmonary fellow and attending physician reached the conclusion that the etiology of the Veteran's pleural/mediastinal lesions was most likely due to post CABG. Given the foregoing, the Board finds that the medical evidence of record has established a link between the Veteran's CABG, to treat his service-connected CAD, and his subsequent development of pleural/mediastinal lesions. However, because the evidence of record had not clearly indicated whether the Veteran's current lung impairment (including noted decreased pulmonary function) for which he was seeking service connection was in fact the result of his pulmonary lesions, the Board requested a medical expert opinion from a healthcare professional in VA's Veterans Health Administration (VHA). See 38 C.F.R. § 20.901(a) (2013) (the Board may obtain a medical opinion from an appropriate health care professional in the VHA of VA on medical questions involved in the consideration of an appeal). In an October 2013 opinion, a VHA specialist reviewed the medical evidence of record and opined that it was likely that the Veteran's lung function impairment was due to the findings on his CT scan. She noted that a decreased diffusion capacity of the degree found in the Veteran may be seen with lung parenchymal disease, as noted on his CT scan which showed scarring, interlobular septal thickening, and emphysema. The specialist further explained that an echocardiogram dated in close proximity to a 2010 CT scan did not show increased right ventricular systolic pressure which would suggest an alternate diagnosis for the Veteran's low diffusion capacity, such as pulmonary hypertension. The specialist additionally ruled out anemia as a cause for low diffusion capacity because the diffusion capacity was shown to be corrected for hemoglobin level. The specialist further noted that there was reduced TLC in 2007 PFT results, which was consistent with restrict lung disease which may be explained by pleural plaques, and/or lung scarring, and/or interstitial lung disease. The VHA specialist finally observed that the Veteran's PFT results, as shown in contemporaneous medical evidence, have remained stable. This is significant because the stability of diffusion shown over a three-year period, together with stability in radiographs, provides more evidence that the Veteran's impaired diffusion is likely due to lung parenchymal disease and not an alternative cause, such as pulmonary hypertension or pulmonary edema, for example. Based on the VHA specialist's fully informed, fully articulated and well-reasoned report, the Board finds that there is sufficient medical evidence of a nexus between the Veteran's current lung disability, represented by decreased pulmonary diffusion capacity, and his service-connected CAD. Therefore, the Board finds that all required elements to establish service connection for the Veteran's claimed lung disability, as secondary to his service-connected CAD, status post myocardial infarction, have been met. See Wallin, supra. Accordingly, all doubt with respect to this claim is resolved in favor of the Veteran and his claim for service connection for a lung disability is granted. 38 U.S.C.A. § 5107(b) (West 2002). ORDER Entitlement to service connection for a lung disability, as secondary to service-connected CAD, status post myocardial infarction, is granted. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs