Citation Nr: 1343349 Decision Date: 12/31/13 Archive Date: 01/07/14 DOCKET NO. 10-03 836 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to service connection for idiopathic fibrosing mediastinitis. REPRESENTATION Veteran represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active service from November 1966 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2008 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Oakland, California. In July 2013, the Board sought an opinion from the Veterans Health Administration (VHA). See 38 C.F.R. § 20.901. Pursuant to this request, the Board received a VHA opinion in August 2013 and it is associated with the claims file. The case is now ripe for appellate consideration. In September 2013, the Veteran submitted additional evidence in support of his claim for service connection for idiopathic fibrosing mediastinitis and waived initial RO consideration of this evidence. See 38 C.F.R. § 20.1304 (2013). Most of the evidence was duplicative of prior evidence already of record. FINDING OF FACT There is a preponderance of the evidence against a nexus between a current diagnosis of idiopathic fibrosing mediastinitis and any incident of service. CONCLUSION OF LAW Idiopathic fibrosing mediastinitis was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA also redefined the obligations of VA with respect to the duty to assist the veteran with the claim. Id. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the letter dated in April 2008 that was sent to the Veteran adequately apprised him of the information and evidence needed to substantiate the claim. The RO thus complied with VCAA's notification requirements. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, on March 3, 2006, the United States Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which 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. The Board finds that VA has met these duties with regard to the claim adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in April 2008 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claim, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the April 2008 letter also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." VA did provide such notice to the Veteran prior to the October 2008 decision that is the subject of this appeal in its April 2008 letter. With respect to the Dingess requirements, in the April 2008 letter, the Veteran was provided with notice of what type of information and evidence was needed to substantiate the claim, as well as the type of evidence necessary to establish a rating or effective date of an award, and such notice was provided prior to the initial decision of the RO. See Dingess, supra. Accordingly, the RO provided proper VCAA notice at the required time. The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claim by VA. Duty to Assist VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence, and the evidence of record includes the Veteran's service treatment records, relevant VA Medical Center (VAMC) outpatient treatment records, and private medical treatment records. In regard to an examination, the Veteran received a VA examination in November 2009. The Board also sought an opinion from the VHA which was obtained in August 2013. The VHA opinion was thorough in nature and addressed the pertinent nexus question. The Board finds that the medical evidence of record is sufficient to resolve this appeal, and the VA has no further duty to provide an examination or opinion. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(c)(4) (2013). See also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Based on the foregoing, it is the Board's determination that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Pertinent Laws and Regulations Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, supra (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "medical nexus of a relationship [sic] between the condition in service and the present condition is required."). Walker, supra. (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). Idiopathic fibrosing mediastinitis is not a "chronic disease" listed under 38 C.F.R. § 3.309(a). Therefore, 38 C.F.R. § 3.303(b) does not apply and, as such, the Veteran is not permitted to show continuity of symptomatology since his service as an alternative means of etiologically linking his idiopathic fibrosing mediastinitis to his military service. See Walker, supra. Lay evidence nonetheless can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). III. Factual Background The Veteran's service treatment records are negative for any complaints or findings of a pulmonary disability, to include fibrosing mediastinitis. In March 1970, the Veteran underwent a discharge examination. At that time, a chest x-ray was reported to be within normal limits. The Veteran's lungs and chest were clinically evaluated as "normal." In a private x-ray report, dated in April 1980, it was noted that the Veteran's chest x-ray was negative. The cardio-aortic silhouette and mediastinum were within normal limits. VAMC outpatient treatment records reflect that in March 1981, the Veteran had a chest x-ray taken. The x-ray was reported to show a right apical bleb. There was no cardiomegaly. The lung fields were clear and no acute abnormality was seen. In January 1983, the Veteran was treated for bronchial problems that had been present for three years. He had undergone numerous x-rays and tests; however, they showed no abnormality. The diagnosis was "chest pain continuous, etiology (?)." A chest x-ray was subsequently taken and was reported to show a right apical bleb and no evidence of acute cardiopulmonary disease. The cardiomediastinal silhouette was normal in size and configuration. Additional VAMC outpatient treatment records show that in May 1983, the Veteran underwent an esophagogram which was reported to be normal. In November 1983, he was treated for complaints of a sore throat on the right side which radiated down to his chest for the last four years. The impression was throat pain of unknown etiology. Private medical records reflect that in May 1984, the Veteran sought treatment for breathing problems. He stated that he had experienced difficulty breathing through his nose for two to three years. The Veteran also noted that he had facial pain and marked pressure. He was diagnosed with severely deviated septum with hypertrophy of the turbinates, total obstruction of the nasal airway, and chronic pansinusitis. Subsequently, he underwent combined sinusotomies involving four sinuses. In July 1986, the Veteran underwent a VA psychiatric examination. He stated that he had a six year history of chronic pain in the back of his throat which radiated to his ears and lungs. The examiner noted that the etiology of such symptomatology was undetermined. The Veteran also reported that he had chronic sinusitis and tinnitus. At the time of the examination, he had an x-ray taken of his chest. The x-ray was interpreted as showing parenchymal calcifications reflecting old granulomatous disease. Bilateral apical pleural thickening was present and there was no evidence of infiltrate, failure, effusion or of any additional significant cardiopulmonary abnormality. There was no significant interval change in the overall radiographic appearance of the chest when compared with the January 1983 study. VAMC inpatient treatment records show that the Veteran was hospitalized from October to November 1987. Upon admission, it was noted that he had a history of experiencing increasing pain in the right neck in association with increasing shortness of breath, cough, wheezing, dyspnea, marked and progressive respiratory distress which simply had gotten steadily and progressively worse, and had failed to respond to intensive outpatient medical management. Due to the Veteran's symptoms, he had not been able to function in his home or at work. Upon his discharge, he was diagnosed with the following: (1) acute and chronic asthmatic bronchitis, (2) status asthmaticus, (3) chronic obstructive pulmonary disease (COPD), and (4) acute pharyngitis with questionable right paratracheal mass. A private medical report shows that in October 1989, the Veteran sought a second opinion from R.V.-M., M.D., regarding his pulmonary status. The Veteran had been working with the Amtrack Railroad Company as a mechanic for approximately 10 years and during that period of time, he had experienced increasing pain, particularly in the neck and chest areas. Following the physical examination, Dr. V.-M. stated that although the Veteran's pulmonary screen was completely normal, given the Veteran's subjective complaints, and in light of the objective evidence that had been viewed by numerous physicians in regard to his underlying problem, it appeared that there was a strong possibility that the pain did emanate from the Veteran's chest. Dr. V.-M. reported that the Veteran had undergone fiberoptic bronchoscopy on two separate occasions, one in November 1987 and the other in June 1989. In both cases, the same location of the Veteran's endobronchial tree, that being the right middle lobe take-off, was noted to be involved in narrowing, as well as chronic bronchitic changes of the mucosa. Thus, in order to prevent further aggravation of the Veteran's coughing, Dr. V.-M. recommended that the Veteran be relieved of his job so that he no longer would be exposed to toxic substances. In a subsequent letter from Dr. V.-M., dated in January 2006, he stated that the Veteran suffered from chronic pain syndrome in the neck and throat area. In February 2008, the Veteran filed a claim of entitlement to service connection for idiopathic fibrosing mediastinitis. In support of his claim, he submitted two private medical statements. The first statement was from Dr. V.-M., dated in November 2007. In the statement, Dr. V.-M. indicated that the Veteran had been his patient for many years. Beginning in approximately 1979, the Veteran had been suffering from mid-sternal and throat pains. He had been worked up extensively with radiographic studies, such as chest x-rays and CT (computed tomography) scans, invasively such as bronchoscopies, and followed clinically both in Southern and Northern California. He had also traveled back East to medical centers for second opinions. According to Dr. V.-M., everything at that time seemed to point to the fact that the Veteran had acquired a process called idiopathic fibrosing mediastinitis. Dr. V.-M. stated that very little was known of that process, but it generally took many years to establish itself as a disease entity. Since clinical symptoms initially presented themselves around 1979, Dr. V.-M., opined that the process most likely began in the late 1960's when the Veteran was in the military. The second statement in support of the Veteran's claim was from R.W.T., M.D., dated in January 2008. In the statement, Dr. T. indicated that the Veteran had been his patient for over 10 years. During that time, he had treated the Veteran for a back injury related to the railroad, and chronic elusive throat and upper chest pain which had defied diagnosis treatment. Dr. T. reported that at present, the operating diagnosis was idiopathic fibrosing mediastinitis which was an orphan disease. Very little was known and no treatment was identified. According to Dr. T., it was known that the disease took a long time to declare itself. It was also known that the disease was a slow progressive disease and it appeared to be infectious in origin. Dr. T. opined that it most likely began in the late 1960's or early 1970's, in a time when the Veteran was in the military. Also in support of his claim, the Veteran submitted an article from the Internet regarding fibrosing mediastinitis. In the article, a private physician, Dr. J.L., was interviewed and asked questions regarding fibrosing mediastinitis. According to Dr. L., most patients with fibrosing mediastinitis were young, in their twenties to forties. The reason was unknown, but most patients probably were initially infected with Histoplasmosis in their youth. It appeared that the scar process grew at about one millimeter (mm) per year and, as such, it was very slow-growing and it could take several years before it led to obstruction of the large arteries, veins or airways, which were about 10-15 mm in diameter. Dr. L. reported that diagnosing fibrosing mediastinitis was best accomplished by chest CT scan which showed the abnormal tissue in the mediastinum (the space between the lungs). In November 2009, the Veteran underwent a VA examination in order to determine the etiology of his idiopathic fibrosing mediastinitis. Following the physical examination and a review of the Veteran's claims file, the examiner opined that the Veteran's idiopathic fibrosing mediastinitis was not caused by or a result of any military experience between 1966 and 1970. The examiner stated that the Veteran had undergone numerous examinations and evaluations for his airways disease which had been described as COPD (which he did not have), asthma (which he had), and bronchitis (which he had). The Veteran also had chronic rhinosinusitis with drainage into his bronchi feeding his bronchitis. He did not have the excruciating pain of mediastinitis which was a rapidly fatal disease if not appropriately treated and was due to trauma or surgery misadventure. According to the examiner, in the past, mediastinitis could be due to histoplasmosis and also tuberculosis. Those were the correlations that Dr. T. and Dr. V.-M. were referring to. However, it did not remain indolent for that period of time with the Histo and TBC becoming reactivated. The Veteran did not know his skin test results and there were no suspicious granuloma on his numerous chest x-rays and CT examinations. The examiner stated that idiopathic fibrosing mediastinitis would not remain indolent for that period of 40 years; it would not remain hidden from modern CT technology. In July 2013, the Board sought a VHA opinion. See 38 C.F.R. § 20.901. The Board requested that a pulmonologist review the entire evidence of record and provide an opinion regarding whether it was at least as likely as not (50 percent or greater probably) that the Veteran's currently diagnosed idiopathic fibrosing mediastinitis had its clinical onset during his active service or was related to any in-service disease, event, or injury? In providing an opinion, the VA physician was requested to comment on the medical opinions from Drs. T. and V.-M. and the November 2009 VA examiner's opinion. Pursuant to this request, the Board received a VHA opinion from N.A.M., M.D., a VA Staff Pulmonologist, dated in August 2013. In the opinion, Dr. M. stated that he had reviewed the Veteran's claims file. Military records did not document a history of pulmonary disease. Discharge chest x-ray was read as normal. Medical records indicated that beginning in 1981, the Veteran was repeatedly evaluated for chronic throat, neck, and chest pain by a number of physicians including pain management specialists. Records indicated that the etiology of the Veteran's symptoms was not conclusively determined. Chest x-rays were consistently read as essentially normal, though comments regarding a bleb at the apex of the right lung were noted. A chest CT scan, dated in September 1983, was negative for parenchymal or mediastinal abnormality specifically stating that no mediastinal lymph nodes were enlarged. In October 1987, the Veteran was admitted to the hospital for inpatient therapy of dyspnea and wheezing. He was under the care of a pulmonologist, Dr. R.L. The Veteran was treated with bronchodilators, antibiotics, and corticosteroids with clinical improvement. Fiberoptic bronchoscopy was performed in November 1987, demonstrating diffuse mucosal inflammatory changes with airway collapse in the right middle lobe compatible with the right middle lobe syndrome. Endobronchial mass lesions were identified. The primary discharge diagnosis was acute and chronic asthmatic bronchitis. In October 1988, the Veteran had a chest CT scan taken at a private facility. The study was read as normal. Specifically, no abnormality was identified in the mediastinum. Repeat fiberoptic bronchoscopy by Dr. L. in June 1989 demonstrated similar mucosal and right middle lobe findings to those noted during the initial bronchoscopy in November 1987. The Veteran was seen by Dr. V.-M. in October 1989, for a chief complaint of chest pain and for a pulmonary status assessment. Physical examination demonstrated scattered expiratory rhonchi, but office spirometry was reportedly normal. The pulmonary screen was reported as negative for significant lung disease. Dr. V.-M. opined that there was a strong possibility that the Veteran's chronic pain was from the chest. He advised the Veteran to terminate his employment with Amtrak, where he worked in maintenance. Reportedly, he was exposed to a variety of toxic chemicals, however, the precise nature of chemical exposure was not specified in Dr. V.-M.'s report. In December 2005, the Veteran had a CT scan of the chest taken at a private facility. That study demonstrated a soft tissue right paratracheal (mediastinal) mass extending from the superior vena cava to the hemiazygous vein, measuring 13 mm in width and 20 mm in length. CT numbers were over 500, possibly consistent with calcification. According to Dr. M., that was the first and only radiographic finding of mediastinal disease in the available medical record. In the November 2007 private medical statement from Dr. V.-M., he related a history of midsternal and throat pain for the Veteran beginning in 1979. Dr. V.-M.'s report also discussed extensive medical consultations, radiographs, and bronchoscopies performed in California and Eastern Medical Centers. The diagnostic conclusion of those evaluations was that the Veteran had acquired fibrosing mediastinitis. Dr. V.-M. opined that since the Veteran's symptoms (i.e., chest pain) began in 1979, the disorder was most likely acquired in the late 1960's during military service. In the January 2008 private medical statement from Dr. T., he stated that the operative diagnosis for the Veteran was fibrosing mediastinitis. It was Dr. T.'s opinion that the origin of that condition was likely to be infectious with onset in the late 1960's or early 1970's when the Veteran was in the military. In the November 2009 VA examination report, it was the examiner's assessment that the Veteran's medical history was consistent with asthma, bronchitis, and rhinosinusitis. The examiner concluded that the clinical picture was not compatible with idiopathic fibrosing mediastinitis acquired during military service. According to the VA examiner, idiopathic fibrosing mediastinitis was usually secondary to histoplasmosis and less often tuberculosis and would not have been inactive in the lung for 40 years. Also, the disorder would not have been hidden from CT technology. In the VHA opinion, Dr. M. stated that fibrosing mediastinitis was an excessive fibrotic reaction of the mediastinum which could compromise vital blood vessels, airways, and other mediastinal structures. It was a rare disease, which could result in substantial morbidity and potential mortality. It was commonly a sequel of pulmonary histoplasmosis, but had also been reported following other pulmonary fungal infections including blastomycosis and aspergillus, as well as pulmonary tuberculosis. An idiopathic form of fibrosing mediastinitis, not associated with infection had been described and may be associated with fibrosis in other organs including the orbit, thyroid, and retroperitoneal space. Fibrosing mediastinitis was typically an insidious progressive disease with a variable natural history. According to Dr. M., symptoms were usually secondary to airway compression and esophageal and vascular obstruction. The average interval from initial symptoms to diagnosis was 5 years in women and 2.2 years in men. Imaging studies including conventional CT, CT angiography and magnetic resonance imaging (MRI) were necessary to confirm the diagnosis. A lung biopsy was not usually necessary for diagnostic confirmation. Treatment was palliative. Based on a review of the available medical record, it was Dr. M.'s medical assessment that the Veteran's diagnosis of idiopathic fibrosing mediastinitis did not have its onset during his military service from November 1966 to March 1970. The available record did not specify how the diagnosis of idiopathic fibrosing mediastinitis was confirmed. However, it was clear that the CT scans of the chest from September 1983 and October 1988, did not demonstrate abnormalities in the lung parenchyma or the mediastinum. Dr. M. noted that Dr. V.-M.'s pulmonary assessment of the Veteran in October 1989 was normal. Although the Veteran complained of chest pain, his clinical and radiographic findings at that time were not consistent with fibrosing mediastinitis. As previously stated, the diagnosis of fibrosing mediastinitis could not be made on clinical grounds alone. Radiographic confirmation was mandatory. In their letters, neither Dr. T. nor Dr. V.-M. provided supporting confirmation by chest CT or MRI of the diagnosis of fibrosing mediastinitis. The CT scan dated in December 2005 demonstrated a unilateral mediastinal abnormality which could be consistent with fibrosing mediastinitis. Dr. M. stated that it was highly implausible that the Veteran developed that condition during military service from November 1966 to March 1970 without manifesting characteristic radiographic findings for over 35 years. Therefore, Dr. M. indicated that he disagreed with Drs. T. and V.-M. that the condition could have developed during military service. As noted, most affected individuals averaged 2-5 years between onset of symptoms and diagnostic confirmation. Therefore, the onset of fibrosing mediastinitis in the Veteran was most likely in the decade prior to December 2005, although that could not be determined with any degree of medical certainty. Dr. M. stated that he essentially agreed with the November 2009 VA examiner's assessment that the Veteran had asthma, bronchitis and rhinosinusitis. That conclusion was based on the Veteran's prior history of sinus surgery and the history of bronchospastic disease which necessitated hospitalization in October 1987. In addition, the bronchoscopic findings noted by Dr. L. were consistent with asthmatic bronchitis. None of those medical conditions were attributable to the Veteran's military service. Therefore, Dr. M. stated that it was his assessment that it was not likely, with a less than 50 percent probability, that the Veteran's diagnosis of fibrosing mediastinitis had its clinical onset during active military service or was in any way related to in-service disease or event. IV. Analysis The Veteran contends that he currently has idiopathic fibrosing mediastinitis which is related to his period of service. According to the Veteran, although he did not exhibit symptoms of idiopathic fibrosing mediastinitis until approximately March 1981, he maintains that he contracted the disease while he was in the military. Based on a thorough review of the record, the Board finds that there is a preponderance of evidence against the Veteran's claim for service connection for idiopathic fibrosing mediastinitis. In this regard, the Veteran's service treatment records are negative for any complaints or findings of a pulmonary disability, to include fibrosing mediastinitis. In addition, in the Veteran's March 1970 discharge examination, his lungs and chest were clinically evaluated as "normal." Moreover, a chest x-ray was reported to be within normal limits. In the August 2013 VHA opinion, Dr. M. stated that the diagnosis of fibrosing mediastinitis could not be made on clinical grounds alone; radiographic confirmation was mandatory. This finding is also supported by Dr. L. in the Internet article submitted by the Veteran. In the article, Dr. L. stated that diagnosing fibrosing mediastinitis was best accomplished by chest CT scan. Thus, imaging studies including CT scans and MRIs are necessary to confirm a diagnosis of fibrosing mediastinitis. In this case, the first diagnosis of fibrosing mediastinitis that is supported by imaging studies is in December 2005, over 35 years after the Veteran's discharge. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]. According to Dr. M. in the August 2013 VHA opinion, the private December 2005 CT scan report confirmed a diagnosis of fibrosing mediastinitis. Thus, the pertinent question in this case is whether the Veteran's currently diagnosed idiopathic fibrosing mediastinitis is related to his period of active service. The evidence of record reflects discrepancies in the medical opinions regarding this pertinent question. In support of the Veteran's claim, Drs. T. and V.-M. have submitted private medical statements wherein they opined that since clinical symptoms initially presented themselves in approximately 1979, the Veteran's idiopathic fibrosing mediastinitis most likely began in the late 1960's when he was in the military. However, the Board finds that the probative value of the opinions from Drs. T. and V.-M. is diminished by several factors. First, they do not provide, nor do they refer to, any imaging studies which confirm the diagnosis of idiopathic fibrosing mediastinitis. As previously stated, imaging studies are necessary to confirm a diagnosis of fibrosing mediastinitis. While Dr. V.-M. noted that the Veteran had undergone prior radiographic studies, including CT scans, he did not refer to a specific study confirming the diagnosis of idiopathic fibrosing mediastinitis. In addition, given that the diagnosis of fibrosing mediastinitis was confirmed in December 2005, then according to Drs. T. and V.-M., the Veteran's initial symptoms presented themselves in approximately 1979, and his idiopathic fibrosing mediastinitis most likely began in the late 1960's when he was in the military. However, they do not explain how the Veteran did not manifest any characteristic radiographic findings in that 35-year timeframe. In the VHA opinion, Dr. M. stated that it was clear that the Veteran's chest CT scans from September 1983 and October 1988 did not demonstrate abnormalities in the lung parenchyma or the mediastinum. Dr. M. specifically noted that Dr. V.-M.'s pulmonary assessment of the Veteran in October 1989 was normal. Although the Veteran complained of chest pain, his clinical and radiographic findings at that time were not consistent with fibrosing mediastinitis. Moreover, Dr. M. specifically reported that most affected individuals averaged 2 to 5 years between onset of symptoms and diagnostic confirmation. Dr. T. and Dr. V.-M. do not address the question of how the Veteran could have experienced symptoms of idiopathic fibrosing mediastinitis for approximately 35 years without manifesting any characteristic radiographic findings. Therefore, in light of the above, the Board finds that the probative value of the opinions from Drs. T. and V.-M. is significantly lessened. See Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997); Hayes v. Brown, 5 Vet. App. 60, 69 (1993) ("[i]t is the responsibility of the BVA . . . to assess the credibility and weight to be given the evidence"). By contrast, the Board attaches significant probative value to the conclusions reached by the VA examiner in November 2009 and Dr. M. in the VHA opinion. The Board finds that these opinions are clearly based upon a review of the relevant evidence in the claims file and are also supported by clear rationales. Both the VA examiner and Dr. M. opine that it was not likely, with a less than 50 percent probability, that the Veteran's diagnosis of fibrosing mediastinitis had its clinical onset during active military service or was in any way related to in-service disease or event. In addition, they both agreed that a diagnosis of idiopathic fibrosing mediastinitis would not remain hidden from modern CT technology for over three decades. In the VHA opinion, Dr. M. specifically stated that given that there was CT confirmation of fibrosing mediastinitis in December 2005, it was highly implausible that the Veteran developed that condition during military service from November 1966 to March 1970 without manifesting characteristic radiographic findings for over 35 years. Therefore, Dr. M. indicated that he disagreed with Drs. T. and V.-M. that the condition could have developed during military service. As noted, most affected individuals averaged 2-5 years between onset of symptoms and diagnostic confirmation. Therefore, the onset of fibrosing mediastinitis in the Veteran was most likely in the decade prior to December 2005. The opinions from the VA examiner and Dr. M. oppose, rather than support, the Veteran's contentions. The Board finds that these opinions are persuasive and assigns them great probative weight. Specifically, with respect to the opinion from Dr. M., this opinion was rendered by a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions). The Board recognizes the Veteran's contention that his currently diagnosed idiopathic fibrosing mediastinitis is related to his period of service. Specifically, the Veteran maintains that during service, he developed the initial symptoms of his idiopathic fibrosing mediastinitis which was not diagnosed until after his discharge in approximately 1981. The Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. The Veteran is certainly competent to testify as to symptoms such as coughing and chest pain. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship. The Veteran is not competent in this instance to opine that his currently diagnosed idiopathic fibrosing mediastinitis is related to his period of service because that is a complex medical question that requires medical expertise and training. Specifically, idiopathic fibrosing mediastinitis is diagnosed on the basis of radiographic studies. Specialized education and/or training are required for a determination as to such diagnosis or to determine the etiology of such disorder. Here, the Veteran has no such training or credentials. Absent such credentials, the Veteran is unable to provide a competent opinion as to a diagnosis and medical causation. See 38 C.F.R. § 1.59(a)(2). As a consequence, the Veteran's lay opinion would be of no more than minimal probative value, and is very substantially outweighed by the August 2013 VHA opinion from Dr. M. because Dr. M. is a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. The Veteran has submitted an article from the Internet regarding fibrosing mediastinitis. A medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses 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 opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). Review of this article reveals that a Dr. L. was interviewed and asked general questions regarding fibrosing mediastinitis. As previously stated, Dr. L. was in agreement with Dr. M. from the VHA opinion that imaging studies were needed to confirm a diagnosis of fibrosing mediastinitis. The Board recognizes that according to the Veteran, when Dr. L. stated that the scar process grew at about one mm per year and that it could take several years before it led to obstruction of the large arteries, veins, or airways, which were about 10 -15 mm in diameter, it was the Veteran's interpretation that Dr. L. reported that the interval from initial symptoms to diagnosis was 10 to 15 years. However, Dr. L. did not specifically state that the interval from initial symptoms to diagnosis was 10 to 15 years. Rather, he providing measurements of the large arteries, veins, or airways, which were about 10 -15 mm in diameter. In addition, even if the Board accepted as true that the interval from initial symptoms to diagnosis was 10 to 15 years, given that the first radiographic evidence of fibrosing mediastinitis was in December 2005, then the Veteran's initial symptoms would have been in approximately 1990, which was approximately 20 years after his discharge. Accordingly, the internet article submitted by the Veteran does not provide competent evidence relating any currently diagnosed idiopathic fibrosing mediastinitis to the Veteran's period of active service. In light of the above, the Board concludes that there is a preponderance of evidence against the Veteran's claim for service connection for idiopathic fibrosing mediastinitis. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claims, the benefit of the doubt doctrine does not apply and the claim must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for idiopathic fibrosing mediastinitis is denied. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs