Citation Nr: 1604390 Decision Date: 02/05/16 Archive Date: 02/11/16 DOCKET NO. 12-26 316 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to an initial compensable rating for pulmonary asbestosis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran had active service from September 1956 to August 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in October 2011 by the Department of Veterans Affairs (VA), Regional Office (RO), in Lincoln, Nebraska, which granted service connection and assigned a non-compensable (zero percent) disability rating for pulmonary asbestosis. In October 2013, the Veteran cancelled his request for a hearing before the Board. The Board remanded the case in February and September 2014 and in January June 2015 to the Agency of Original Jurisdiction (AOJ) (in this case, the RO). This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. The Board has considered the decision of the United States Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009). In that case, the Court held that a request for a total disability rating based upon individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation (whether in an original claim or as part of a claim for increased rating). Id. Here, the Veteran has not submitted a claim for TDIU and the evidence of record does not otherwise suggest that he is unemployable due to his pulmonary asbestosis, which the VA examiners have described as mildly disabling at most. Therefore, the Board finds that entitlement to TDIU is not for consideration. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The Veteran's service-connected pulmonary asbestosis, manifested by calcified bilateral pleural plaques, is best represented by his FVC PFT reading; his nonservice-connected COPD/emphysema is solely responsible for his DLCO PFT reading, his symptoms of cough, sputum production and shortness of breath and his need for supplemental oxygen and inhaled medications. 2. For the time period from June 10, 2011 to February 24, 2014, the Veteran's service-connected pulmonary asbestosis was manifested by post-bronchodilator FVC readings of at least 98.3 percent predicted. 3. For the time period from February 25, 2014 to September 1, 2014, the Veteran's service-connected pulmonary asbestosis was manifested by a post-bronchodilator FVC reading of 77.3 percent predicted. 4. For the time period since September 2, 2014, the Veteran's service-connected pulmonary asbestosis has been manifested by post-bronchodilator FVC readings of over 100 percent predicted. CONCLUSION OF LAW The criteria for an initial 10 percent rating from February 25, 2014 to September 1, 2014, for pulmonary asbestosis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321(b), 4.1, 4.2, 4.97, Diagnostic Code (DC) 6833 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. The Veteran's higher initial rating claim for pulmonary asbestosis is a "downstream" element of the AOJ's grant of service connection for this disability in the currently appealed rating decision. For such downstream issues, notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection. See VAOPGCPREC 8-2003 (Dec. 22, 2003). Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In June 2011, VA notified the Veteran of the information and evidence needed to substantiate and complete the service connection claim for pulmonary asbestosis, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). VA also notified the Veteran of the criteria for establishing an initial disability rating and effective date of award. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to the timing of the notice, the Board points out that the United States Court of Appeals for Veterans Claims (Court) has held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, all of the VCAA notice was provided prior to the currently appealed rating decision issued in October 2011; thus, all of this notice was timely. The Board is aware of the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) in which the Court held that, for an increased-compensation claim, § 5103(a) requires, at a minimum, VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Because this appeal arises from an initial rating decision, VCAA notice obligations are satisfied fully once service connection has been granted. Any further notice and assistance requirements are covered by 38 U.S.C. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, upon the filing of a timely NOD with respect to the initial rating or effective date assigned following the grant of service connection. Thus, Vazquez-Flores is inapplicable to this claim. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess/Hartman, 19 Vet. App. at 490-91. As noted above, the June 2011 AOJ notice advised the Veteran of the potential downstream issues of establishing a disability rating and an effective date of award. As the currently appealed rating decision was fully favorable to the Veteran on the issue of service connection for pulmonary asbestosis, and because the Veteran was fully informed of the evidence needed to substantiate this claim, the Board finds no prejudice to the Veteran in proceeding with the present decision. See also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the Board. It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Board observes that a VA examiner in September 2015 referenced the results from a PFT test conducted in the clinic setting that same month. The full results of that test are not of record, but the Board observes that the VA examiner is deemed competent to describe the test results accurately. A further remand to obtain any additional VA clinic records which are not capable of substantiating the claim would not serve any useful purpose at this time. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (finding that further development would serve no useful purpose when it would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). The Board is unaware of the existence of any relevant records in the possession of the Social Security Administration (SSA). The Veteran has been provided with VA examinations which address the current nature and severity of his service-connected pulmonary asbestosis. In this case, a controversy exists as to which pulmonary symptoms are attributable to service-connected pulmonary asbestos as opposed to nonservice-connected COPD. The Veteran was afforded VA examinations in August 2011 and May 2014 which recorded his description of pulmonary symptomatology and functional limitations, obtained physical examination findings and measured pulmonary function with pulmonary function tests (PFTs). A September 2015 VA Compensation and Pension (C&P) examination report, which is based upon review of the claims folder, explained the findings expected from pulmonary asbestosis based upon reference to medical literature, and provided a clear explanation of the Veteran's symptoms attributable to the service-connected pulmonary asbestosis as opposed to nonservice-connected COPD/emphysema. These examination reports are supplemented by findings in the private and VA clinic setting. Overall, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claim adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. Finally, the Board finds that there was substantial compliance with the February 2014, September 2014, January 2015 and June 2015 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, the Board in February 2014 directed the AOJ to ensure that all VCAA notification and development had occurred, to include contacting the Veteran to obtain information concerning VA and private treatment. Moreover, the AOJ was also directed to schedule the Veteran for appropriate VA examination which included PFT testing with FVC and DLCO findings and to determine the degree of impairment due to service-connected pulmonary asbestosis. In February 2014, the AOJ sent additional VCAA notice which requested authorization or information for all medical facilities and practitioners identified in the Board's remand. That same month, the AOJ obtained updated VA clinic records, and obtained a May 2014 VA examination wherein the examiner interviewed and examined the Veteran, but stated that current testing was not necessary. In so doing, the examiner stated that there had been no change in the Veteran's PFTs since August 2013 although the examination report cited multiple PFTs which were inconsistent regarding FVC and DLCO findings. The examiner also did not explain why current testing was not necessary. In September 2014, the Board again remanded the claim for an addendum opinion to clarify the basis for concluding that there was no change in the Veteran's condition since the August 2013 PFTs and why current testing was not necessary, to interpret the PFT findings referenced in the May 2014 examination including the specific percentage results attributable to each PFT in terms of FVC and DLCO findings, to clarify the date when each test was conducted, and determine if there was a disparity in the PFTs regarding FVC and DLCO findings and, if so, state the test which most accurately reflected the Veteran's level of disability. Additionally, the Board requested the AOJ to obtain updated VA clinic records. In response, the AOJ obtained updated VA clinic records in October 2014 and a VA C&P medical opinion in October 2014. The October 2014 VA C&P examiner provided a rationale as to why a repeat PFT had not been necessary during the May 2014 VA examination by clarifying that he had relied on a February 2014 PFT report (conducted in the VA clinic setting), clarified the findings from a September 2014 PFT, and opined that the Veteran's FVC rather than his DLCO finding appeared to be a more accurate reflection of the Veteran's level of disability. In January 2015, the Board remanded this claim for another addendum opinion as the October 2014 examiner did not adequately describe and clarify the apparent disparity between the Veteran's PFTs regarding FVC and DLCO findings, and did not provide sufficient rationale which indicated that either the Veteran's FVC or DLCO findings most accurately reflected his level of disability from service-connected pulmonary asbestosis. At this time, the Board also directed the AOJ to ensure that all VCAA notification and development had occurred, to include contacting the Veteran to obtain information concerning VA and private treatment. In April 2015, the AOJ sent additional VCAA notice which requested authorization or information for all medical facilities and practitioners and obtained updated VA clinic records. Also in April 2015, the AOJ obtained an addendum VA C&P examination report wherein the VA examiner stated that the Veteran's FVC findings most accurately reflected his level of disability due to pulmonary asbestosis and that his DLCO measurement would be more representative of his service-connected COPD/emphysema based on "all medical information taken into account" as well as the Veteran's "severe COPD." The examiner did not provide further rationale for this conclusion. In June 2015, the Board remanded this claim again to the AOJ for an addendum opinion which described and clarified whether the Veteran's service-connected pulmonary asbestosis resulted in any respiratory impairment and, if so, describe the associated symptomatology, which attempted to distinguish the Veteran's symptoms between nonservice-connected COPD/emphysema from his asbestos-related pleural disease, explain the differences in symptoms between these two diseases, and to explain whether FVC and DLCO values are indicative of impairment due to asbestosis-related pleural disease, impairment due to COPD, or a combination of both. The Board also directed the AOJ to ensure that all VCAA notification and development had occurred, to include contacting the Veteran to obtain information concerning VA and private treatment. In September 2015, the AOJ sent additional VCAA notice which requested authorization or information for all medical facilities and practitioners and obtained updated VA clinic records. Also in September 2015, the AOJ obtained another VA C&P examination report which, as discussed above, complies with the Board's prior remand directives and satisfies VA duty to obtain medical examination and opinion in this case. Accordingly, the Board finds that there has been substantial compliance with the prior remand directives and, therefore, no further remand is necessary. See Stegall, 11 Vet. App. at 268; D'Aries, 22 Vet. App. at 104. In summary, the Board finds that all reasonable efforts have been undertaken by VA with respect to the instant appeal, and no further development is required under these circumstances. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Laws and Regulations The Veteran contends that his service-connected pulmonary asbestosis is more disabling than currently evaluated. He specifically contends that all of his pulmonary symptoms are attributable to his service-connected pulmonary asbestosis rather than his nonservice-connected COPD and emphysema. In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as in this case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected pulmonary asbestosis, which is manifested by calcified bilateral pleural plaques consistent with asbestos exposure, is rated by analogy to asbestosis. See 38 C.F.R. § 4.97 DC 6833. Asbestosis is rated pursuant the general rating formula for interstitial lung disease. A 10 percent rating applies when there is Forced Vital Capacity (FVC) of 75 to 80 percent predicted, or a diffusion capacity of carbon monoxide (DLCO) of 66 to 80 percent predicted. A 30 percent rating applies when there is FVC of 65 to 74 percent predicted, or DLCO of 56 to 65 percent predicted. A 60 percent rating applies when there is FVC of 50 to 64 percent predicted or DLCO of 40 to 55 percent predicted, or maximum exercise capacity of 15 to 20 ml/kg/min. oxygen consumption with cardiorespiratory limitation. A rating of 100 percent applies when there if FVC less than 50 percent predicted, DLCO less than 40 percent predicted, maximum exercise capacity of less than 15 ml/kg/min. oxygen consumption with cardiorespiratory limitation, cor pulmonale or pulmonary hypertension, or when outpatient oxygen therapy is required. Id. VA evaluates PFT results based upon post-bronchodilation results which help to ensure consistent evaluations. See 61 Fed. Reg. 46720, 46723 (Sept. 5, 1996). VA amended the rating schedule concerning respiratory conditions, effective October 6, 2006, to clarify the use of PFTs in evaluating respiratory conditions. See 71 Fed. Reg. 52457 -01 (Sept. 6, 2006). A new paragraph (d) to 38 C.F.R. § 4.96, titled "Special provisions for the application of evaluation criteria for diagnostic codes 6600, 6603, 6604, 6825-6833, and 6840-6845" has seven provisions. In general, PFTs are required to evaluate respiratory conditions except in certain situations. If a DLCO (SB) test is not of record, evaluation should be based on alternative criteria as long as the examiner states why the DLCO (SB) test would not be useful or valid in a particular case. When the PFTs are not consistent with clinical findings, evaluation should generally be based on the PFTs. Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes with some exceptions; when evaluating based on PFTs. Post-bronchodilator results are to be used unless they are poorer than the pre-bronchodilator results, then the pre-bronchodilator values should be used for rating purposes. When the results of different PFTs (FEV-1, FVC, etc.) are disparate, the test result that the examiner states most accurately reflects the level of disability should be used for evaluation, and if the FEV-1 and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV-1/FVC ratio should not be assigned. In issuing the final rule for section (d) above, VA noted that the regulations did not require that a maximum exercise capacity test be conducted in any case. VA stated that the test was not routinely conducted and not even available in some medical facilities. Rather, the standard of measure could provide an alternative to an increased rating if already available of record. See 71 Fed. Reg. at 52458. The Veteran also has respiratory disability due to nonservice-connected COPD and emphysema. In general, the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In Johnson, the Federal Circuit held that 38 C.F.R. § 3.321 required consideration of whether a Veteran is entitled to referral to the Director, Compensation Service, for consideration of the assignment of an extraschedular rating based on the impact of his or her service-connected disabilities, individually or collectively, on the Veteran's "average earning capacity impairment" due to such factors as marked interference with employment or frequent periods of hospitalization. See Johnson v. McDonald, 762 F.3d 1362 (2014); see also 38 C.F.R. § 3.321(b)(1). As is explained below in greater detail, following a review of the record evidence, the Board concludes that the symptomatology experienced by the Veteran as a result of his service-connected disabilities, individually or collectively, does not merit referral to the Director, Compensation Service, for consideration of the assignment of an extraschedular rating. In other words, the record evidence does not indicate that the Veteran's service-connected disabilities (bilateral hearing loss and pulmonary asbestosis), individually or collectively, show marked interference with employment or frequent periods of hospitalization or otherwise indicate that the symptomatology associated with them is not contemplated within the relevant rating criteria found in the Rating Schedule. Factual Summary Historically, the Veteran filed his service connection claim for asbestos-related disease in June 2011. In pertinent part, the Veteran's VA clinic records include a September 2004 PFT reflecting a post-bronchodilator reading of an FVC of 111.1 percent predicted and a DLCO (SB) of 54.5 percent predicted. The spirometry results were interpreted as showing mild airflow obstruction with modest improvement after bronchodilators, and moderately reduced diffusion capacity. An April 2010 examination report from Midwest Pulmonary/Critical Care, P.C., noted that, during a recent hospitalization for kidney stones, the Veteran had developed hypoxemia, pulmonary infiltrates and cough. He was a former smoker. Examination disclosed that the lungs were clear to auscultation. A PFT indicated an FEV of 75 percent and diffusion capacity of 56 percent. The examiner did not report an FVC reading. The Veteran's assessments included mild obstructive lung disease, and resolved hypoxemia. A July 2010 examination report from Midwest Pulmonary/Critical Care, P.C., reported the Veteran to have a history of mild COPD. He described symptoms of fatigue, lack of energy, hoarse voice and chronic dry cough. He had quit smoking 2 months previous. Examination disclosed that the lungs were clear to auscultation. He was given assessments of chronic dry cough possibly associated with blood pressure medications, fatigue of unclear etiology and mild COPD with an FEV-1 at 72 percent. The examiner did not report an FVC reading. A January 2011 x-ray examination of the chest was interpreted as showing mild interstitial thickening and pleural thickening of the right lateral chest. A January 2011 computed tomography (CT) scan of the chest was interpreted as showing, inter alia, severe emphysematous changes as well as calcified and non-calcified pleural plaque likely the sequela of prior asbestosis exposure. A May 2011 chest x-ray was interpreted as showing hyperinflation with interstitial changes, and calcified pleural plaque consistent with asbestos-related disease. On his initial VA examination on August 2011, the Veteran reported ongoing shortness of breath with exertion. He experienced dyspnea with mild exertion and had additional symptoms of a cough productive of clear sputum. Examination revealed no abnormal breath sounds. A PFT demonstrated a post-bronchodilator reading of an FVC of 110.7 percent predicted. The examiner was unable to perform DLCO testing as there was no diffusion gas. It was noted that the Veteran had an obstructive spirometry pattern with mild airflow obstruction unimproved following bronchodilator. It was commented that there was no significant change since the September 2004 PFT. The examiner offered diagnoses of pulmonary asbestosis and COPD. The examiner opined that the Veteran's pleural plaques demonstrated on x-ray examination were at least as likely as not a result of in-service asbestos exposure, but that his long-term smoking history was the likely cause of his long-standing COPD. An October 2011 AOJ rating decision granted service connection for asbestosis, and assigned an initial 0 percent rating under DC 6833 effective June 10, 2011. In pertinent part, an August 2013 VA pulmonary consultation in the clinic setting documented the Veteran's report of a gradual worsening of dyspnea on exertion (DOE), initiated with climbing stairs but resolving within minutes of rest, over the last several months. The examiner indicated that the Veteran likely had COPD causing DOE. The Veteran was started on inhaler therapy and advised to quit smoking. A subsequent PFT in August 2013 revealed post-bronchodilator readings of an FVC of 98.3 percent predicted and DLCO (SB) of 45.6 percent predicted. The spirometry results were interpreted as showing a variable extrathoracic obstruction spirometry pattern of mild severity. It was further noted that the diffusing capacity was moderately reduced. The examiner indicated that there was no significant change since the PFT conducted in August 2011. Thereafter, a December 2013 VA primary care clinic note included the Veteran's report of shortness of breath (SOB) even at rest. He had an oxygen saturation of approximately 90 after a six minute walk test and approximately 88 with activity. The Veteran described feeling tired most of the time, easy SOB with activity, a dry cough at night, and a productive, clear cough in the morning. He was noted to appear cyanotic. At that time, the Veteran was prescribed Spiriva plus Albuterol as needed (PRN) and approved for home oxygen therapy. He was further advised to quit smoking. In February 2014, a CT scan of the chest was ordered based upon the severity of the Veteran's symptoms and his degree of hypoxemia despite only mild obstruction being found on PFTs. A CT scan of the chest was interpreted as showing severe emphysema and calcified bilateral pleural plaques consistent with prior asbestos exposure. A follow-up consultation later that month reflected the Veteran's report of no change in his tolerance of activity with home oxygen and rescue inhaler use. However, he did report that his medications were helping. A PFT, conducted on February 25, 2014, showed post-bronchodilator readings of an FVC of 77.3 percent predicted and a DLCO (SB) of 41.7 percent which, according to the examiner, showed minimal change since the last examination. The Veteran underwent VA examination in May 2014. He was described as having a long-standing history of COPD which required outpatient oxygen therapy. He worked part-time delivering newspapers, and could walk 30 to 40 steps before getting out of breath. The VA examiner diagnosed COPD and bilateral pleural plaques, and indicated that current PFT testing was not necessary. On review of the record, the VA examiner commented that the Veteran had CT scan evidence of bilateral pleural plaques consistent with prior asbestos exposure as well as severe emphysema. It was noted that, in many cases, pleural plaques were usually present but of no clinical or physical significance. The Veteran had pleural plaques bilaterally, but the vast majority of his respiratory issues were coming from his severe emphysema. Therefore, the VA examiner reasoned that, concerning his respiratory status, the current severity of the Veteran's service-connected asbestosis would be mild at best because his bilateral pleural plaques were far outweighed by his severe emphysema - which had caused his difficulty breathing and was less likely due to the pleural plaques in and of themselves. The examiner also opined that, if the Veteran did not have COPD, his exercise capacity would likely be very minimal to mild as many patients had pleural plaques and pleural thickening but most did not exhibit any specific respiratory complaints. Thereafter, the Veteran's VA clinic records reflect that a PFT performed on September 3, 2014 demonstrated post-bronchodilator readings of an FVC of 113.0 percent predicted, and a DLCO (SB) of 41.1 percent predicted. The claims file was returned for an addendum opinion in October 2014. The examiner first explained that additional PFT testing was not performed as the Veteran had undergone PFT testing several months previously. It was noted that the last 3 PFTs showed no significant change, and that the Veteran denied any change in his respiratory status. In fact, at a July 2014 clinic visit, the Veteran reported that his breathing was better. Additionally, the PFT was a difficult test for the Veteran to perform as he had COPD, which exhausted him and caused him to be out of breath. Thus, it was clinically contraindicated given that the Veteran had undergone PFT testing 2 to 3 months earlier and additional testing had a medical risk. The examiner acknowledged a disparity in the PFT readings, but noted that the results had improved. Additionally, the examiner stated that the Veteran's FVC readings appeared to be the more accurate reflection of his disability level. Thereafter, VA clinic records in December 2014 reflect the Veteran's report that his SOB was at baseline. He continued to smoke cigarettes, and had not used his inhalers recently. Examination showed minimal wheezing with decreased air entry bilaterally. The AOJ obtained a VA medical opinion, based upon review of the claims folder, in April 2015. The examination report reflects that the opinion was prepared with consultation with a pulmonologist. It was indicated that the Veteran's FVC findings most accurately reflected his level of disability that he experienced from his pulmonary asbestosis which was based upon "all medical information taken into account." It was noted that the DLCO reading would be more representative of the Veteran's COPD/emphysema which explained the disparity between the FVC and DLCO readings. The examiner found no evidence to suggest aggravation. In pertinent part, VA clinic records in April and May 2015 noted that the Veteran had no rales or rhonchi on physical examination. The Veteran reported oxygen use for sleep only. An additional VA examination, based upon review of the claims folder, was obtained in September 2015. The examiner indicated that the Veteran demonstrated pleural plaques on imaging of the chest, but that there was no radiographic or histologic evidence to confirm the presence of interstitial pulmonary fibrosis. The Veteran had a reduced DLCO which was most likely secondary to his COPD due to significant smoking history. However, it is noted that the Veteran's lung volumes appeared well-preserved with his most recent PFT values in clinic setting in September 2015 being over 100% of predicted value. Furthermore, it was noted that the most recent VA primary care visitations in September and October 2015 found no rales or crackles on physical examination of the lungs to indicate the presence of pulmonary interstitial fibrosis. The VA examiner indicated that the Up To Date online version noted that three key findings supported the diagnosis of asbestosis - 1) a reliable history of exposure to asbestos with a proper latency period from the onset of exposure to the time of presentation and/or the presence of markers of exposure (e.g., pleural plaques, which were virtually pathognomonic of previous exposure, or recovery of sufficient quantities of asbestos fibers/bodies in bronchoalveolar lavage (BAL) or lung tissue; 2) definite evidence of interstitial fibrosis, as manifested by one or more of the following: end-inspiratory crackles on chest examination; reduced lung volumes and/or DLCO; presence of typical chest radiograph or high resolution CT scan (HRCT) findings of interstitial lung disease; or histologic evidence of interstitial fibrosis and 3) the absence of other causes of diffuse parenchymal lung disease. The VA examiner, based on review of evidence of record, VA clinic records, previous exams/opinions and online medical resources, opined that, although Veteran does have asbestos-related pulmonary disease in the form of pleural plaques, there was little, if any, symptomatology related to the asbestos-related pleural plaques. It was further opined that the Veteran's symptoms of cough, sputum production, shortness of breath, need for supplemental oxygen, and inhaled medications were most likely attributable to his COPD/emphysema with ongoing tobacco use. As previously opined/explained, the Veteran's DLCO per PFT was most indicative of his COPD/emphysema and his FVC would be more indicative of any impairment due to pleural plaques at the present time. Analysis At the outset, the Board notes that VA primarily evaluates pulmonary asbestosis according to FVC or DLCO PFT readings. In this case, the Veteran is service-connected for pulmonary asbestosis manifested by bilateral pleural plaques but he also manifests a co-existing COPD/emphysema which is not service-connected. VA may award compensation only for service-connected disability. 38 U.S.C.A. §§ 1110, 1155. Here, a September 2015 VA examiner found that the Veteran's service-connected pulmonary asbestosis symptomatology is limited to his FVC PFT reading, and that his nonservice-connected COPD/emphysema is manifested by his DLCO PFT reading with symptoms of cough, sputum production and shortness of breath as well as his need for supplemental oxygen and inhaled medications. The Board places great probative weight to this opinion as it is based upon the medical examiner's medical training and review of medical literature in light of the clinical and radiographic findings. This examiner indicated that a finding of bilateral pleural plaques, in and of itself, did not result in any symptoms in most people. The Board further notes that this examiner's opinion is consistent with the prior VA opinions of record, although those opinions are not supported by adequate rationale. On the other hand, the only opinion which attributes the Veteran's impaired DLCO PFT reading, as well as symptoms of cough, sputum production and shortness of breath with his need for supplemental oxygen and inhaled medications, consists of the personal opinion of the Veteran. The Veteran, while competent to describe symptoms such as cough, sputum production, shortness of breath and the use of supplemental oxygen and inhalers for breathing difficulties, is not shown to possess the requisite medical training and expertise to speak to the complex medical issues involving the nature and etiology of his pulmonary symptoms. Overall, the Board finds that the opinion of the September 2015 VA examiner greatly outweighs the Veteran's lay opinion on this issue. As such, the Board finds that the Veteran's service-connected pulmonary asbestosis, manifested by calcified bilateral pleural plaques, is best represented by his FVC PFT reading. The Board also finds that the Veteran's nonservice-connected COPD/emphysema is solely responsible for his DLCO PFT reading, his symptoms of cough, sputum production and shortness of breath and his need for supplemental oxygen and inhaled medications. The Board next finds that, for the time period from June 10, 2011 to February 24, 2014, the criteria for an initial compensable rating for pulmonary asbestosis have not been met. In this respect, the evidence during this time period reflects post-bronchodilator FVC readings of 110.7 percent predicted in August 2011 and 98.3 percent predicted in August 2013. These PFT values fall well short of the criteria for an FVC value of at least 80 percent predicted to warrant the minimum 10 percent rating. In contrast, the Board finds that the criteria for an initial 10 percent rating have been met on February 25, 2014 when a PFT conducted in the VA clinic setting reflected an FVC of 77.3 percent predicted. The Board finally finds that, for the time period from September 2, 2014 to the present, the criteria for an initial compensable rating for pulmonary asbestosis have not been met. In this respect, the evidence during this time period reflects post-bronchodilator FVC readings of 113 percent predicted on September 2, 2014 and an FVC reading of over 100 percent predicted in September 2015. In arriving at this conclusion, the Board observes that all of the Veteran's FVC values have been greater than 98 percent predicted with the exception of the single, anomalous reading of 77.3 percent predicted on February 25, 2014. The Board observes that there is no indication of record that the PFT testing conducted on February 25, 2014 was invalid for any reason and the record reflects the Veteran's treatment at that time for an exacerbation of respiratory symptoms. As such, the Board resolves reasonable doubt in favor of the Veteran by finding that the PFT reading on February 25, 2014 was a valid measurement of his respiratory status at that time and, as such, finds that an initial compensable rating is warranted. The Board next finds that it is not factually ascertainable whether the Veteran met the criteria for a compensable rating prior to February 25, 2014. In this respect, the Veteran did report an exacerbation of respiratory symptoms in December 2013, but the record does not reflect any objective measurement of his forced vital capacity at this time and the prior reading in August 2013 reflected an FVC of 98.3 percent predicted which was well above the criteria for a compensable rating under DC 6833. The Board further finds that, since September 2, 2014, the record reflects that the criteria for an initial compensable rating for pulmonary asbestosis have not been met. As noted by the VA examiner in October 2014, the Veteran reported an improvement of his breathing difficulties which are reflected in his subsequent FVC values being greater than 100 percent predicted. Overall, the short time period from February 25, 2014 to September 1, 2014 at best represents a temporary period of an exacerbation of symptomatology which, when resolving reasonable doubt in favor of the Veteran, meets the criteria for a compensable rating. The evidence before and after this time period overwhelming reflects that the criteria for a compensable rating under DC 6833 have not been met. The Board has found the Veteran's reported symptomatology of cough, sputum production and shortness of breath with a need for supplemental oxygen and inhaled medications to be credible and consistent with the medical evidence of record. As noted elsewhere, however, the Board also has found that the credible and competent evidence of record has attributed these symptoms to the Veteran's nonservice-connected COPD/emphysema. The Board has placed greater probative weight on the measurements of the Veteran's pulmonary capacity by a more accurate and objective measure of PFT testing as well as the other clinical findings by VA physicians who have greater training and expertise than the Veteran in evaluating a pulmonary disorder. For these reasons, the Board finds that the criteria for an initial 10 percent rating for pulmonary asbestosis from February 25, 2014 to September 1, 2014 have been met. As the preponderance of the evidence is against any further compensation, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected pulmonary asbestosis. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluations assigned for the Veteran's service-connected pulmonary asbestosis are not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected pulmonary asbestosis. In this respect, the VA examiners have indicated that the Veteran's FVC value most accurately describes the pulmonary impairment due to asbestosis, which has been measured on multiple occasions during the appeal period. Additionally, the VA examiners have described any symptoms attributable to pulmonary asbestosis as being, at best, minimal to mild in degree. This description of disability is consistent with the staged ratings assigned. The VA examiners have not described any unusual or exceptional features associated with his pulmonary asbestosis. And, as noted elsewhere, the Veteran's own belief that all his pulmonary symptoms are attributable to service-connected etiology is outweighed by the opinion of the September 2015 VA examiner. In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See also Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board notes that under Johnson, 762 F.3d at 1362, a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, after applying the benefit of the doubt under of Mittleider, 11 Vet. App. at 181, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. ORDER Entitlement to an initial 10 percent rating from February 25, 2014 to September 1, 2014 for pulmonary asbestosis is granted. ____________________________________________ MICHAEL T. OSBORNE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs