Citation Nr: 1607643 Decision Date: 02/26/16 Archive Date: 03/04/16 DOCKET NO. 06-16 738 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a back disorder, to include post-operative residuals of lumbar surgeries and degenerative disc and joint disease. 2. Entitlement to service connection for a lung disorder, to include as secondary to asbestos exposure. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD A. Barner, Counsel INTRODUCTION The Veteran served on active duty from May 1960 to May 1962. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran and his spouse appeared and testified at a hearing in November 2008 before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In September 2011 the Board issued a decision denying the Veteran's claim of entitlement to service connection for a back disorder, and remanding the claim of entitlement to service connection for a lung disorder. In April 2013, the United States Court of Veterans' Claims (CAVC) issued a decision vacating the Board's September 2011 decision, and directing that the Board remand to request inpatient clinical records from the United States Naval Hospital in Jacksonville, Florida; reassess the credibility of the Veteran's statements; and if necessary, request another VA examination that accounts for the appellant's reported history. In November 2014 the Board remanded the appeal requesting further records development and VA examination for the back and for the lungs. Records were requested and VA examinations provided. There has been substantial compliance with the remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with Board's remand instructions). FINDINGS OF FACT 1. A low back disability was not present in service, lumbar arthritis was not compensably disabling within a year of separation from active service, and a low back disorder is not the result of any incident or incidents of the Veteran's active military service. 2. The preponderance of the evidence is against finding that the Veteran's lung disorder is related to active military service or events therein, to include asbestos exposure or pneumonia in service. CONCLUSIONS OF LAW 1. A back disorder, to include post-operative residuals of lumbar surgeries and degenerative disc and joint disease, was not incurred in active service, and spinal arthritis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1131, 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a) (2015). 2. A lung disorder was not incurred in or caused by active military service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in May and June 2004, of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain. The January 2011 supplemental statement of the case provided notice regarding the assignment of disability ratings and effective dates. The claim was most recently readjudicated in September 2015. VA has also satisfied its duty to assist. The claims folder contains the Veteran's service treatment and personnel records. In March 2015 VA was informed that any records from Boca Chica sick bay, or the Jacksonville Hospital (now the Naval Branch Health Clinic) were at the National Personnel Records Center. In August 2015 the National Personnel Records Center indicated that there were no records for the Veteran's treatment in 1961 at Boca Chica. Further, although some Social Security records are associated with the claim the Social Security Administration informed VA that any further records they may have once held had been destroyed, and therefore they are not available for review. The Veteran was provided a VA examination most recently in January 2015 with a September 2015 addendum provided, to address the nature and etiology of his claimed lumbar disorder, and in December 2014 to address the nature and etiology of his claimed lung disorder. On review, the examination reports appear comprehensive and include a rationale for the opinion provided, which addresses specific evidence as requested by the remand instructions. As such, the exam is considered adequate and additional examination is not warranted at this time. In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. See 38 C.F.R. § 3.159. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131 (West 2014). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2015). Some disabilities may be presumed to have been incurred in service if shown to have manifested to a compensable degree within one year after the date of separation from service, to include arthritis. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). The provisions of 38 C.F.R. § 3.303(b) are constrained by 38 CFR § 3.309(a), regardless of the point in time when a veteran's chronic disease is either shown or noted, in that the regulation is only available to establish service connection for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed.Cir.2013). Although there is no specific statutory or regulatory guidance regarding claims for residuals of asbestos exposure, VA has several guidelines for compensation claims based on asbestos exposure. See M21-1MR, IV.ii.2.C.9; and M21-1MR, IV.ii.1.H.29. In addition, an opinion by the VA General Counsel discussed the provisions of M21-1 regarding asbestos claims and, in part, concluded that medical nexus evidence was needed to establish a claim based on in-service asbestos exposure. VAOPGCPREC 4-00; 65 Fed. Reg. 33422 (2000). Essentially, VA must determine whether military records demonstrate evidence of asbestos exposure during service; whether there was pre-service, post-service, occupational, or other asbestos exposure; and whether there is a relationship between asbestos exposure and the claimed disease. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015). Lumbar Disorder In October 2004, VA denied entitlement to service connection for a back disability. The Veteran disagreed and subsequently perfected this appeal. The Veteran contends that his lumbar disorder is related to service, to include due to repetitive heavy lifting that he performed in service. In statements and testimony, the Veteran described some of his in-service jobs. For example, he reported that he had to label, prepare for shipment, and ship hundreds of five gallon buckets of paint; that he dealt with heavy equipment while working in aircraft supply; that he carried heavy supplies to replenish the ship; and that he had to hang heavy drop tanks. He reported that he went to sick bay for back pain while stationed at the Naval Air Station Key West (aka Boca Chica Field), and while on board the USS Saratoga. He has reported continuing back pain following discharge. A review of service treatment records does not show complaints or diagnoses related to the low back. At an April 1962 separation examination the Veteran's spine was reported as normal on clinical evaluation. Notwithstanding, the Veteran is competent to report that he experienced back pain during his military service. See Charles v Principi, 16 Vet App 370, 374 75 (2002) (appellant competent to testify regarding symptoms capable of lay observation). The Veteran's DD Form 214 indicates that he was a seaman. Thus, his reports of moving heavy supplies and other miscellaneous manual labor appear consistent with his military duties. The Veteran has reported that he spent two weeks in the Naval Hospital recovering from conditions to include back problems. Evidence of record shows a history of multiple post-service lumbar procedures. A private medical record dated January 19, 2000 documents a history of a laminectomy in 1973, and lumbar fusions in 1980 and 1994. A private record dated January 25, 2000 notes a laminectomy in 1978, a fusion and hip graft in 1982, and a fusion with rods and screws in 1993. The Veteran was involved in an accident in May 1997 and has had back pain since. Records from Piedmont Hospital indicate that the Veteran underwent additional lumbar spine surgery in May 2000 for pseudoarthrosis and broken hardware. On VA examination in June 2004, the Veteran reported low back pain since 1961. Following examination, the diagnosis was status-post lumbar surgeries with residuals of intervertebral disc disease at L2-3 and degenerative changes. VA records show continued complaints and treatment for back pain. Records dated in February 2007 indicate that the Veteran was in another accident and had increasing pain in the low back and both legs. In December 2007, the Veteran reported that he injured his low back during service but that the records were lost. He was requesting a benefit support letter. A December 2007 statement from Dr. A. Scheid indicates that the Veteran suffered from chronic low back pain which the appellant reported having since service. He related that he was required to label hundreds of five gallon paint buckets which started his back pains and that he saw several military doctors. The Veteran reported that the military was unable to locate his records, that since leaving the military he had low back surgery, and that he still has back pain. Given this information, the physician believed the Veteran's back pain was most likely the result of activities he did while in the Navy and that he should be service-connected for back pain. The Veteran submitted an October 2008 letter from Dr. Osborn confirming that the Veteran had been examined, and his history reviewed, to include the Veteran's report of injuring his back when loading heavy cans of paint on a repetitive basis in the 1960s, although his related Navy Medical treatment records from that time were no longer available. The Veteran reported that he continued to experience pain following service, and eventually underwent four lumbar surgical procedures. Dr. Osborn opined that to a reasonable degree of medical certainty the Veteran's on-going back problems that led to four surgical procedures and resulted in continued pain resulted from injury while performing heavy lifting in the Navy. Dr. Osborn concluded that the Veteran would likely have ongoing needs with respect to his back and further surgery due to adjacent level degeneration next to his fusion. A November 2008 statement from Dr. Scheid indicates that he is the Veteran's primary care physician. He reported that the Veteran suffered from chronic low back pain which started while he was in the military. The appellant reported that he had to lift and carry many paint cans which caused him to visit the infirmary on multiple occasions. Given this history, Dr. Scheid believed that chronic low back pain was more likely than not related to the Veteran's work while in the Navy. A January 2009 mental health evaluation notes that the Veteran worked for an airline for ten to eleven years and then following a back injury, did cabin service control for twelve to thirteen years. VA examination of the lumbar spine was obtained in July 2010; however, the Court has indicated that the probative value is questionable because it is unclear that the Veteran's full medical history was reviewed. In light of the Court's concern the Board will assign this report no probative value. In November 2013 a VA doctor wrote that the Veteran was regularly followed in the clinic, reporting multiple episodes of back pain, and currently having significant low back pain, with arthritis and degenerative disk disease, as well as past radiculopathy post surgery. The doctor opined that it was at least as likely as not that the Veteran's current back problems were related to his back injuries while in the military. Significantly, no reasoning was provided with this opinion, such that it is afforded little probative value as for etiological opinion. This letter was resubmitted in December 2013. In December 2013 the Veteran wrote his medical provider noting that he had requested a nexus letter attributing his back problems to service, and because the examiner had not provided help in this matter, the Veteran indicated that while he could have been closer to having the ability to pay the bill in full, he was unable to do so at present. In May 2014 the Veteran was afforded a VA examination for his back. The diagnosis were degenerative arthritis of the spine, and degenerative joint disease of the lumbosacral spine. The Veteran reported that in service he had episodes of back pain due to heavy lifting. He did not give a history of back injury in service, but did report going to sick bay many times for back pain. He did not identify specific back treatment post-service. He indicated that he worked office jobs post service until approximately 1968, and then worked as a ramp agent for airlines, at which time his back problems flared-up again. The Veteran reported that in 1973 he began working in baggage handling and air cargo. In 1975 he had a ruptured disc, which led to a laminectomy. In 1980 he was on light duty. He had his first fusion in 1982, and two more operations, with the most recent in 2000. The Veteran reported that he experienced severe back pain, especially with walking and sitting, but that he did not receive any treatment for his back, although he had received pain medication in the previous month for other medical issues. In 2011 he was weaned off narcotics and put on anti-inflammatories. The Veteran reported regularly using a cane and brace as assistive devices for locomotion. Imaging from 2013 was reviewed, and the impression was stable postsurgical changes at L3-4 related to discectomy/intervertebral cage placement and posterior fusion; mild to moderate spondylosis in the lumbar spine above and below the fusion, and mild grade 1 retrolisthesis at L2-3, stable, likely of a degenerative etiology. The May 2014 VA examiner observed that the Veteran had severe low back pain and had undergone four operations on his back between the 1970s and 2000s. The examiner opined that it was less likely than not that the Veteran's low back disorder was related to service. He reasoned that he had examined the Veteran's low back in July 2010, at which time he was unable to connect the Veteran's low back disorder to service. Following review of the Veteran's service records there was no contemporaneously prepared evidence showing that he injured his back inservice. Further, on separation examination, and a later examination in October 1962 the Veteran marked "no" to all musculoskeletal questions including use of a brace or back support. In addition, following service there was no evidence that the Veteran was treated for a low back condition. From 1968 to 1975 the Veteran worked as a baggage handler and did other heavy work, and the examiner considered this as support for the conclusion that the Veteran's back functioned well at that time. In the mid-1970s the Veteran herniated a disc and received surgical therapy. The examiner concluded that he could not determine or accurately estimate loss of range of motion when the Veteran reported he had flare-ups of pain, fatigue, weakness or incoordination, without resorting to mere speculation. An addendum opinion was provided in September 2014 wherein the physician opined that it was less likely than not that the Veteran's low back condition was related to service. He reasoned that the Veteran had been seen by him in 2010, at which time he had been unable to connect the claimant's lumbar disorder to service. The examiner noted that a review of service treatment records did not show evidence of a back injury. Then, the April 1962 separation examination and an additional October 1962 examination showed the Veteran marked 'no' to all musculoskeletal questions including use of brace or back support. Following service, there was no evidence that the Veteran was treated for a low back condition, and from 1968 to 1975 the Veteran worked as a commercial airline baggage handler and did other heavy work. The examiner considered this to be evidence that the Veteran's back functioned well at the time. The Veteran then had a herniated disc and underwent surgery in 1975. The Board notes that this opinion is afforded little probative value in light of its reliance on the absence of records, and failure to discuss the Veteran's reported history of continuous back pain since service, as well as his reported history of heavy lifting in service. In January 2015 the Veteran was afforded another VA examination for his lumbar spine. The Veteran's diagnoses of lumbar strain in 1962, degenerative arthritis of the spine in 1993, and intervertebral disc syndrome in 1993, and spinal fusion in 1993 were reviewed. The Veteran reported that he injured his back in service while working in aviation supply and lifting heavy equipment and labeling numerous five gallon cans of pain. The Veteran reported that he sought treatment on several occasions in service, and that he treated his back pain with medication, but did not receive physical therapy or X-rays. He denied that inservice falls injured his back. He reported experiencing pain with walking, prolonged sitting and standing. The Veteran described pain in his low back going down his legs, with numbness of his legs and feet. He had undergone four back surgeries; a laminectomy in 1972, and three spinal fusions since. He also had a surgery to replace the pins from his previous surgeries that were broken when he was in a motor vehicle accident. At present, the Veteran did not take medications for pain because of other medical complications. Work history involved civilian office jobs, and four years as a baggage handler, and fifteen years in fueling for the airlines. Following examination, the examiner opined that the Veteran's back disorder was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that the Veteran's provided service treatment records did not document any clinic visits or treatment for back pain, and all reports of physical examinations in service were negative for back complaints. Further, the examiner observed that the Veteran had been found physically fit to perform his duties on all of his military examinations. The examiner considered that the Veteran reported performing tasks while in the service that required him to lift heavy drums of pain, and to bend frequently to label the paint drums, and that these activities could possibly cause acute lumbar strain even though service treatment records did not show treatment for such. The examiner concluded, however, that acute lumbar strain generally resolves without residuals. The Veteran denied that a fall injured his back. Medical records did not document treatment for back problems within one year of discharge from service. The Veteran had a long history of low back problems. He had a laminectomy in 1972 approximately ten years after separation from service. Then there was a spinal fusion surgery in 1993, and CT from 1997 and 1998 showed pseudoarthrosis and spinal stenosis. The Veteran's current reports of symptomatology related to his multiple back surgeries and the degenerative arthritis and disc disease. The examiner concluded that it was unlikely that the lumbar sprain that may have occurred in service contributed to any of the subsequent lumbar spine problems that the Veteran subsequently developed. In a September 2015 addendum opinion, a VA examiner considered Dr. Scheid's 2009 opinion, and concluded that Dr. Scheid failed to indicate that he reviewed the Veteran's military records, and based his opinion on subjective information provided by the Veteran, rather than objective medical evidence. The VA examiner noted that Dr. Scheid treated the Veteran many years post-service, but Dr. Scheid's statement did not discuss the Veteran's post-service back surgeries. In addition, the examiner reviewed Dr. Osborn's medical records showing surgeries performed on the Veteran, and noted that an opinion as to whether the claimant's back pain was related to service was not provided. The examiner also discussed the Veteran's reported heavy lifting in service, as well as post-service as a baggage handler and as a refueler, and concluded that no medical records supported the Veteran's treatment for back injuries prior to 1972 when he had his first surgery. As such, the examiner concluded that it was more likely than not that the Veteran suffered a back injury from work in which he was employed after discharge from service. Although the Veteran is competent to report his symptomatology, he is not competent, on the facts of this case, to render a medical opinion as to the diagnosis or etiology of his low back disorder. In this regard, on the facts of this case, the Board notes lay evidence is not competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). VA, however, "must consider lay evidence, but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Little probative value is given to the Veteran's etiological assertions as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Notwithstanding, the evidence does not support a finding of a chronic back disorder during service. At separation from service, the Veteran's lumbar spine was normal. Although Dr. Scheid noted that there was chronic back pain since service, pain alone is not a chronic disease listed in 38 C.F.R. § 3.309. The Board notes that the Veteran did not claim entitlement to service connection for a low back disorder until 2004, many years following discharge. Although the Veteran has reported low back symptoms experienced in and since service, the Board finds he is not competent to diagnose arthritis or a specific disability, and the most probative evidence of record does not support a finding of continuity of clinically observable low back symptomatology. As such, even if reports of back pain and symptomatology are credible, the Veteran is not competent to diagnose a chronic low back disorder or arthritis or provide an opinion connecting it to service. Positive nexus evidence of record includes Dr. Scheid's December 2007 and November 2008 opinions, and Dr. Osborn's October 2008 opinion. In addition, a November 2013 VA treating provider provided a positive nexus opinion relating the Veteran's back problems to service. Nevertheless, these opinions are of little probative value where they are based on an incomplete medical history of the Veteran's back symptomatology and treatment, as well as an incomplete understanding of his work history in the timeline of events that led to his back treatment. As such, Dr. Scheid and Dr. Osborn did not provide adequate reasoning to support a positive nexus opinion, and the VA treating provider failed to provide any reasoning in support of the opinion. Negative nexus evidence of record includes the July 2010 VA examiner's opinion, and a subsequent May 2014 VA examination and opinion, as well as a January 2015 VA examination and opinion with September 2015 VA addendum. As explained above, the July 2010 VA opinion is given little probative value, because as the Court explained, it is unclear that it was based on a complete history of the Veteran's low back symptomatology and treatment history. Nevertheless, the most recent opinions from 2014 and 2015 have continued to find no nexus between service and any current back disorder. The 2014 examination included a review of the Veteran's history and resulted in an opinion that it was less likely than not that the Veteran's low back condition was related to service. The January 2015 specialist concluded that it was unlikely that the lumbar sprain that may have occurred in service contributed to any of the subsequent lumbar spine problems that the Veteran subsequently developed. The examiner also noted that the Veteran was not treated for his back within the year following service, and arthritis was diagnosed in the late 1990s. In September 2015 the addendum opinion considered the positive nexus opinions by Dr. Scheid and Dr. Osborn but concluded that it was more likely than not that the Veteran suffered a back injury from work in which he was employed after discharge from service. These medical opinions are persuasive as they are supported by physical examination and medical findings and provided thorough explanation for the conclusion reached, and as such are afforded great probative value. Considering either the May 2014 opinion, or the January 2015 opinion with September 2015 addendum, the Board finds that the evidence against the claim for service connection for a low back disorder outweighs that in support of a nexus. In summary, the preponderance of the evidence is against a finding that the Veteran's low back disorder was incurred in or caused by service, to include heavy lifting in service. The VA examiners considered the Veteran's long history of back problems in formulating the opinion, and reasoned that current reports of symptomatology related to the Veteran's post-service multiple back surgeries and degenerative arthritis and disc disease rather than the acute lumbar strain experienced in service. The preponderance of the evidence is against the Veteran's claim and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 3.102. Lung Disorder The Veteran contends that he is entitled to service connection for a lung disorder, to include residuals of pneumonia, and to include as secondary to exposure to asbestos while in service. The Veteran reported that he was treated for two weeks in the Jacksonville, Florida dispensary for pneumonia. In November 1961, the Veteran was hospitalized for pneumonia. An X-ray dated in December 1961 "revealed that the pneumonic process had cleared entirely" according to the narrative hospital summary. On examination for separation in April 1962, the Veteran's lungs were reported as normal on clinical evaluation, and chest X-ray was negative. In May 2004, the Veteran filed a claim of entitlement to service connection for lung problems. He reported being hospitalized during service for pneumonia, and that over the prior 40 years he had pneumonia at least three times, as well as frequent bouts of pleurisy and bronchitis. He believed that the pneumonia during service was the reason for these problems. The Veteran underwent a VA examination in June 2004. At that time, the examiner indicated there was no respiratory pathology upon which to offer a diagnosis. The examiner further stated that the Veteran did not have any complications secondary to pulmonary disease. VA records show multiple visits for complaints of coughing. The Veteran was treated with antibiotics for bronchitis. A December 2004 pulmonary note includes an impression of recurrent pulmonary infections and sputum production, and bronchiectasis was suspected as the underlying diagnosis, likely as a result of multiple pneumonias. A March 2005 pulmonary clinic note indicates, however, that after additional testing, there was no evidence of chronic pulmonary infections or infections such as bronchiectasis. The symptoms were judged to be secondary to recurrent chronic rhinosinusitis. A VA note dated in September 2005 includes an assessment of chronic bronchitis, history of asbestosis, and allergic rhinitis. In a May 2006 statement, the Veteran reported that he had more than average problems with lung disease since having pneumonia in 1961. He indicated that he had continued chest colds and chest congestion, and that this information did not appear to be shown in the service records. At the hearing, the Veteran testified that his VA primary care doctor had submitted a statement in support of his claim. In its June 2010 remand, the Board indicated that it could not locate this statement. Additional evidence has been added to the record since that time. In April 2009 Dr. Scheid wrote that the Veteran reported that he suffered from pneumonia and exposure to asbestos on the USS Saratoga. Dr. Scheid indicated that since he became the Veteran's physician in 2004 the Veteran had suffered from chronic bronchitis and required multiple courses of antibiotics annually to help relieve the symptoms. As such, Dr. Scheid concluded that it was more likely than not that the Veteran's current respiratory symptoms were related to his previous long term exposure to asbestos and the in-service pneumonia. A February 2010 pulmonary clinic note documented a continued cough productive of greenish thick secretions. The physician noted "no known asbestos exposure." The assessment included chronic bronchitis. The physician indicated that the Veteran was not compliant with Flunisolide and appeared to have post-nasal drip as an aggravating symptom. Pulmonary function tests did not point at obstructive lung disease, the Veteran was being treated for gastroesophageal reflux disease, and chest CT was unremarkable. Other considerations included less common etiologies. VA records dated in November 2010 show that the Veteran was admitted to the hospital with shortness of breath and hypoxia. A pulmonary consult indicated that he had been seen for a cough that was supposed to be secondary to chronic rhinitis but had been resistant to treatment. This was the first time hypoxia had been documented and it was of unclear etiology. VA treatment records show that in 2011 the Veteran was seen for a history of exertional dyspnea and chronic cough, and a July 2011 X-ray showed diminished bilateral lung capacity and mild expiratory wheeze in the lower fields. The Veteran was afforded a December 2011 VA examination for his respiratory disorders, in which his 2006 diagnosis of chronic bronchitis, 2008 diagnosis of chronic obstructive pulmonary disease, and unknown date diagnoses of shortness of breath and hypoxemia were reviewed. The examiner reviewed the imaging results, which showed normal lungs. Review of the service treatment records showed that the Veteran was hospitalized for pneumonia in December 1961, and in January 1962 he visited sick bay for a low grade temperature expressing concern that he had pneumonia again, but was diagnosed and treated for an upper respiratory infection. On his physical of April 1962 his chest X-ray was normal. In a 2004 VA examination there was no lung pathology, although review of medical records showed work-up for hemoptysis, chronic cough, chronic bronchitis, allergic rhinitis, and sinusitis. The examiner concluded that the Veteran's respiratory disorder was less likely than not incurred in or caused by the claimed in service injury, event or illness. The Veteran's current pulmonary disorder was hypoxemia of unclear etiology. The Veteran had been diagnosed as having pneumonia in service, which was treated. The examiner indicated that documented chest radiography at separation was normal, indicating resolution of the bacteria infection. The examiner noted that pneumonia is an inflammation of the lungs caused by infection, and a curable condition. Medical records since did not show lung disease. The Veteran claimed asbestos exposure while on board ship in 1960 or 1962, and literature review notes that asbestosis which occurred as a result of asbestos exposure is defined as diffuse pulmonary fibrosis caused by inhalation of excessive amounts of asbestos fibers. It was identified that asbestos exposure can lead to lung cancer and pulmonary fibrosis of which the Veteran did not have restrictive lung disease or malignancy. Following record review and in-person examination, and a March 2013 VA examination for respiratory conditions, the examiner indicated that the Veteran had been diagnosed as having chronic bronchitis in 2009. In addition, in 2004 he was diagnosed as having a cough, and in November 2010 the Veteran had been diagnosed as having hypoxia. The Veteran reported that he had experienced a productive cough since service, during which time he had pneumonia. He also reported experiencing dyspnea since service, with some days worse than others, but oxygen being required for the previous three years. A July 2011 imaging report indicated that the Veteran's lungs were clear without effusion or consolidation. A July 2012 CT report indicated that the trachea and main bronchi were patent, with no pleural effusion or pneumothorax, and no nodules or masses were seen within the lung parenchyma. The impression was that there was no radiographic evidence of chronic obstructive pulmonary disease or emphysematous changes. Following review of pulmonary notes from 2004 to 2013 the examiner indicated that the predominant complaint was of chronic productive cough complicated by yearly exacerbations that were treated with antibiotics or steroids. Several diagnoses were considered for this condition, including bronchiectasis and chronic obstructive pulmonary disease; however, imaging studies including multiple X-rays and CT scans all showed normal lungs with the exception of some hyperinflation mentioned on a few of the chest X-rays. There was no emphysema or bronchiectasis noted, and there was never any evidence to support pulmonary changes from exposure to asbestos. In 2009 spirometry was normal, but by 2010 pulmonary function tests during admission for hypoxia showed obstruction and a low diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO). In 2012 repeat pulmonary function tests showed normal spirometry, mild hyperinflation and a persistently decreased DLCO. The examiner noted the Veteran had been treated for his chronic cough since 2004, during which time medical specialist had considered diagnoses to include allergic rhinitis, sinusitis, chronic bronchitis, bronchiectasis, pneumonia, rhinosinusitis, chronic obstructive pulmonary disease and obstructive sleep apnea. However, CT scans repeatedly failed to show any bronchiectasis, and the Veteran was found not to have this. As far as the allergic rhinitis, sinusitis and rhinosinusitis, although these conditions of the nose and the sinuses could lead to recurrent drainage and cough as the Veteran had experienced for years, these conditions were not related or caused by exposure to asbestos or pneumonia experienced in service. Although pneumonia was a diagnosis that the Veteran had since 2004, there was no evidence of any pneumonia at any time during this period. Additionally, pneumonia was not a known complication of either prior asbestos exposure, or prior resolved pneumonia as evidenced by multiple normal chest X-rays and CT scans. Chronic bronchitis indicated recurrent cough with sputum production for more than three months in a row or for three or more consecutive years. This diagnosis could be related to a remote pneumonia only if the pneumonia had resulted in damage to the lung tissue or the airway. The Veteran's CT scans had not shown any airway damage or significant scarring of the lungs that would be expected to lead to cough and chronic bronchitis. It was therefore unlikely that the cough was the result of the pneumonia experienced in service. Further asbestos exposure was not known to lead to chronic cough without the presence of lung disease seen on the CT scan. As for chronic obstructive pulmonary disease, it appeared on a CT in 2010, but was not a known complication of pneumonia in the absence of abnormalities in the lungs, seen on a CT of the chest. Further, asbestos exposure usually resulted in a restrictive disorder of the lungs, not an obstructive disorder, and therefore this was not related to any history of asbestos exposure. The Veteran's diagnosis of obstructive sleep apnea was considered not related to remote history of pneumonia during service, or history of asbestos exposure. Finally, hypoxemia of unclear etiology since 2010 occurred in the absence of any abnormalities in the lungs, as evidenced by CT scan, and it was unlikely to be the result of a prior pneumonia or asbestos exposure because it did not show up on CT scan of the chest. The Veteran was afforded a September 2014 VA examination for his lungs by a nurse practitioner, which reviewed diagnosis of chronic bronchitis in 2000, 2004 and 2009 (resolved), and 1960s diagnosis of pneumonia (resolved). The Veteran reported that he was treated for pneumonia for two weeks while in service and that he experienced pneumonia a few times since service. He reported that he worked for an airline for twenty-six years. August 2014 CT impression included findings that were consistent with prior granulomatous exposure. The examiner reviewed the Veteran's history to include, his treatment for rales in the left lower lobe in 1961, and later documentation of "no significant abnormalities" following chest X-ray. In addition, records showed treatment for worsening cough diagnosed as bronchitis with sinusitis in 2000. An August 2000 chest X-ray revealed no infiltrates or areas of consolidation, such that there was no abnormal lung condition. In May 2004 the Veteran had a normal respiratory examination. The examiner explained that a chest X-ray was the most common way to detect asbestos-related diseases, such as pleural plaque and pleural effusion. The examiner reviewed a chest X-ray taken during acute bronchitis, which included a shadow over the left lung, and notes that this probably reflected a nipple shadow. The lungs were well expanded and free of active infiltrate with mild chronic interstitial charge and slight thickening of the bronchial mucosa. The examiner indicated that following review of conflicting medical evidence there was no nexus because there was no current pathology for lung disease, and no current or past diagnosis of asbestosis. Current pulmonary function tests and CT were normal, and the Veteran had not had an abnormal radiological test since November 2010. The examiner observed that the Veteran's diagnoses in the treatment records included chronic renal failure disease and congestive heart failure, which could cause symptoms of shortness of breath. The examiner also reviewed Dr. Scheid's note, and suggested that he had simply provided a statement as requested by the Veteran with regards to reported chronic bronchitis, and without review of 2009 notes from pulmonologist, Dr. Perez, which noted normal lung function. A December 2014 VA examination of the lungs indicated that the Veteran was diagnosed as having granulomatous disease of the lungs, and had a past history of pneumonia in 1961. The examiner noted that the Veteran had reported being hospitalized and treated for two weeks for pneumonia. He also reported asbestos exposure in the Navy. He reported that he worked for an airline as a baggage handler and fueler. The Veteran denied treatment for tuberculosis or other respiratory disease. He had been on oxygen in the past year, but was not currently. The examiner extensively reviewed the August 2013 chest X-ray and August 2014 chest CT. Lung sounds were clear, with no wheezes, rales or crackles. In December 2014, Dr. Allam, a board certified pulmonary physician provided a negative nexus opinion. Following record review, to include Dr. Scheid's opinion from April 2009, Dr. Allam concluded that the Veteran's disorder was less likely than not incurred in or caused by the claimed in service injury, event or illness. Dr. Allam disagreed with Dr. Scheid's opinion finding that it was not based on the evidence. She reviewed the history of the Veteran's exposure to asbestos both in the military and occupationally following service, as well as his episode of pneumonia requiring hospitalization in 1961. She observed that the Veteran had reported productive cough for several years, and received a diagnosis of chronic bronchitis. In addition, in 2010 he was diagnosed as having hypoxemia requiring oxygen for two years. In 2013 the Veteran's condition had improved so that oxygen was no longer required. Most recently, an August 2014 CT scan of the chest showed normal lungs. The Veteran did not have any findings suggestive of asbestos-related lung damage (no pleural plaques, no interstitial lung disease). The examiner opined that, therefore, the Veteran's exposure to asbestos had not affected his lungs. In addition, there were no findings suggestive of lung damage from his in-service pneumonia; rather, his pneumonia had completely resolved, which was usually the case, and there was no evidence that any long-term lung damage was sustained from the Veteran's temporary illness. In September 2015 an addendum opinion concluded that medical findings did not show asbestos related disease or restrictive lung disease, and X-rays were negative for scarring from pneumonia. The Veteran's work history included exposure to airplane exhausts and large particulate matter, both of which are respiratory irritants, and contain many chemicals. The examiner opined that the Veteran's lung disease was most likely due to his past workplace exposures. The Veteran is competent to report respiratory symptoms such as coughing. Charles v. Principi, 16 Vet. App. 370, 374-75 (2002) (appellant competent to testify regarding symptoms capable of lay observation). Although the Veteran is competent to report his symptomatology, he is not competent, on the facts of this case, to render a medical opinion as to the diagnosis or etiology of his lung or respiratory disorder. In this regard, the Board notes lay evidence is not competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). VA, however, "must consider lay evidence, but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Little probative value is given to the Veteran's etiological assertions as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Here the negative nexus evidence outweighs the positive nexus evidence. Specifically, although the 2009 opinion from Dr. Scheid related the Veteran's respiratory symptoms to his in-service exposure to asbestos and pneumonia, no reasoning was provided and it was unclear that the Veteran's medical history had been reviewed. As such, the opinion was not supported by adequate reasoning, and is afforded little probative value. There are numerous medical opinions against finding a medical nexus between the Veteran's respiratory symptoms and service. The VA examiner in December 2011 found that the Veteran's hypoxemia was less likely than not incurred in or caused by the claimed in service injury, event or illness. The examiner reasoned that the Veteran had been diagnosed as having pneumonia in service, which was treated, and documented chest radiography at separation was normal, indicating resolution of the bacterial infection. The examiner explained that pneumonia is an inflammation of the lungs caused by infection, and a curable condition. Further, the examiner considered the Veteran's asbestos exposure, and concluded that although literature review showed that asbestos exposure could lead to lung cancer and pulmonary fibrosis, the Veteran did not have restrictive lung disease or malignancy. Then, in March 2013 a VA examiner conducted record review and examination, and concluded that there was never any evidence to support pulmonary changes from exposure to asbestos, and imaging of the lungs was normal with the exception of some hyperinflation. The examiner systematically explained why the Veteran's varying diagnoses of allergic rhinitis, sinusitis, chronic bronchitis, bronchiectasis, pneumonia; rhinosinusitis, chronic obstructive pulmonary disease and obstructive sleep apnea were not related to his prior pneumonia or asbestos exposure in service. The reasoning is discussed more fully above, but in sum, it rested on multiple imaging reports showing an absence of abnormalities in the lungs, to include airway damage or scarring of the lungs. The September 2014 VA examiner also provided a negative nexus opinion; however, this evidence is given little probative value, because it did not discuss the many respiratory and or lung problems experienced by the Veteran, and narrowed the consideration of his lung disorder. Finally, and most persuasively, there is a December 2014 VA examiner's opinion, provided by a doctor who is board certified pulmonologist with a September 2015 addendum opinion by another physician. To recap, the examiner concluded that the Veteran's exposure to asbestos had not affected his lungs, and that there were no findings suggestive of lung damage from his in-service pneumonia. Indeed, the examiner found that the Veteran's pneumonia had completely resolved, which was usually the case, and there was no evidence that any long-term lung damage was sustained from the Veteran's temporary illness. The examiner opined that the Veteran's lung disease was most likely due to his past workplace exposures included exposure to airplane exhausts and large particulate matter, both of which are respiratory irritants, and contain many chemicals. The Board finds this medical examiner's opinion particularly persuasive in light of the doctor's medical specialization in pulmonary disease, and related expertise in understanding this complex medical causation. Further, the examiner based her opinion on a complete record review and examination, to include consideration of the Veteran's reports of symptomatology since service, to include his productive cough and repeated treatment for upper respiratory problems. In summary, the most probative evidence of record indicates that the Veteran's current lung disorder is not related to active military service or events therein, to include his bout of pneumonia or asbestos exposure. The preponderance of the evidence is against a finding that the Veteran's lung disorder was incurred in or caused by service. The preponderance of the evidence is against the Veteran's claim and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a back disorder is denied. Entitlement to service connection for a lung disorder is denied. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs