Citation Nr: 18142124 Decision Date: 10/16/18 Archive Date: 10/12/18 DOCKET NO. 16-06 098 DATE: October 16, 2018 ORDER The claim of entitlement to service connection for diabetes mellitus is denied. The claim of entitlement to service connection for ischemic strokes, to include as due to service-connected asbestosis, is denied. The claim of entitlement to an initial evaluation in excess of 30 percent for asbestosis with fibrosis is denied. REMANDED The claim of entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as due to service-connected asbestosis with fibrosis is remanded. The claim of entitlement to service connection for a heart condition, to include as due to asbestos exposure is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s diabetes mellitus is neither proximately due to nor aggravated beyond its natural progression by his service-connected asbestosis with fibrosis, and is not otherwise related to an in-service injury, event, or disease. 2. The Veteran’s ischemic strokes are neither proximately due to nor aggravated beyond their natural progression by his service-connected asbestosis with fibrosis, and are not otherwise related to an in-service injury, event, or disease. 3. The Veteran’s service-connected asbestosis with fibrosis is not currently productive of a forced vital capacity (FVC) of 50 to 64 percent of predicted; or a diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO/SB) of 40 to 55 percent of predicted; or a maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardiorespiratory limitation. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.310(a) (2018). 2. The criteria for service connection for ischemic strokes are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.310(a) (2018). 3. The criteria for an evaluation in excess of 30 percent for asbestosis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.14, 4.96, 4.97, Diagnostic Code 6833 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from October 1970 to October 1973. Service Connection Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by service. 38 U.S.C. §§ 1110 (2012). A grant of service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (“nexus”) between the present disability and the in-service event, injury, or disease. 38 C.F.R. § 3.303 (2017); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. 1. The claim of entitlement to service connection for diabetes mellitus The Veteran contends that his diabetes mellitus is related to active duty service or his service-connected asbestosis with fibrosis. The question for the Board is whether the Veteran diabetes is proximately due to or the result of, was aggravated beyond its natural progress by service-connected disability, or otherwise the result of active duty service. The Board concludes that, while the Veteran has a current diagnosis of diabetes, the preponderance of the evidence is against finding that the Veteran’s diabetes is proximately due to or the result of, aggravated beyond its natural progression by service-connected disability, or otherwise etiologically related to active duty service. 38 U.S.C. §§ 1110; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The Veteran’s October 1970 entrance examination does not note a diagnosis of diabetes mellitus. The Veteran’s service treatment records do not reflect a diagnosis of diabetes during active duty service. His August 1973 separation examination similarly does not note a diagnosis of, or symptoms related to, diabetes. Post-service medical evidence of record does not reflect a diagnosis of diabetes within one year of active duty service. The Veteran’s post-service medical treatment records do not suggest an etiological relationship between the Veteran’s diabetes and either active duty service or his service-connected asbestosis. While the Veteran believes his diabetes is proximately due to or the result of, aggravated beyond its natural progression by asbestosis, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran has not shown that he has the necessary education and training to provide such an etiological opinion. Consequently, the Board affords the Veteran’s lay statements as to etiology significantly reduced probative weight. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s diabetes is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran is similarly not competent to report an etiological relationship between his diabetes and active duty service. The medical evidence of record does not indicate onset within one year of active duty service, nor does it report medical opinions that his diabetes is related to military service. As there is no indication that the Veteran’s present diagnosis of diabetes relates either to active duty service or his service-connected asbestosis, an examination is not required for the purposes of adjudication. While the McLendon factors set a low bar to trigger an examination pursuant to VA’s duty to assist, an examination is not required every time a claim is filed. McLendon v. Nicholson, 20 Vet. App. 79 (2006). A VA examination is only required when necessary to decide a claim. Despite the permissive language of VA’s duty to assist, the Court has stated that “[i]f Congress had wanted the Secretary to automatically provide an examination on all possible theories, then section 5103A would not read the way it does.” Robinson v. Peake, 21 Vet. App. 545, 553 (2008). See also Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (a claimant’s mere “conclusory generalized statement” that an in-service illness caused his current disability did not trigger VA’s requirement to obtain an examination, and it rejected the theory “that medical examinations are to be routinely and virtually automatically provided to all veterans in disability cases involving nexus issues”). Here, there is no credible evidence that the Veteran’s diabetes is related to active duty service or service-connected asbestosis, other than the Veteran’s lay statements, which have been afforded significantly diminished probative weight. Therefore, the RO did not err in its duty to assist by failing to provide an examination. The preponderance of the evidence of record weighs against an etiological relationship between the Veteran’s diabetes and either active duty service or his asbestosis. As such, the rule regarding reasonable doubt is not for application. The Board finds that service connection, on either a direct or secondary basis, for diabetes mellitus must be denied. 2. The claim of entitlement to service connection for ischemic strokes, to include as due to service-connected asbestosis The Veteran contends that his ischemic strokes are related to his service-connected asbestosis. The question for the Board is whether the Veteran’s ischemic strokes were caused by or aggravated beyond their natural progress by service-connected asbestosis. The Board concludes that, while the Veteran has a history of ischemic strokes, the preponderance of the evidence is against finding that the Veteran’s strokes are proximately due to or the result of, or aggravated beyond their natural progression by service-connected asbestosis. 38 U.S.C. §§ 1110; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The Veteran’s October 1970 entrance examination is silent with respect to strokes or related symptomatology, as is his August 1973 separation examination. His service treatment records do not reflect a diagnosis of, or symptoms related to, ischemic strokes. The Veteran’s post-service treatment records reflect a history of transient ischemic attacks (TIAs), as noted in May 2015. In September 2016, the Veteran’s attorney cited a British Medical Journal study that purported to link asbestos exposure with heart disease and strokes. The Veteran underwent a VA examination to assess the nature and etiology of his ischemic strokes in January 2017. The Veteran was noted to have had 2 or 3 TIAs in 2015, and perhaps 1 or 2 more that did not result in medical evaluation. In March 2015, he had sudden and transient left facial weakness and slurred speech, resulting in evaluation that included negative imaging of the brain, unremarkable carotid ultrasound, and eventually negative echocardiogram for embolic focus. Imaging studies showed ischemic white matter changes bilaterally and subcortically. The Veteran was treated with Plavix until he suffered a stroke in January 2016. Subsequent Magnetic Resonance Imaging (MRI) of the brain showed lacunar infarcts predominating in the right frontal and parietal region, though the acuteness of these changes was not mentioned. The Veteran was found to have paroxysmal atrial fibrillation, and started on Coumadin on that admission, but there was no conclusion that the atrial fibrillation was the source of stroke. He remained hemiparetic and went to a rehabilitation center, reportedly for 3 weeks, where he improved and could ambulate upon leaving with a cane. The Veteran reported using a walker occasionally at home. An April 2016 MRI of the brain showed white matter changes, bilaterally and no large territorial stroke. The examiner noted the Veteran’s past medical history of diabetes that had been poorly controlled for over 7 or 8 years with recent improvement. The Veteran’s hypertension was also not well controlled, and he had diagnoses of hyperlipidemia, cardiomyopathy, and atrial fibrillation. The examiner noted findings of asbestosis within the previous three years, as well as ongoing diagnoses of COPD and obstructive sleep apnea. The Veteran also reported a long history of smoking, which he quit in 1974. The examiner concluded that the Veteran’s ischemic strokes were less likely than not related to active duty service. The Veteran had numerous strong risk factors for stroke, including his history of transient ischemic attacks (TIAs). The Veteran also has long-standing diabetes and hypertension, which were not well-controlled around the time of his stroke. In addition, the Veteran’s risk factors include paroxysmal atrial fibrillation, cardiomyopathy, and hyperlipidemia. The examiner stated that any one of these factors typically may cause the type of stroke experienced by the Veteran, and it was highly likely that one or several of these risks factors did, in fact, lead to his stroke. The examiner noted the Veteran’s contention that his asbestosis caused his stroke, but concluded that this etiological relationship was very unlikely. While the Veteran’s attorney cited pulmonary journals that reference an association between asbestosis and stroke, noting that a comparatively high number of patients with asbestosis suffered stroke and heart attack, that did not establish an etiological relationship between asbestosis and the Veteran’s stroke. An observed association between these illnesses was insufficient to demonstrate a causal relationship, and it was very unlikely, given the Veteran’s other significant medical problems, that asbestosis contributed to his stroke. While the Veteran believes his ischemic strokes are proximately due to or the result of his service-connected asbestosis, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board also notes that the Veteran’s attorney submitted medical journal evidence purporting to establish an etiological relationship between ischemic strokes and asbestosis; however, the January 2017 VA examination report also addressed why the findings of that study do not establish causation, merely an association, which was insufficient to find an etiological relationship between the two. Consequently, the Board gives more probative weight to the opinions of the January 2017 VA examination of record. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s ischemic strokes are related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran is competent to report in-service observable symptomatology, and his reports are credible and entitled to probative weight. However, the Veteran has not asserted that he received a diagnosis of strokes or TIA in service, nor did he report related symptomatology within one year of discharge. Instead, the January 2017 VA examiner opined that the Veteran’s ischemic strokes were not at least as likely as not related to an in-service injury, event, or disease. Instead, the strokes were more likely related to the Veteran’s other numerous risk factors, as discussed above. While the Veteran believes his ischemic strokes are related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran has not reported that he has sufficient training or education in this area in order to provide a competent etiological opinion. Consequently, the Board gives more probative weight to the January 2017 VA examination of record. The preponderance of the evidence of record weighs against an etiological relationship between the Veteran’s ischemic strokes and either active duty service or his asbestosis. As such, the rule regarding reasonable doubt is not for application. The Board finds that service connection, on either a direct or secondary basis, for ischemic strokes must be denied. Increased Rating Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran’s claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. VA’s determination of the “present level” of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities must be reviewed in relation to their entire history. 38 C.F.R. § 4.1. VA must also interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person’s ordinary activity. 38 C.F.R. § 4.10. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Functional loss may be due to pain if supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Functional impairment may be due to pain, including during flare-ups, or from repetitive use. Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. 3. The claim of entitlement to an initial evaluation in excess of 30 percent for asbestosis with fibrosis The Veteran in this case also seeks an increased evaluation for service-connected asbestosis with fibrosis. In pertinent part, it is contended that current manifestations of that disability are more severe than presently evaluated, and productive of a greater degree of impairment than is reflected by the 30 percent schedular evaluation now assigned. In this regard, the Veteran has been assigned a 30 percent rating for his asbestosis under C.F.R. § 4.97, Diagnostic Code 6833. Under Diagnostic Code 6833, asbestosis is to be rated under the General Rating Formula for Interstitial Lung Disease. A 10 percent evaluation is warranted for FVC of 75- to 80-percent predicted, or; DLCO (SB) of 66- to 80-percent predicted. A 30 percent evaluation is warranted for FVC of 65- to 74-percent predicted, or; DLCO (SB) of 56- to 65-percent predicted. A 60 percent evaluation is warranted for FVC of 50 to 64 percent predicted, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardio-respiratory limitation. A 100 percent evaluation is warranted for FVC less than 50 percent of predicted value, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption with cardio-respiratory limitation, or; cor pulmonale (right heart failure) or pulmonary hypertension, or; requiring outpatient oxygen therapy. 38 C.F.R. § 4.97. In June 2014, VA treatment records reflect a pulmonary function test (PFT) found a FVC of 4 liters, which was 70 percent predicted. The FEV-1 was 3.25 liters, 76 percent predicted. The FEV1/FVC ratio was normal. The total lung capacity was normal. The diffusion capacity was normal. The Veteran reported a history of COPD, but the examining clinician determined that his PFTs did not support that diagnosis. He opined that there may be some mild obstructive lung disease which would manifest if he were not obese. The clinician also described his pleural calcifications, and reported that they did not seem to be actively causing him any problems as there was no evidence of interstitial lung disease from asbestos based on physical exam and imaging studies. There did not seem to be any effusion. The clinician concluded that asbestos was asymptomatic and not an active issue for him. In July 2014, VA treatment records reflect a diagnosis of mild chronic obstructive pulmonary disease with a moderate obstructive ventilatory defect. Chest x-ray showed emphysema, which was in line with the Veteran’s smoking history. It was noted that the best treatment would be weight loss. In November 2014, the Veteran underwent a VA examination to assess his respiratory diagnoses. The Veteran was diagnosed with COPD and interstitial lung disease. He did not require the use of oral or parenteral corticosteroid medications, oral bronchodilators or antibiotics. The Veterans FEV-1/FVC was 75 percent predicted for both pre- and post-bronchodilator in his PFT. The Veteran’s DLCO was 102 percent predicted. Exercise capacity testing was not performed. The functional impact of the Veteran’s respiratory conditions was determined to be dyspnea. In June 2017, the Veteran underwent a second VA examination to assess the nature and severity of his respiratory disorder. He was diagnosed with COPD and pulmonary fibrosis due to asbestos exposure. The Veteran reported a progressive shortness of breath that started about four years ago. The corresponding PFT showed that the Veteran’s FEV-1/FVC was 73 percent predicted, and DLCO was 68 percent predicted. The FVC value was determined to be the more accurate reflection of the Veteran’s level of disability. Exercise capacity testing was not performed. The Board has reviewed all of the evidence but finds no evidence of record that would warrant a rating in excess of 30 percent for the Veteran’s service-connected asbestosis with fibrosis at any time during the period pertinent to this appeal. Again, under Diagnostic Code 6833, higher ratings are warranted for FVC of 50 to 64 percent predicted, or less than 50 percent of predicted value. In this case, throughout the pendency of the claim, the Veteran’s FVC has far exceeded 64 percent predicted, including at the time of the June 2014 PFT, the November 2014 PFT, and the June 2017 PFT. Based on this evidence, the Board finds that the disability picture more closely resembles the criteria for the currently assigned 30 percent rating. DLCO results have also been considered. For a 60 percent rating, DLCO must be between 40 and 55 percent. Review of the aforementioned PFTs shows that none of the available DLCO results were within this range - the lowest DLCO was reported as 68 percent in June 2017. Thus, the Board finds that the DLCO findings do not support the assignment of a rating in excess of 30 percent. Lastly, a rating in excess of 30 percent may be assigned if the maximum exercise capacity is 15 to 20 ml/kg/min oxygen consumption with cardiorespiratory limitation, or if there is cor pulmonale, pulmonary hypertension or the requirement of oxygen therapy. First, the medical evidence does not show cor pulmonale, pulmonary hypertension, or the requirement of oxygen therapy. Therefore, an increased rating is not warranted based on these criteria. Second, an increased rating is not warranted based on exercise capacity. In this regard, exercise capacity was not tested in the VA examinations of record, and no other medical evidence of record to suggest that the Veteran’s asbestosis with fibrosis has resulted in a maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardio-respiratory limitation at any point during the appeal. Consequently, while there have been day-to-day fluctuations in the manifestations of the Veteran’s service-connected asbestosis with fibrosis, the evidence shows no distinct periods of time in the course of the appeal, during which the Veteran’s condition has varied to such an extent that a rating greater than 30 percent would be warranted. The Board lastly finds that Diagnostic Code 6833 is the most appropriate Diagnostic Code because it specifically pertains to the service-connected disability in this case: asbestosis. The Board finds that no other diagnostic code would be more appropriate other than Diagnostic Code 6833. The Board has considered other diagnostic codes for other respiratory disorders such fibrosis (Diagnostic Code 6845), and chronic pleural effusion or fibrosis (Diagnostic Code 6845), but these Diagnostic Codes would not provide higher ratings, even on the basis of the Veteran’s FEV-1, FEV, or DLCO readings. The Board notes that neither the Veteran nor his representative has requested that another diagnostic code be used to evaluate his service-connected disability. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 6833. In reaching the above conclusions, the Board has considered the Veteran’s statements regarding the severity of his asbestosis with fibrosis. Certainly, as a lay person, the Veteran is competent to attest to physical symptoms that he experiences, such as shortness of breath. His statements describing his symptoms are considered to be competent evidence. King v. Shinseki, 700 F.3d 1339 (Fed.Cir.2012); Layno v. Brown, 6 Vet. App. 465 (1994). These statements, however, must be viewed in conjunction with the medical evidence as required by the rating criteria. The Veteran is not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s pulmonary function has been provided by the medical personnel who examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluation. The medical findings, as provided in the examination reports, directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran’s subjective complaints of increased symptomatology. In sum, the preponderance of the evidence of record weighs against the assignment of a rating in excess of 30 percent for service-connected asbestosis with fibrosis. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107 (b). REASONS FOR REMAND 1. The claim of entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as due to service-connected asbestosis with fibrosis is remanded. The Board cannot make a fully informed decision regarding the issue of entitlement to service connection for COPD as the medical evidence of record is inadequate. The Veteran underwent a VA examination in November 2014 to assess the etiology of his COPD. The opinion provided, however, contradicts itself. The clinician stated that the Veteran’s obesity and smoking history were more likely causative factors for his COPD, but then quoted his treating physician who stated that his COPD would have manifested even if he were not obese. The Veteran’s attorney also believes that this contradiction undermines the validity of the examination report, as stated in a September 2016 correspondence. The November 2014 examiner also did not discuss aggravation of COPD by the Veteran’s asbestosis. Accordingly, a new examination is necessary on remand in order to obtain a more thorough etiological opinion. 2. The claim of entitlement to service connection for a heart condition, to include as due to asbestos exposure is remanded. The Board cannot make a fully informed decision regarding the issue of entitlement to service connection for a heart condition as the medical evidence of record is inadequate, and an examination was not afforded to assess the Veteran’s congestive heart failure. In September 2016, the Veteran’s attorney discussed a British Medical Journal study that linked asbestos exposure with heart disease. A VA examination has not been provided to assess the etiology of the Veteran’s congestive heart failure. This medical evidence of a possible causal relationship between asbestos exposure and heart disease presents at least an indication that the Veteran’s congestive heart failure may be related to his service-connected asbestosis. Accordingly, an examination is necessary on remand. See McLendon v. Nicholson, 20 Vet. App. 79, 82-3 (2006). 3. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. As the Veteran is asserting entitlement to TDIU, the Board finds that this issue is inextricably intertwined with the resolution of the remanded issue. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, this issue is remanded for readjudication following evidentiary development. The matters are REMANDED for the following action: 1. Contact the Veteran and his representative in order to identify any outstanding non-VA treatment records regarding the issues on appeal. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran and his representative, and afford an opportunity for him to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). All attempts to contact the Veteran should be documented in the record. 3. Once the aforementioned development is complete, schedule the Veteran for a VA examination with an appropriate clinician to assess the nature and etiology of his COPD. A complete copy of the claims file must be made available to the examiner. The examiner should consider the Veteran’s lay reports of observable symptomatology. After a thorough review of the medical and lay evidence of record, the examiner should opine as to the following: (a.) Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran’s COPD had its onset during active service or within one year of separation from service, or, otherwise resulted from active military service, to include exposure to asbestos? (b.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran’s COPD was caused by or aggravated by his service-connected asbestosis with fibrosis? (c.) If aggravation of the COPD is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the COPD prior to aggravation. Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Once the aforementioned development is complete, schedule the Veteran for a VA examination with an appropriate clinician to assess the nature and etiology of his heart condition. A complete copy of the claims file must be made available to the examiner. The examiner should consider the Veteran’s lay reports of observable symptomatology. The examiner should also address the British Medical Journal study cited by the Veteran’s attorney in a September 2016 correspondence. After a thorough review of the medical and lay evidence of record, the examiner should opine as to the following: (a.) Identify any and all diagnoses pertaining to the Veteran’s heart; (b.) For each diagnosis, is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran’s heart condition had its onset during active service or within one year of separation from service, or, otherwise resulted from active military service, to include in-service asbestos exposure? 5. Following completion of the foregoing, the AOJ should review the record and readjudicate the claims on appeal. If any remain denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel