Citation Nr: 19174741 Decision Date: 09/26/19 Archive Date: 09/25/19 DOCKET NO. 19-00 482 DATE: September 26, 2019 ORDER Entitlement to service connection for pulmonary disorders, to include interstitial pulmonary fibrosis, bronchiectasis, and chronic obstructive pulmonary disease (COPD), claimed as due to asbestos exposure, is denied. FINDING OF FACT The probative evidence is against a finding that the Veteran’s pulmonary disorders manifested during, or are otherwise related to, his active military service, to include exposure to asbestos. CONCLUSION OF LAW The criteria for entitlement to service connection for pulmonary disorders, to include interstitial pulmonary fibrosis, bronchiectasis, and COPD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had honorable active duty service with the United States Navy from July 1958 to June 1961. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran’s appeal was previously on appeal from a June 2015 rating decision, the appeal of which was denied by the Board in February 2018. In May 2018, the Veteran filed a petition to reopen the Board’s previously denied claim, which the Board reopened and remanded in January 2019. It has since been returned for further appellate review. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. The Veteran asserts that he has a current pulmonary disorder that is related to his military service. The record does indeed reflect diagnoses of interstitial pulmonary fibrosis, bronchiectasis, and COPD. For the reasons that follow, however, the Board finds that service connection must, unfortunately, be denied. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has established certain rules and presumptions for chronic diseases, such as bronchiectasis. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Veteran’s STRs do not note treatment or complaints of symptoms indicative of any chronic pulmonary disorder. During his June 1991 separation examination, evaluation of the lungs and chest was normal. The medical evidence is negative for a diagnosis of any pulmonary disability until an open lung biopsy in 2014 revealed interstitial pulmonary fibrosis, many years after the Veteran’s separation from service. While the Board acknowledges that the Veteran has stated that his disability has progressed since his active service (see October 2016 Statement in Support of Claim), the medical record is absent of documentation of any diagnosed pulmonary disability until this biopsy. As a chronic pulmonary disability, such as the bronchiectasis noted in his medical treatment records, is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of a chronic pulmonary disability is not shown, in-service incurrence cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309(a). To the extent the Veteran asserts a continuity of symptomatology beginning during service, the Board finds these statements to lack credibility as they are in direct conflict with the Veteran’s report of medical examination at separation from service where no lung disability was found. The Board finds the report of medical history at separation from service to be more reliable than more recent assertions as it was done contemporaneous to service and for the purpose of identifying disability at that time. Additionally, while bronchiectasis is indeed listed as a “chronic disease” under 38 C.F.R. § 3.309(a), the list excludes COPD and pulmonary fibrosis. Hence, presumptive service connection for is not warranted in this case. Nevertheless, while no presumption of service connection has been satisfied, the claim must be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). Here, the Veteran has claimed exposure to asbestos while serving aboard the USS Willard Keith. The United States Court of Appeals for Veterans Claims (Court) has held that VA must analyze an appellant’s claim for service connection for asbestosis or asbestos-related disabilities under the appropriate administrative guidelines. Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). While there is no specific statutory guidance with regard to asbestos-related claims, nor has the VA Secretary promulgated any regulations in regard to such claims, the M21-1 Adjudication Procedure Manual (“M21-1”) provides information concerning claims for service connection for disabilities resulting from asbestos exposure. See M21-1, III.i.3.A.2.a. According to the M21-1, asbestos is a fibrous form of silicate mineral of varied chemical composition and physical configuration, derived from serpentine and amphibole ore bodies that is commonly found in steam pipes for heating units and boilers, ceiling tiles, roofing shingles, wallboard, fire-proofing materials, and thermal insulation. Id. at IV.ii.2.C.2.a. Many people with asbestos-related diseases have only recently come to medical attention because the latent period for development of disease due to exposure to asbestos ranges from 10 to 45 or more years between first exposure and development of disease. Id. at IV.ii.2.C.2.f. Asbestos fiber masses tend to break easily into tiny dust particles that can float in the air, stick to clothes, and may be inhaled or swallowed. Id. at IV.ii.2.C.2.b. Asbestos-related diseases can be caused by even brief or indirect asbestos exposure. Id. at IV.ii.2.C.2.c. Inhalation of asbestos fibers can produce fibrosis (the most commonly occurring of which is interstitial fibrosis or asbestosis); tumors; pleural effusions and fibrosis pleural plaques; and cancers of the lung, bronchus, larynx, pharynx and urogenital system (except the prostate). Id. at IV.ii.2.C.9.b. In Dyment v. West, 13 Vet. App. 141, 145(1999), the Court found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of the M21-1 IV, did not create a presumption of exposure to asbestos. Medical-nexus evidence is required in claims for asbestos-related disease related to alleged asbestos exposure in service. VAOGCPPREC 04-00. In short, with respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. See M21-1, IV.ii.2.C.9.h. Although there is no specific statutory or regulatory guidance with regard to claims for service connection for asbestos-related diseases, the M21-1 does provide that claims based on exposure to asbestos require a military occupational skill with exposure to asbestos or other exposure event associated with service sufficient to request an examination with medical opinion as described in M21-1, IV.ii.1.I.3.f, and a diagnosed disability that has been associated with in-service asbestos exposure. The M21-1 also provides a table to determine the probability of asbestos exposure by military occupational specialty (MOS). In the instant case, the Veteran’s MOS was listed as a radioman, with a related civilian occupation of radio operator. Upon a review of the M21-1, a MOS of radioman reflects that exposure to asbestos is minimal. See IV.ii.1.I.3.c. However, it further directs that if an MOS is listed as minimal, probable, or highly probable, asbestos exposure for the purposes of scheduling an examination should be conceded. See IV.ii.1.I.3.e. This MOS has a minimal risk of exposure to asbestos. Therefore, the Board concedes minimal exposure to asbestos while on active duty. The Board’ analysis now turns to whether there is a nexus between the Veteran’s current pulmonary diagnosis and his active duty service; specifically, his conceded minimal asbestos exposure. A January 2014 private treatment record indicated that the Veteran underwent a lung biopsy which revealed interstitial pulmonary fibrosis, extensive, nonspecific. It was noted that the predominant histologic pattern of injury in the specimen most resembled that of usual interstitial pneumonia (UIP) and was etiologically nonspecific. Upon VA examination in June 2015, the examiner noted the Veteran’s history of bronchiectasis and lung biopsy, but that he had never been diagnosed with asbestosis. While chest x-rays revealed chronic pulmonary fibrosis and changes of COPD, there were no pulmonary infiltrates, vascular congestion, or pleural effusion, and no obvious calcified pleural plaques were seen. The examiner opined that based on interview, examination, and review of the evidentiary record, the Veteran’s interstitial pulmonary fibrosis, bronchiectasis, and COPD were less likely than not related to active duty service, explaining that the Veteran’s x-rays had not shown any plaques, effusion, or pleural disease and that the Veteran’s private lung physician had not documented asbestosis as a diagnosis. In October 2016, the Veteran submitted additional evidence and argument, stating that he was a lifelong nonsmoker and his only history of exposure to asbestos had been during his more than two years of active duty aboard the Willard Keith. During war games maneuvers, he asserted, the firing of “big guns” and other actions would cause abnormal amounts of asbestos dust to discharge. The Veteran also stated that he was exposed to asbestos in both sleeping and working spaces, noting that he worked in the emergency radio room often, which was a small, dusty, confined, asbestos-exposed electrical room below deck. The Veteran reported that from 1961 to the 1990’s, his interstitial pulmonary fibrosis slowly progressed. Due to this new information submitted by the Veteran, the Board remanded the issue for an addendum medical opinion in January 2017, which was provided later that month. Upon review of the record, the examiner acknowledged the Veteran’s minimal exposure to asbestos while aboard the Willard Keith, his lifetime as a nonsmoker, the absence of a family history of any type of lung disease, and no civilian employment that may have caused asbestos exposure. The examiner opened that it was less likely than not that the Veteran’s pulmonary disorders were incurred in or caused by active duty service, observing that pulmonary fibrosis was confirmed through biopsy, with no report of asbestos fibers, and that a computerized tomography scan noted bilateral infiltrates and bronchiectasis with no notation on pleural plaques. The examiner continued that a definitive diagnosis of asbestos exposure can only be made by biopsy when fibers are present, but normally, the risk associated with the invasive biopsy is too great for the purpose of a compensation and pension claim. In this case, the examiner pointed out that the Veteran had already undergone a biopsy due to other medical necessity which appeared to indicate that his pulmonary fibrosis was not due to asbestos fibers and was, in fact, idiopathic, meaning there is no known underlying cause. He also noted that often times pulmonary plaques were seen on image studies such as CT scans; however, there was no evidence of pulmonary plaques on the Veteran’s CT scan. The Veteran had no hallmark signs of pleural plaques and his lung biopsy effectively disproved any indication of asbestos fibers causing his current respiratory conditions. As this left a diagnosis of idiopathic pulmonary fibrosis, and given all the other factors, the examiner opined that it could not be stated at a good medical probability of 50 percent or greater that the Veteran’s current respiratory diagnoses were secondary to any act of military service, to include asbestos exposure. In June 2017, updated treatment records were received from the Veteran’s private pulmonologist and the AOJ ordered a supplemental medical opinion after review of the new records, which was provided, along with an additional interview and examination, in July 2017. The examiner noted that based on his review and examination, the Veteran did not have a diagnosis of asbestosis incurred during or caused by active duty, explaining that there was no medical documentation showing that the Veteran had ever been diagnosed with asbestosis or that he had ever been exposed to asbestos during military service. In addressing the Veteran’s 2014 pathology report noting “alveolar macrophages are scattered singly and a few small clusters; some macrophages contain iron,” the examiner explained that the presence of alveolar iron described in the report was not indicative of the presence of asbestos or an asbestosis diagnosis, but rather indicative of chronic inflammatory-immune processes of the Veteran’s idiopathic interstitial pulmonary fibrosis. In October 2017, the Board found that the July 2017 VA examiner incorrectly found no evidence of asbestos exposure and failed to consider the Veteran’s acknowledged “minimal” asbestos exposure due to his MOS as a radioman. Accordingly, the Board remanded for an addendum medical opinion, specifically directing the VA examiner to consider, for the purposes of offering the opinion, both the Veteran’s conceded minimal asbestos exposure, as well as his lay statements that he had been exposed to asbestos as the result of the firing of ship’s guns and other actions during war game maneuvers and during time spent working in a dusty, dirty electrical room with purported asbestos wrapped wires and in his sleeping quarters. A rather extensive addendum opinion was then provided by the July 2017 VA examiner in October 2017. The examiner stated that the Veteran had a diagnosis of idiopathic pulmonary fibrosis, which by definition was not caused by asbestos exposure. The examiner acknowledged that the Veteran may have been at risk for asbestos exposure and that the risk of asbestos exposure was “minimal.” He added that this minimal risk of exposure was not proof of asbestos exposure or asbestos-related lung disease and was clearly contradicted by the overwhelming medical evidence. The examiner noted that there was no medical documentation in the Veteran’s service treatment records or post-service treatment records that showed he was ever diagnosed with asbestosis or an asbestosis-related lung disease. Specifically addressing the Veteran’s contentions that he was exposed to asbestos as a result of the firing of the ship’s guns and other actions that would cause an abnormal amount of asbestos dust to be discharged, the examiner determined it was unlikely that the dust aboard the ship contained significant amounts of asbestos. He explained that the composition of dust aboard a military vessel was like any other place where people lived and worked and was composed mostly of human and animal hair and skin cells, plant pollens, textile and paper fibers, minerals from soils, burnt meteorite particles, gun powder, and many other types of microscopic debris. While the firing of ship’s guns may have aerosolized the dust, there was no evidence that this dust contained asbestos. Further, with regard to the Veteran’s contentions that he worked in proximity to asbestos-wrapped wires, this was of negligible risk as any asbestos there was bound and not aerosolized, and therefore could not enter the lungs. In regard to the paragraph of unsourced medical literature submitted by the Veteran in October 2016, which alleged that iron bodies noted in his biopsy are typically indicative of asbestos inhalation, the examiner explained that the presence of alveolar iron described in the Veteran’s January 2014 pathology report was not indicative of the presence of asbestos or an asbestosis diagnosis, but rather indicative of chronic inflammatory-immune processes of the Veteran’s idiopathic interstitial pulmonary fibrosis. The examiner noted that the Veteran had been diagnosed with idiopathic pulmonary fibrosis by his private pulmonologist, which he emphasized was not an interchangeable term with interstitial pulmonary fibrosis. The examiner explained that interstitial pulmonary fibrosis was a broad term applied to conditions causing inflammatory changes and fibrosis in the tissues of the lung. Interstitial pulmonary fibrosis could be caused by several conditions, the most common of which was idiopathic pulmonary fibrosis. Once all other known causes were eliminated, the interstitial pulmonary fibrosis was then attributed to idiopathic pulmonary fibrosis. The examiner further explained that while the causes of idiopathic pulmonary fibrosis were not known, the diagnostic criteria included eliminating any known causes, including asbestosis exposure/asbestosis. The examiner indicated that in the present case, asbestosis had reasonably been eliminated as a cause, as the Veteran’s lung biopsy did not show the presence of asbestos or asbestosis. With regard to the Veteran’s history of nonsmoking, the examiner noted that smoking was a risk factor for smoking-related lung disease, including COPD-related interstitial pulmonary fibrosis; however, smoking was not a factor for the Veteran’s idiopathic pulmonary fibrosis. As he had previously stated, to receive a diagnosis of idiopathic pulmonary fibrosis, all other causes must have first been eliminated. The examiner further noted that the Veteran’s life-long environmental and occupational exposures to airway irritants were impossible to analyze beyond speculation; however, if such analysis were possible, they would likely reveal a more temporally proximal likely cause of his pulmonary disorders. Finally, the examiner noted that the Veteran’s lack of family history of idiopathic pulmonary fibrosis was immaterial, as the condition was not genetic. The Veteran’s claim was returned to the Board in February 2018. Based on the above medical evidence, the Board determined that the evidence remained against a finding that the Veteran’s pulmonary disabilities were the result of in-service asbestos exposure. A motion for reconsideration by the Veteran was denied in May 2018, and the Board’s February 2018 decision then became final. The Veteran, however, sought to reopen his claim, and submitted additional VA treatment records that noted an amendment to his documented Problem List that now indicated a diagnosis of pulmonary fibrosis “secondary to asbestosis.” Based on these new records, the Board again reopened and remanded the Veteran’s claim in January 2019 for an additional addendum opinion to address these new records and to determine whether the it was at least as likely as not that the Veteran’s pulmonary disabilities are related to in-service asbestos exposure. The opinion was provided in July 2019 by the examiner who provided both the July 2017 opinion and the October 2017 addendum. The examiner noted that, after conversation with his VA pulmonologist, the Veteran’s diagnosis was changed to pulmonary fibrosis secondary to asbestos exposure after the Veteran successfully petitioned to have his problem list amended. This diagnosis, the examiner continued, was not supported by the objective medical and pathological evidence, however, which indicates that he does not have asbestosis. Rather, the Veteran has a diagnosis of idiopathic pulmonary fibrosis, which by definition is not caused by asbestos exposure. His condition, rather, has followed the natural course of idiopathic pulmonary fibrosis and not that of asbestosis related pulmonary fibrosis, and that his treatment plan includes the medication Pirfenidone, which the examiner noted has only been approved to treat idiopathic pulmonary fibrosis, not asbestosis-related pulmonary fibrosis. Additionally, the examiner noted a May 2019 treatment record where the Veteran’s pulmonologist justified the prescription for pirfenidone by verifying the diagnosis of idiopathic pulmonary fibrosis. A part of that justification was the exclusion for other known causes of interstitial lung disease to include occupational environmental exposures such as asbestos. In reconciling the conflicting medical evidence of the Veteran’s particular case, the examiner found the probative weight should be given to the objective diagnostic findings and treatment course for idiopathic pulmonary fibrosis, not the pulmonologists speculative and conflicting diagnosis of fibrosis secondary to asbestos, which the examiner commented was “clearly and unambiguously in error.” Based on the foregoing, and as there is no other medical evidence in significant conflict with the opinions of the VA examiners, the Board again finds the evidence is against a finding that the Veteran’s pulmonary disability is related to in-service asbestos exposure. In June 2015, the VA examiner opined that the Veteran’s pulmonary disorders were less likely than not due to his active duty service, noting that the Veteran had never been diagnosed with asbestosis. X-rays conducted concurrently with the 2015 examination failed to reveal pulmonary infiltrates, vascular congestion, pleural effusion, or obvious calcified pleural plaques, indicative of asbestos exposure. The January 2017 VA examiner concurred that the Veteran’s pulmonary disorders were less likely than not related to his active duty exposure. The examiner acknowledged the Veteran’s conceded minimal asbestos exposure during active duty, his history of nonsmoking, and the absence of a genetic family history of lung disease and no post-service asbestos exposure. The examiner noted that a definitive diagnosis of asbestos exposure could only be made by biopsy when fibers are present and that the Veteran had undergone biopsy in 2014. He noted that the Veteran’s biopsy did not indicate, nor did the Veteran’s private pulmonologist report, any evidence linking the Veteran’s pulmonary disorders to asbestos exposure. No pulmonary plaques were seen on CT scan and further treatment for the Veteran’s pulmonary disorders failed to reveal any evidence linking the disorders to asbestos. The examiner explained that the Veteran had idiopathic pulmonary fibrosis, meaning there was no underlying cause, as there had been no hallmark signs of pleural plaques and his lung biopsy effectively disproved any indication of asbestos fibers causing his current respiratory conditions. The Board acknowledges that the VA examiner that provided the October 2017 addendum and conducted the July 2017 examination seemingly dismissed the Veteran’s conceded minimal exposure to asbestos during his active duty service. Therefore, the opinions offered on these dates are afforded limited probative weight in regard specifically to his actual exposure. The examiner, nevertheless, is competent to opine as to the etiology of his current pulmonary conditions, to include their relationship to asbestos exposure, regardless of the Veteran’s actual exposure. In that regard, the examiner explained that while the causes of idiopathic pulmonary fibrosis were not known, the diagnostic criteria included eliminating any known causes, including asbestosis exposure/asbestosis, and in this Veteran’s case, asbestosis had reasonably been eliminated as a cause via his lung biopsy. This opinion was confirmed again by the same examiner in July 2019, who continued to find no evidence that the Veteran’s pulmonary disability was related to asbestos exposure, despite the Veteran’s successful petition to amend his treatment records to reflect the opposite in the presence of conflicting diagnostic findings. The Board finds these VA medical opinions addressing the relationship between the Veteran’s disability and his conceded asbestos exposure, as a whole, to be supported by a detailed rationale. Moreover, they are not contradicted by any other medical opinions of record. The Board has considered the Veteran’s statements, to include his assertions that his acquired psychiatric disorders are related to service, specifically, asbestos exposure. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). In this regard, the Veteran has asserted that he spent two and a half years aboard a navy vessel which was commissioned at the height of asbestos use and has not had a history of smoking, genetic lung diseases, or post-service exposure to asbestos, and that, while a biopsy could diagnose the presence of asbestos fibers or pulmonary plaques, his 2014 biopsy was done due to other medical necessity and was not extensive enough to either rule in or rule out the presence of asbestos fibers or pulmonary plaques. The Board also notes his submission of an unsourced paragraph of medical literature to support his assertion that the presence of microphages and iron in his 2014 biopsy was indicative of asbestos inhalation. Finally, the Veteran asserted that the risk factors for idiopathic pulmonary fibrosis were still being researched, but asbestos was a known cause. He asserted that asbestos exposure was his only risk factor and that his “substantial exposure” while in service established causation The Veteran, however, is not competent to independently render a medical diagnosis or opine as to the specific etiology of a pulmonary condition as these are medically complex issues. There is no medical evidence of record to support the Veteran’s contention that his biopsy was not extensive enough to rule out the presence of asbestos. In this regard, the October 2017 VA examiner explained that a diagnosis of idiopathic pulmonary fibrosis resulted from eliminating all known causes of pulmonary fibrosis, including asbestosis exposure and asbestosis. Therefore, contrary to the Veteran’s assertions, idiopathic pulmonary fibrosis could not be diagnosed if asbestosis exposure and asbestosis were not ruled out by biopsy. The Board notes that while the October 2017 VA examiner’s medical opinion has been afforded lesser probative weight due to failure to concede minimal asbestos exposure, he is competent and credible to expound on such medical concepts. Thus, the Veteran’s lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. The Board also notes that the Veteran has submitted medical literature in support of his claim. With regard to the unsourced paragraph of medical literature submitted in October 2016, the Board notes that this is of little probative value, as its origins are unknown. While the paragraph alleged that ferruginous (iron) bodies were typically indicative of asbestos inhalation, the October 2017 VA examiner explained that the presence of alveolar iron described in the Veteran’s January 2014 pathology report was not indicative of the presence of asbestos or an asbestosis diagnosis, but rather indicative of chronic inflammatory-immune processes of the Veteran’s idiopathic interstitial pulmonary fibrosis. Again, while the October 2017 examiner’s opinion regarding the etiology of the Veteran’s pulmonary disorders is afforded lesser weight, the examiner is competent and credible to interpret the results of the Veteran’s biopsy in relation to his submitted medical literature. Additional medical literature was submitted in December 2017, addressing idiopathic pulmonary fibrosis and the consequences of asbestos exposure. One article, from a website containing peer-reviewed educational materials, noted that the etiology of idiopathic pulmonary fibrosis is unknown, but there are potential risk factors that have been described. The Veteran highlighted “sand, stone, and silica” and indicated that the other listed risk factors did not apply. Another article defined asbestos, discussed asbestosis, and indicated that certain service members, including those in the Navy who served aboard ships, were at risk for asbestos exposure. The Board does not dispute that the Veteran has been diagnosed with idiopathic pulmonary fibrosis. Likewise, the Board has conceded that there was asbestos aboard the Willard Keith and that the Veteran had minimal exposure to asbestos during active duty service (but not “substantial” exposure as the Veteran asserts). However, the issue here is whether it is at least as likely as not that the Veteran’s pulmonary disorders are the result of his asbestos exposure during military service. In this regard, the Board affords the VA medical opinions of record more probative weight than the Veteran’s submissions of medical literature, as they were provided after review of the full record and interview/examination of the Veteran, and contained reasoned medical explanations. Finally, the Board acknowledges the Veteran’s argument that the several of the VA examiner opinions were not provided by a pulmonologist. See September 2018 Notice of Disagreement. Unless the claimant challenges the adequacy of the examination or opinion, the Board may assume the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009). Id. However, even when the claimant challenges a VA examination or opinion, the Board may assume the competency of the VA medical examiner as long as, under 38 C.F.R. § 3.159(a)(1), he or she is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). In this case, the Board has found no reasons why any of the examiners were not qualified through their education, training, or experience to provide an adequate examination and opinion in regard to the etiology of the Veteran’s pulmonary condition. In sum, the evidence is against a finding that the Veteran’s pulmonary disorders are etiologically related to in-service asbestos exposure, and the claim for service connection must be denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). B. Mullins Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Scarduzio, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.