Citation Nr: 20017737 Decision Date: 03/06/20 Archive Date: 03/06/20 DOCKET NO. 20-01 472 DATE: March 6, 2020 ORDER New and material evidence having been received, the claim for entitlement to service connection for residuals of tuberculosis is reopened. Entitlement to service connection for residuals of tuberculosis is granted. FINDINGS OF FACT 1. An unappealed May 2015 rating decision is the last final decision that denied service connection for residuals of tuberculosis. 2. The evidence received since the final May 2015 rating decision is new and relates to unestablished facts necessary to substantiate the claim for service connection for residuals of tuberculosis. 3. The Veteran’s current pulmonary conditions, to include pulmonary mycobacterial infection, chronic cough, hemoptysis, bronchiectasis, and shortness of breath, are etiologically related to the pulmonary tuberculosis incurred in and treated for during active service. CONCLUSIONS OF LAW 1. The May 2015 rating decision denying service connection for tuberculosis pneumonia, claimed as lung condition secondary to tuberculosis, is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.160(d), 20.302, 20.1103. 2. The criteria to reopen the service connection claim for residuals of tuberculosis are met. 38 U.S.C. §§ 5107, 5108; 38 C.F.R. § 3.156(a). 3. The criteria for entitlement to service connection for residuals of tuberculosis are met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from June 1968 to May 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2019 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which reopened the Veteran’s claim for service connection for pulmonary tuberculosis, but denied it on the merits. Although the RO previously reopened the Veteran’s claim, it is the Board’s jurisdictional responsibility to consider whether it is proper for a claim to be reopened. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). By way of procedural background, the Board notes that the Veteran was granted service connection for tuberculosis and assigned a 100 percent disability rating from May 1969 to March 1971, at which time he was assigned a noncompensable rating as his tuberculosis was found to be inactive. See rating decisions dated October 1969, December 1970, and November 1975. However, the Board notes that recent rating decision codesheets, for reasons unclear, do not include the Veteran’s prior award of service-connection for his tuberculosis. See codesheets dated May 2015, December 2017, and January 2019. The Veteran and VA have, at various times, phrased the issue on appeal as tuberculous pneumonia, pulmonary tuberculosis, a lung condition secondary to tuberculosis, a respiratory condition secondary to tuberculosis, tuberculosis residuals, and tuberculosis increase. See September 2017 claim application; May 2015 rating decision; June 2017 petition to reopen; December 2017 rating decision; October 2018 petitions to reopen; January 2019 rating decision. After reviewing the contentions and evidence of record, the Board recharacterizes the Veteran’s claim as entitlement to service connection for residuals of tuberculosis. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009); Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Also, the Board notes that in January 2020 Third Party Correspondence, the Veteran, through his representative, requested an extension of time until April 2020 to submit additional evidence and argument. In correspondence received February 2020, the Veteran, through his representative, stated that he waived the remaining extension time. Thus, the Board will proceed with adjudication. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the appellant and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). 1. Whether new and material evidence has been received to reopen a claim of service connection for residuals of tuberculosis Rating decisions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160, 20.201, 20.302. If the Board issues a decision on appeal confirming the RO’s decision, then the Board’s decision subsumes the RO’s decision on the same issue at hand. 38 C.F.R. § 20.1104. Moreover, if the Board’s decision is not timely appealed, then it, too, is final and binding based on the evidence then of record. 38 C.F.R. § 20.1100. VA may reopen a claim that has been previously denied if new and material evidence is submitted by or on behalf of the claimant. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Regarding applications for reopening, 38 C.F.R. § 3.156(a) defines “new” evidence as evidence not previously submitted to agency decision makers and “material” evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179 (2003). In order to reopen a claim, it is not necessary that new and material evidence be received regarding each previously unproven element of a claim. Indeed, newly submitted evidence need not be overwhelming as a “low threshold” standard is applied. Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). In this matter, the Veteran’s original service connection claim for residuals of tuberculosis was first denied by the RO in a May 2015 rating decision because there was no evidence of a current lung condition or permanent residual or chronic disability. The Veteran did not appeal the May 2015 rating decision, nor was new and material evidence received within a year of notification of the rating decision. 38 C.F.R. § 3.156(b). Therefore, the May 2015 rating decision became final. 38 U.S.C. § 7105(c); 38 C.F.R. § 3.104(a). Thus, the question before the Board is whether the evidence received after the final May 2015 rating decision is both new and material. The record reflects that when the RO issued the May 2015 rating decision, the Veteran’s claims file contained a September 2014 claim application, service treatment records (STRs), military personnel records, VA treatment records, and an April 2015 VA examination report and medical opinion. Evidence received since the May 2015 rating decision includes June 2017 and October 2018 petitions to reopen, updated VA treatment records, an October 2018 VA examination report and medical opinion, a November 2018 Statement in Support of Claim, private treatment records received December 2018, a January 2019 NOD, an August 2019 private “Respiratory Conditions” Disability Benefits Questionnaire (DBQ), and an April 2019 private treatment record. Of note, in the April 2019 private treatment record, the provider, R.C.B., a pulmonologist, diagnosed the Veteran with pulmonary mycobacterial infection, chronic cough, hemoptysis, bronchiectasis, and shortness of breath. Dr. R.C.B. found that the Veteran’s current pulmonary mycobacterial infection was “consequent of cavitary lesion as a sequela from tuberculosis that was treated in the 1960s while the patient was in the military service.” He also noted that the Veteran’s chronic cough was “[r]elated to bronchiectasis and right upper lobe cavitary lesion, from old tuberculosis while in the service” and found that the Veteran’s current hemoptysis and shortness of breath were from the same causes. The Board finds that the April 2019 private treatment record is new as it was not previously submitted to the RO and it is material because it relates to the unestablished elements of a current disability and a nexus between the Veteran’s current diagnoses and his in-service tuberculosis. Therefore, the Board concludes that the evidence received since the last final decision is new and material and, for these reasons, the petition to reopen is granted. In Bernard v. Brown, 4 Vet. App. 384, 392 (1993), the Court of Appeals for Veterans Claims held that claims to reopen previously and finally denied claims implicated both the question of whether there is new and material evidence to reopen the claim and the question of whether, upon such reopening, the claimant is entitled to the requested benefits. Therefore, the “matter” over which the Board has jurisdiction under 38 U.S.C. § 7104(a) is the Veteran’s claim of entitlement to VA benefits. The Board finds no prejudice to the Veteran in adjudicating the claim. Moreover, the Board grants the claim and such award is a complete grant of the benefits sought. 2. Entitlement to service connection for residuals of tuberculosis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 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). As pertinent here, bronchiectasis and active tuberculosis are considered by VA to be “chronic diseases” listed under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions based on “chronic” in-service symptoms and “continuous” post-service symptoms under 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestation in service will permit service connection. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Where a Veteran served ninety days or more of active service, and certain chronic diseases, such as bronchiectasis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). For tuberculosis, it must have become manifest to a degree of 10 percent or more within 3 years after the date of separation from such service. While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. A lay person is competent to report on the onset and reoccurrence of current symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board must determine on a case-by-case basis whether a Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). When all evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Here, the Veteran asserts his current pulmonary conditions are related to the tuberculosis incurred in active service. As an initial matter, the Board finds that the Veteran has current diagnoses of pulmonary mycobacterial infection, chronic cough, hemoptysis, bronchiectasis, and shortness of breath. See April 2019 private treatment record. Thus, a current disability is established. Next, the Board finds the Veteran was diagnosed with and treated for tuberculosis during active service. See December 1968 STR from the Naval Hospital at Portsmouth, Virginia. Accordingly, an in-service event is established. Thus, the question remaining before the Board is whether there is a nexus between the Veteran’s current pulmonary conditions and his in-service tuberculosis. By way of background, in a December 1968 STR from the USS John F. Kennedy, the provider noted that a chest X-ray showed “density in right upper lobe with central cavity.” In a December 1968 STR from the Naval Hospital at Portsmouth, Virginia, follow-up chest X-rays revealed a marked change and “much more diffuse infiltrate of the right upper lung which appears to be posterior.” A January 1969 X-ray report of the Veteran’s chest revealed a consolidation in the right upper lobe of his lungs. In Physical Evaluation Board (PEB) Proceedings dated September 1972, the PEB found the Veteran was unfit to perform his duties because of a physical disability of “Tuberculosis, pulmonary, far advanced, inactive, with right upper lobe cavity.” In a September 2011 record from Jackson Memorial Hospital, the private treatment provider, A.L., MD, wrote, “The patient notes that he developed a viral infection starting some time in July, which he characterizes as a dry cough, malaise, weakness, and night sweats. He notes that over the next few weeks the viral illness did resolve. He did, however, have persistent night sweats for that period of time... The patient noted that the time that he did have PPD test that was placed in the past and was found to be positive. He denied any ongoing cough for or productive sputum. He denied chills, however, he does note night sweats for sometime now...” Dr. A.L. noted that the Veteran had a CT scan of his chest showing findings “consistent with a distal segmental mainly subsegmental pulmonary embolism of the left basilar segment of the right lower lobe. There also signs of bronchiectasis and low long volumes also noted. There is a questionable cavitary lesion versus cystic bronchiectasis noted also in the right upper lobe. There was also read to have a cluster of centrilobular nodular densities in a tree, but arrangement in the lateral basal segment of the right lower lobe as well, which could indicate infection, inflammation. In the differential, possibly TB. Additional pulmonary nodules were noted in the right lower lobe and lingula these will were recommended by radiology to be followed up in 3 months time.” Dr. A.L. also noted the Veteran had three AFB (acid-fast bacilli) negative sputum tests and a bronchoscopy failed to reveal any acid-fast bacilli or active signs of tuberculosis. Ultimately, the Veteran’s private treatment providers ruled out a diagnosis of active tuberculosis and his symptoms improved. A September 2011 private radiology report of the Veteran’s chest from Jackson Memorial Hospital revealed a “[s]table appearance of the right upper lobe parenchymal scarring with mild traction bronchiectatic changes.” A September 2011 private CT scan report of the Veteran’s chest from Jackson Memorial Hospital revealed “evidence of linear densities in the right upper lung and to a lesser extent in the left lower lung suggestive of scarring versus subsegmental atelectasis...There is evidence of biapical linear densities suggestive of apical pleural thickening and/or pulmonary scarring. In the apical and posterior segments of the right upper lobe there is evidence of linear densities associated with traction bronchiectatic changes and anterior shift of the major fissure findings suggestive of pulmonary fibrotic changes with volume loss changes likely due to post primary TB changes. Also noted in the apical segment of the right upper lobe is a possible round cavitary lesion measuring up to 1.4 cm in diameter with mildly thickened walls that may represent either a small cavitary lesion versus a cystic bronchiectasis…” In conclusion, the interpreting radiologist found the CT scan showed, in pertinent part, “[f]ibrotic changes associated with bronchiectasis and volume loss changes in the apical and posterior segments of the right upper lobe likely related to post primary TB changes.” In September 2014, the Veteran filed a claim for service connection for a “lung condition secondary to Tuberculosis.” See September 2014 claim application. In April 2015, the Veteran was provided a VA examination to determine the likely etiology of his current lung condition. The VA examiner, an Advanced Registered Nurse Practitioner-Certified, conducted an in-person examination of the Veteran and reviewed the Veteran’s claims file. The examiner diagnosed the Veteran with tuberculous pneumonia and noted the date of diagnosis as 1968. In describing the history of the Veteran’s respiratory condition, the VA examiner wrote, “Veteran is claiming lung condition that was incurred in or caused by the inservice treatment for TB. STR shows positive PPD on entering to service. He was treated for a diagnosis was tuberculous pneumonia on RUL by Xray in service. He was treated with TB drugs which he completed. About 2 years ago, he started coughing with a little bloody tinged, he went to see his PCP and vet was admitted to JMH. He was tested for PPD and came back positive. He was put on isolation while undergoing studies, this included lung CT, endoscopic lung procedures, he does not know the exact result but was told it was not cancer. He reports he was put on warfarin after which he took for more than a year and he self stop this in 2014. His last CXR was about a year ago by his outside PCP. It was reported within normal limits. He has not treated for TB since service.” The Board notes that RUL is an abbreviation for right upper lobe. The VA examiner indicated that pulmonary function testing results accurately reflected the Veteran’s current pulmonary function, and that there were no other significant diagnostic test findings and/or results. Ultimately, the VA examiner opined that the Veteran’s claimed lung condition was less likely than not incurred in or caused by his in-service tuberculosis. She reasoned that there was no medical evidence of a current lung condition that was associated with his in-service treatment of tuberculosis, noting that although he was admitted to a hospital a few years ago, records from that hospitalization were not available and the Veteran reported he was not treated with anti-tuberculosis drugs. The VA examiner also found that the Veteran had no active signs or symptoms of tuberculosis. In a January 2016 private X-ray report of the chest, the “indication” for the X-ray was noted to be “history of cough,” and the interpreting radiologist found the X-ray showed “a few interstitial markings at the upper right lung zone with apical pleural thickening bilaterally. There are a few interstitial markings at the left base [as] well.” In June 2017, the Veteran filed a petition to reopen his claims for “TB increase, TB residuals, lung condition sec to TB, [and] respiratory condition sec to TB.” In a June 2017 VA primary care E & M note, the Veteran reported he had been coughing all of his life, was diagnosed with tuberculosis with a cavitary lesion in 1969, and was treated with injections and medications and the tuberculosis resolved. He reported he still had a chronic cough and had been seeing some specks of blood for the last 2 to 3 years. He stated that he had a workup done by an outside pulmonogist that was negative and he endorsed losing a lot of weight in 3 years and having night sweats for at least the last 10 years. The provider noted that on a review of systems, the Veteran was positive for hemoptysis and cough. The provider referred the Veteran for a pulmonary consultation and a chest X-ray. In an August 2017 VA nursing outpatient note, the Veteran endorsed a history of tuberculosis for which he was medically discharged from service. He reported that in 2011, he was treated for tuberculosis in a private hospital and complained of having a cough with blood and night sweats. In an August 2017 VA pulmonary consultation record, the “Reason for Consult” was noted to be “concern for pulmonary tuberculosis.” The provider noted the Veteran had a history of pulmonary tuberculosis that was treated with 4 drugs 40 years ago. The Veteran reported that 2 years ago, while in Miami, he had a chronic cough with some blood specks and was hospitalized and put under airborne precautions. The provider noted there were no records from Jackson Memorial Hospital. The Veteran complained of occasional fevers and night sweats, noted his appetite was good but he felt he had been losing weight, had an occasional cough, and that sometimes after a bout of coughing, he had flecks of blood in it. The provider found that a CT scan of the chest “shows fibrotic cavity in RUL, no infiltrates or effusions or mediastinal lymphadenopathy” and his pulmonary function test results showed mild obstruction, no restriction or air trapping, and normal DLCO (diffusing capacity of lung for carbon monoxide). The provider found the Veteran had a right upper lobe fibrocavitary lesion, a history of pulmonary tuberculosis, and chronic cough. She also noted the Veteran “may have bronchiectasis causing cough and sputum and trace hemoptysis.” In a November 2017 VA pulmonary E & M note, the provider noted the Veteran had pulmonary tuberculosis while in service, a CT scan of his chest showed scarring on the right upper lobe and traction bronchiectasis, pulmonary function tests from 2015 did not show evidence of COPD (chronic obstructive pulmonary disease), Quantiferon test results were negative, and the Veteran endorsed an occasional runny nose. After physical examination, the provider found the Veteran had a chronic cough, “likely upper airway syndrome [or] due to focal bronchiectasis…less likely to be TB, no systemic symptoms of fevers or night sweats or appetite or weight change, quantiferon negative. Recommend follow-up CT of the thorax in 12 months to document stability of some of the more solid appearing components.” In a December 2017 rating decision, the RO denied the Veteran’s petition to reopen as no new and material evidence had been submitted. In an August 2018 VA pulmonary E & M note, the provider noted an impression of: “Chronic cough with intermittent hemoptysis x 15-20 years. Lung Tb treated from 1969 to 1972, RUL scar tissue with associated bronchiectasis...Unknow[n] reason of cough could be related to an infection as MAC vs neurologic? Or the scar tissue from TB infection with residual bronchiectasis.” The Board notes that MAC is a medical abbreviation for mycobacterium avium complex. In an August 2018 VA infection control note, the provider, a registered nurse and infection preventionist, found that the Veteran required airborne precautions for suspected tuberculosis. In October 2018, the Veteran filed petitions to reopen his claims for “Tuberculous Pneumonia” and “Pulmonary Tuberculosis.” In an October 2018 VA primary care E & M note, the Veteran requested a “nexus letter for Pulmonary TB SVC connection.” The provider, a medical doctor and primary care physician, noted she would complete the nexus letter “today.” In an October 2018 nexus statement, an internal medicine and primary care physician noted that they had reviewed the Veteran’s STRs and examined the Veteran before rendering the following professional medical opinion. The physician found the Veteran had a current disability of pulmonary tuberculosis that was most likely caused by or a result of events while in service, reasoning that the Veteran “was diagnosed with pulmonary tuberculosis in military service.” The physician provided their signature at the bottom of the page. Based on the date of the nexus statement and the Veteran’s request for a nexus letter in the aforementioned October 2018 VA primary care E & M note, as well as the VA provider’s credentials as a medical doctor and primary care physician, the Board finds that the October 2018 nexus statement was authored by the Veteran’s VA primary care provider. In October 2018, the Veteran was provided an additional VA examination to determine the likely etiology of his claimed condition. The Veteran was not examined in-person, but his claims file was reviewed by the VA examiner, a medical doctor, for completion of an examination report. The VA examiner found the Veteran was diagnosed with pulmonary tuberculosis in December 1968. In describing the history of the Veteran’s respiratory condition, the examiner wrote, “Veteran was diagnosed with pulmonary TB in December 1968. [He] had a positive intermediate PPD in boot camp with 11mm of induration. He underwent chest xray every 6 months. First xray in July was normal but six days prior to admission he developed a non[productive] cough with pain. Xray revealed a RUL infiltrate with central cavitation. Gastric aspirate culture with positive for Mycobacterium TB at Portsmouth Naval Hospital. He was treated with INH, Sodium PAS and streptomycin. Per med Board he was not motivated for continued Naval Service. Veteran was seen in Miami VA for chronic cough- documented that it was not TB.” The VA examiner found the Veteran had “Other pulmonary conditions, pertinent physical findings or scars due to pulmonary conditions.” The VA examiner noted that an August 2018 CT scan of the chest showed evidence of scarring with associated traction bronchiectasis of the right upper lobe. The examiner also found that pulmonary function testing results accurately reflected the Veteran’s current pulmonary function, and that they showed “mild restrictive ventilatory impairment…with mildly [diffused] capacity. Muscles forces were reduced both for inspiration and expiration indicating weakness of both the diaphragm and skeletal respiratory muscles.” See October 2018 VA examination report. Ultimately, the VA examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by his in-service tuberculosis, reasoning that the Veteran did not have active tuberculosis, nor did he have “TB pneumonia. It is resolved.” See October 2018 VA medical opinion. In a November 2018 Statement in Support of Claim, the Veteran wrote, “I want to clarify that the condition under claim is Pulmonary Tuberculosis. VA records show Tuberculosis pneumonia instead. Please correct this in order to avoid confusion.” In a December 2018 VA pulmonary E & M note, the Veteran endorsed a chronic cough for the past 15 to 20 years, intermittent shortness of breath with exertion, acid reflex symptoms, nighttime coughs and gasping for air. He reported having tuberculosis that was treated 30 years prior. The Veteran also endorsed intermittent hemoptysis and intermittent productive cough in the morning. The provider noted an impression of chronic cough that was possibly related to aspiration, acid reflux, and fungal infection, and hemoptysis. The provider requested an AFB sputum culture and a chest CT scan in 3 months. In a January 2019 NOD, the Veteran wrote, “I believe my pulmonary tuberculosis is due to the TB I contracted during my military service. I request the VA review my file and grant me service connection for my pulmonary tuberculosis.” In a March 2019 VA pulmonary E & M note, the provider, an Advanced Practice Registered Nurse and Board Certified Family Nurse Practitioner, noted an impression of chronic cough and hemoptysis and found a July 2017 CT scan of the Veteran’s chest “reveal[ed] RUL bronchiectasis secondary to hx of Tuberculosis >30 yrs ago. In an April 2019 private treatment record, Dr. R.C.B., a pulmonologist, noted the Veteran had a history of pulmonary tuberculosis that was treated for about 1 year back in 1968 and 1969 when the Veteran was in service. Dr. R.C.B. noted that the Veteran “brings records today from the VA” which show he was treated, his tuberculosis was cured, and he had a residual right upper lobe cavity. The Veteran complained of shortness of breath with moderate exertion, a chronic cough with white sputum and sometimes with specks of blood for the past 10 years, occasional night sweats, and some snoring. Dr. R.C.B. found that a March 2019 CT scan of the chest revealed right upper lobe bronchiectasis and scarring. He also found that the bacterial infections of his lungs caused hemoptysis, and opined that the Veteran had a “right upper lobe cavitary lesion secondary to tuberculosis that was treated while he was in military service...” Dr. R.C.B. ultimately diagnosed the Veteran with pulmonary mycobacterial infection, chronic cough, hemoptysis, bronchiectasis, and shortness of breath. Dr. R.C.B. found that the Veteran’s current pulmonary mycobacterial infection was “consequent of cavitary lesion as a sequela from tuberculosis that was treated in the 1960s while the patient was in the military service.” He also noted that the Veteran’s chronic cough was “[r]elated to bronchiectasis and right upper lobe cavitary lesion, from old tuberculosis while in the service” and found that the Veteran’s current hemoptysis and shortness of breath were from the same causes. In a June 2019 VA primary care note, the Veteran was found to have a history of pulmonary tuberculosis and the provider noted that a nexus letter was given to the patient in the past, as he requested. In an August 2019 VA pulmonary E & M note, the Veteran endorsed a history of asbestos exposure and tuberculosis 30 years ago and complained of a chronic productive cough with clear mucous and occasional blood streaks for years that was worse at night. He also reported increased nasal drainage, sinus congestion and headaches, and post nasal drip. The provider noted that an August 2019 CT scan of the chest showed, in pertinent part, “Unchanged right upper lobe segmental traction/cylindrical scratch that bronchiectasis with associated fibrosis/scarring which may reflect prior infection.” The provider noted an impression of chronic cough with intermittent blood streaks, a history of tuberculosis, and found that allergies and GERD (gastroesophageal reflux disease) may be contributing to his coughs as well. In an August 2019 Statement in Support of Claim, the Veteran wrote, “I am providing the attached disability benefits questionnaire in support of my claim for residual lung condition as a result of the TB I had during my military service. As you will see, I have a chronic cough that is so bad I cough up blood. I ask that you please consider this information in making a decision on my claim.” In August 2019, the Veteran’s private pulmonologist, Dr. R.C.B., completed a “Respiratory Conditions” DBQ. Dr. R.C.B. indicated the Veteran had the following diagnoses: pulmonary mycobacterial infection, bronchiectasis, a “personal history of tuberculosis,” hemoptysis, and chronic cough. Dr. R.C.B. noted he did not review the Veteran’s claims file and instead only reviewed the Veteran’s private treatment records from Florida Lung, Asthma, and Sleep Specialists. Dr. R.C.B. noted the Veteran’s respiratory conditions require the use of antibiotics, stating “antibiotic type, dose, frequency to be decided when exacerbations occur.” He found that the Veteran’s daily productive cough with intermittent blood-tinged sputum was attributable to bronchiectasis. While Dr. R.C.B. indicated that the current status of the Veteran’s bacterial infection of the lungs was inactive, he found that the Veteran’s night sweats and hemoptysis were symptoms attributable to a bacterial infection of the lung or chronic lung access. Dr. R.C.B. noted that a March 2019 CT scan of the chest revealed bronchiectasis of the right upper lobe, and a March 2019 bronchoscopy found mucus plugs in the right upper lobe and cultures that were positive for non-tuberculosis mycobacteria. Dr. R.C.B. did not provide an etiology opinion. On review, the Board finds that the preponderance of the evidence supports a finding that the Veteran’s current pulmonary diagnoses are related to his in-service disease of tuberculosis. First, the Board finds the April 2015 and October 2018 VA examination reports and medical opinions inadequate. In April 2015, the VA examiner opined that the Veteran’s claimed lung condition was less likely than not incurred in or caused by his in-service tuberculosis. She reasoned that there was no medical evidence of a current lung condition that was associated with his in-service treatment of tuberculosis, noting that although he was admitted to a hospital a few years ago, records from that hospitalization were not available and the Veteran reported he was not treated with anti-tuberculosis drugs. The VA examiner also found that the Veteran had no active signs or symptoms of tuberculosis. While records from the Veteran’s September 2011 hospitalization at Jackson Memorial Hospital confirm he had no active signs of tuberculosis at that time, a September 2011 private CT scan report of the Veteran’s chest showed, in pertinent part, “[f]ibrotic changes associated with bronchiectasis and volume loss changes in the apical and posterior segments of the right upper lobe likely related to post primary TB changes.” As the September 2011 records from Jackson Memorial Hospital were not available to the April 2015 VA examiner, and they tend to show the Veteran had a current lung condition that was “likely related to post primary TB changes,” the examiner was not informed of all relevant facts before conducting an examination and rendering a medical opinion; thus, the Board affords the April 2015 VA examination report and medical opinion no probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). In the October 2018 VA examination report, the VA examiner only noted a diagnosis of pulmonary tuberculosis in December 1968, although she did indicate that the Veteran had “Other pulmonary conditions, pertinent physical findings or scars due to pulmonary conditions,” and acknowledged an August 2018 CT scan of the chest showing evidence of scarring with associated traction bronchiectasis of the right upper lobe. Ultimately, the VA examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by his in-service tuberculosis, reasoning that the Veteran did not have active tuberculosis, nor did he have “TB pneumonia. It is resolved.” However, the October 2018 VA examiner failed to consider whether the Veteran’s current pulmonary conditions were related to his in-service tuberculosis. As the October 2018 VA medical opinion did not address the instant question before the Board, the Board finds it incomplete and affords it no probative value. Second, the weight of the medical evidence demonstrates that the Veteran’s current pulmonary conditions are related to a right upper lobe cavity lesion that was caused by his in-service tuberculosis. In-service chest X-rays showed evidence of changes in the Veteran’s right upper lobe, and the PEB found the Veteran was unfit to perform his duties because of a physical disability of “Tuberculosis, pulmonary, far advanced, inactive, with right upper lobe cavity.” See December 1968 STRs; January 1969 X-ray report; September 1972 PEB Proceedings. Significantly, post-service radiographic reports still revealed lesions in the Veteran’s right upper lobe, which multiple medical providers found were due to tuberculosis and caused his current pulmonary conditions, to include pulmonary mycobacterial infection, chronic cough, hemoptysis, bronchiectasis, and shortness of breath. See September 2011 private radiology report (revealing a “[s]table appearance of the right upper lobe parenchymal scarring with mild traction bronchiectatic changes…”); September 2011 private CT scan report (showing “[f]ibrotic changes associated with bronchiectasis and volume loss changes in the apical and posterior segments of the right upper lobe likely related to post primary TB changes.”); August 2017 VA pulmonary consultation record (provider’s finding that the Veteran had a right upper lobe fibrocavitary lesion, a history of pulmonary tuberculosis, and chronic cough, and that he “may have bronchiectasis causing cough and sputum and trace hemoptysis.”); November 2017 VA pulmonary E & M note (provider’s finding that Veteran had a chronic cough, “likely upper airway syndrome [or] due to focal bronchiectasis…”); August 2018 VA pulmonary E & M note (provider’s impression of “Chronic cough with intermittent hemoptysis x 15-20 years. Lung Tb treated from 1969 to 1972, RUL scar tissue with associated bronchiectasis... Unknow[n] reason of cough could be related to an infection as MAC vs neurologic? Or the scar tissue from TB infection with residual bronchiectasis.”); March 2019 VA pulmonary E & M note (provider’s impression of chronic cough and hemoptysis and finding that a July 2017 CT scan of the Veteran’s chest “reveal[ed] RUL bronchiectasis secondary to hx of Tuberculosis >30 yrs ago.”); April 2019 private treatment record (Dr. R.C.B.’s findings that the Veteran had a residual right upper lobe cavity from tuberculosis, that a March 2019 CT scan of the chest revealed right upper lobe bronchiectasis and scarring, that the bacterial infections of the Veteran’s lungs caused hemoptysis, that the Veteran had a “right upper lobe cavitary lesion secondary to tuberculosis that was treated while he was in military service...,” diagnoses of pulmonary mycobacterial infection, chronic cough, hemoptysis, bronchiectasis, and shortness of breath, and opinions that the Veteran’s current pulmonary mycobacterial infection was “consequent of cavitary lesion as a sequela from tuberculosis that was treated in the 1960s while the patient was in the military service,” that the Veteran’s chronic cough was “[r]elated to bronchiectasis and right upper lobe cavitary lesion, from old tuberculosis while in the service,” and that the Veteran’s current hemoptysis and shortness of breath were from the same causes). (Continued on the next page)   The Board affords great probative value to the aforementioned medical nexus statements, particularly those authored by Dr. R.C.B. in an April 2019 private treatment record, as they were based on an accurate history of the Veteran’s tuberculosis treatment in service, considered radiologic reports showing a residual right upper lobe cavity from his tuberculosis, and adequately addressed the causal relationships amongst his current pulmonary conditions and his in-service tuberculosis. As probative medical evidence establishes a nexus between the Veteran’s current pulmonary conditions and his in-service tuberculosis, service connection for residuals of tuberculosis, to include pulmonary mycobacterial infection, chronic cough, hemoptysis, bronchiectasis, and shortness of breath, is warranted. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. M. Gill, 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.