Citation Nr: 21001916 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-48 542 DATE: January 12, 2021 REMAND Entitlement to service connection for a pulmonary disability to include interstitial lung disease and asthma, claimed as the result asbestos exposure, is remanded. REASONS FOR REMAND The Veteran had active service from August 1960 to September 1963. He had additional duty with the Naval Reserve. Entitlement to service connection for a pulmonary disability to include interstitial lung disease and asthma, claimed as the result asbestos exposure, is remanded. The service documentation of record reflects that the Veteran served with the Naval Reserve and was discharged in November 1966. The Veteran’s periods of active duty, active duty for training, and inactive duty for training with the Naval Reserve have not been verified and all service medical documentation associated with any such duty has not been requested for association with the record. A December 2016 chest computerized tomography study from W. Didle, M.D., revealed findings consistent with right lower lobe “focal atelectasis and/or scarring” and “additional minimal areas of subpleural nodular thickening/scarring of the left lingular segment and bilateral lung bases.” The study indicates that it had been requested by Antonio Meily, M.D. Clinical documentation from Dr. Meily is not of record. A July 2017 pulmonary evaluation from M. Patel, M.D., states that the Veteran was diagnosed with asthma, interstitial lung disease, and pulmonary hypertension. Clinical documentation from Dr. Patel is not of record. Asbestos-related pulmonary disease is interstitial in nature. See M21-1, IV.ii.2.C.2.b (identifying general effects of asbestos exposure); See also Dorland’s Illustrated Medical Dictionary 161-62 (32nd ed. 2012). (defining asbestosis as “a form of pneumoconiosis (silicatosis) caused by inhaling fibers of asbestos, marked by interstitial fibrosis of the lung ...”). Department of Veterans Affairs (VA) clinical documentation dated after August 2020 is not of record. VA should obtain all relevant military, VA, and private treatment records which could potentially be helpful in resolving the Veteran’s claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The report of a July 2019 VA pulmonary examination states that the examiner noted that the Veteran had been “discharged in 1993” and he had a “h/o exposure to asbestosis for 2 years while in service, but he does not have any evidence of asbestos related lung disease based on normal CXR, no evidence of pleural plaques or interstitial lung disease by CT scan and no evidence of restrictive defect on PFT.” The Veteran was diagnosed with asthma. An August 2020 addendum to the July 2019 VA respiratory examination report states that “there is no objective evidence in the record that he had recurrent asthma attacks during service, to suggest that his asthma was aggravated during service” and “for these reasons, it is not at least as likely as not (50 percent or greater) that the Veteran’s asthma did not incur during, or otherwise caused or aggravated by active duty service or any incident therein, to include as due to his conceded in-service exposure to asbestos.” The examiner did not note or otherwise address the Veteran’s duty with the Naval Reserve, the December 2016 chest computerized tomography findings of bilateral lung scarring and nodules, and Dr. Patel’s diagnosis of interstitial lung disease. Given such deficiencies, the Board of Veterans’ Appeals (Board) finds that the July 2019 examination report and the August 2020 addendum thereto to be of essentially no probative value. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board therefore finds that further VA respiratory evaluation is necessary. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider, including Antonio Meily, M.D., and M. Patel, M.D., who has treated him for any pulmonary disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Contact the National Personnel Records Center (NPRC) and/or the appropriate service entity and request that the Veteran’s periods of active duty, active duty for training, and inactive duty for training with the Naval Reserve be verified and all available service medical records associated with that duty be forwarded for incorporation into the record. 3. Schedule the Veteran for a VA pulmonary examination conducted by a medical doctor to assist in determining the nature and etiology of any identified pulmonary disabilities and any relationship to active service. The examiner must review the record, including the December 2016 chest computerized tomography study from W. Didle, M.D., and the July 2017 pulmonary evaluation from M. Patel, M.D., and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all pulmonary disabilities found. If interstitial lung disease is not found, the examiner should specifically state that fact. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified pulmonary disability had its onset during active service or is related to any incident of service, including the conceded asbestos exposure. . J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Edward G. Lent 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.