Citation Nr: 21069029 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 18-26 765 DATE: November 17, 2021 ORDER 1. The appeal to reopen a claim of service connection for depression is granted. 2. The appeal to reopen a claim of service connection for anxiety is granted. 3. Entitlement to service connection for a variously diagnosed psychiatric disability, to included depression and anxiety, is granted. 4. A 10 percent (but no higher) rating for asbestosis is granted prior to October 19, 2017, from (the earlier effective date) of August 1, 2015. REMANDED 5. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. 6. Entitlement to a rating in excess of 30 percent for asbestosis from October 19, 2017 is remanded. FINDINGS OF FACT 1. An unappealed April 2015 rating decision denied the Veteran service connection for depression, finding essentially that the disability was not related to the Veteran's service. 2. Evidence received since the April 2015 rating decision suggests that the Veteran's depression may be related to complaints in service; relates to an unestablished fact necessary to substantiate the claim of service connection for depression; and raises a reasonable possibility of substantiating such claim. 3. An unappealed August 2015 rating decision denied the Veteran service connection for anxiety, finding essentially that the disability was not related to the Veteran's service. 4. Evidence received since the August 2015 rating decision suggests that the Veteran's anxiety may be related to complaints in service; relates to an unestablished fact necessary to substantiate the claim of service connection for anxiety; and raises a reasonable possibility of substantiating such claim. 5. Competent medical evidence establishes that the Veteran's variously diagnosed psychiatric disorder was, at least in part, caused by his service-connected asbestosis. 6. From the earlier effective date of August 1, 2015 to October 19, 2017, the Veteran's asbestosis is shown to have manifested in impairment medically determined to be consistent with PFT FEV-1 finding of 77 percent; it is not shown to have manifested in impairment medically determined to be consistent with PFT results of FVC of 65-74 percent predicted, or DLCO (SB) of 56-65 percent predicted. CONCLUSIONS OF LAW 1. New and material evidence has been received and the claim of service connection for depression may be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 2. New and material evidence has been received and the claim of service connection for anxiety may be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. Service connection for a variously diagnosed psychiatric disability is warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 4. Prior to October 19, 2017, from the (earlier effective date) of August 1, 2015, a 10 percent (but no higher) rating is warranted for asbestosis. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.96, 4.97, Diagnostic Code (Code) 6833. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from January 1984, to June 1984 and from December 1986 to December 1990. He also had additional periods of National Guard service. This matter is before the Board of Veterans' Appeals (Board) on appeal from September 2016 and February 2017 rating decisions. An interim (August 2018) rating decision increased the rating for asbestosis to 30 percent, effective October 19, 2017. In January 2020, a videoconference hearing was held before the undersigned; a transcript is in the record. At the outset, the Board notes that the Veteran initially filed separate claims of service connection for depression and anxiety. As noted below, the claims were denied in separate (April 2015 and August 2015) rating decisions which became final, and such claims are being reopened. At the January 2020 videoconference hearing, the Veteran confirmed that the claims of service connection for depression and anxiety were to be characterized as entitlement to service connection for a variously diagnosed psychiatric disability. Therefore, the issue (on de novo review) is recharacterized, as stated above, to reflect that the claim encompasses any psychiatric disability shown, however diagnosed. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). 1., 2. The appeals to reopen claims of service connection for depression and anxiety are granted. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. New and material evidence is defined by regulation. New evidence means evidence not previously submitted to agency decision-makers. Material evidence is 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 prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of establishing the claim. See 38 C.F.R. § 3.156(a). The U.S. Court of Appeals for Veterans Claims (CAVC) has held that the phrase 'raises a reasonable possibility of establishing the claim' must be viewed as enabling rather than precluding reopening. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). An April 2015 rating decision denied service connection for depression based essentially on a finding that such was not shown to be related to his service. The Veteran was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and it is final. 38 U.S.C. § 7105. Evidence received since the April 2015 rating decision includes a January 2020 private treatment record with the provider's opinion that the Veteran's depression is more likely than not related to his military service. An August 2015 rating decision denied service connection for anxiety based essentially on a finding that such disability was not shown to be related to his service. He was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and it is final. 38 U.S.C. § 7105. Evidence received since the August 2015 rating decision includes a January 2020 private treatment record with the provider's opinion that the Veteran's anxiety is more likely than not related to his military service. As service connection for depression and anxiety was previously denied on the basis that such disabilities were not shown to be related to the Veteran's service, for evidence to be new and material in the matters, it would have to be evidence not previously of record that tends to show that the Veteran's depression and anxiety are etiologically related to his service. The private medical statement relates the Veteran's depression and anxiety to service and/or a service-connected disability. Such evidence relates to an unestablished fact necessary to substantiate the claims of service connection for depression and anxiety, and raises a reasonable possibility of substantiating such claims (particularly considering the low threshold standard for reopening endorsed by the CAVC in Shade, supra). Therefore, the additional evidence received is both new and material, and the claims of service connection for depression and anxiety, may be reopened. 38 U.S.C. § 5108. De novo consideration of the claims is discussed below (as explained above, as service connection for a variously diagnosed psychiatric disability, to include depression and anxiety). 3. Entitlement to service connection for a variously diagnosed psychiatric disorder (to include depression and anxiety) is granted. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection is warranted for a disability that was caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310. The Veteran has established service connection for asbestosis. The Veteran contends that he has a psychiatric disability related to his service and/or secondary to his service-connected asbestosis. His service treatment records (STRs) are silent for complaints, treatment, findings, or diagnosis of a psychiatric disability. A March 2014 VA treatment record notes that the Veteran reported periods of depression and that he isolates, avoids big crowds, and tires easily. He related that he worked at a brick factory but was now unable to work because he did not have the stamina due to his sarcoidosis. Adjustment disorder with depressed mood was diagnosed. An October 2014 VA treatment record notes diagnoses of anxiety disorder and rule out posttraumatic stress disorder (PTSD). A December 2014 VA psychosocial assessment notes that the Veteran reported periods of depression following his sarcoidosis diagnosis and financial problems related to an inability to work. Sertraline was prescribed. He related that during service his unit was sent to El Salvador, and he saw young kids with weapons who would come up to the edge of the camp on Thursdays, but no gunfire was exchanged. The Veteran reported witnessing a boat fire and experiencing discrimination in the Coast Guard. He reported that his breathing problems left him unable to work, which has caused depressive symptoms and financial problems. A January 2015 VA treatment record notes that the Veteran began experiencing depressive and anxiety symptoms after being off work due to sarcoidosis. An April 2015 VA treatment record notes that the Veteran had a fairly recent history of depressive symptoms after receiving a diagnosis of sarcoidosis. He related that he was overwhelmed by financial difficulties, loss of functioning, and uncertainty about his future. The provider indicated that the diagnosis of sarcoidosis had since been reevaluated and that his symptoms seem to more accurately fit the clinical picture of asbestosis. An August 2016 VA treatment records notes diagnoses of alcohol use disorder, tobacco use disorder, and major depressive disorder. At the January 2020 videoconference hearing, the Veteran testified that he was traumatized in service when he had to help pull dead bodies out of the water and because he had a constant fear of water due to an inability to swim. He related that he was exposed to racial discrimination. He related that other members of his unit of a different race were allowed to go out on patrols, but he was left in the kitchen washing dishes and that his supervisor often harassed him. In a February 2020 private medical statement, the provider (a licensed psychologist) indicated that he reviewed the Veteran's claims file and conducted a 1-hour interview. The Veteran reported that during service (in the Coast Guard) they patrolled the waters off the coast of New York City (NYC), periodically had to assist with retrieving bodies from the water, and witnessed a boat fire, which was extremely traumatic. He reported experiencing discrimination from a Chief Petty Officer (CPO) in the form of excessive punishment for minor infractions and that he was often hassled by police in NYC, in what he thought were racially motived incidents (he related that he was left alone when they discovered he was in the military). He reported that during service he became extremely distressed by the treatment he experienced, as well as from witnessing the bodies in the harbor, and often fantasized about going AWOL to try and escape. He related that after service he owned a home renovation company, had arguments with contractors, and at one point pulled a gun on them. He related that he was unable to work in any supervisory or high stress capacity after those incidents. The provider noted that the Veteran had been receiving VA outpatient counseling and medications since early 2014 and adjustment disorder with depressed mood was diagnosed, later clarified to be anxiety disorder and major depression. March and April 2014 VA treatment records note that Veteran reported that he experienced depression and anxiety due to persistent tiredness and the impact that his inability to work due to his respiratory disorders was having on his finances. He related that he felt, pessimistic, depressed, and worthless because he was unable to work. The provider notes that April 2015 VA treatment records indicate that the Veteran reported a fairly recent history of depressive symptoms upon receiving a diagnosis of sarcoidosis (the diagnosis was reevaluated and seemed to fit more precisely a clinical picture of asbestosis), that he was overwhelmed by financial difficulties, and that he had a loss of functioning and uncertainty about his future. In an April 2015 VA psychological assessment, the provider notes that the Veteran began experiencing depressive and anxiety symptoms upon becoming unable to work due to a lung disorder. The private provider noted current diagnoses of alcohol dependence in sustained remission, generalized anxiety disorder, and persistent depressive disorder and opined that the Veteran's anxiety began during service after witnessing the boat fire, and that his depression began in service to a mild degree after experiencing a boat fire and seeing child soldiers in El Salvador. The provider also opined that the Veteran's depression worsened by a significant degree after he received a diagnosis of his service-connected asbestosis. It is not in dispute that the Veteran has diagnoses of various psychiatric disabilities, to include generalized anxiety disorder and depressive disorder, which are noted in his VA treatment records. It is also not in dispute that he has established service connection for asbestosis. He contends that his psychiatric disability is related directly to his service or is secondary to (was caused or aggravated by) his service-connected asbestosis. A VA mental disorders examination has not been conducted, and no VA examiner has provided an opinion against the Veteran's claim. December 2014, January 2015, and April 2015 VA treatment records note, in part, that the Veteran reported periods of depression following his sarcoidosis (now asbestosis) diagnosis and financial problems related to his inability to work. The February 2020 provider noted current diagnoses of alcohol dependence in sustained remission, generalized anxiety disorder, and persistent depressive disorder and opined that the Veteran's anxiety began during service after he witnessed a boat fire, and that his depression began in service upon witnessing a boat fire and seeing child soldiers in El Salvador. The provider also opined that the Veteran's depression worsened to a significant degree after he was found to have [his service-connected] asbestosis. The Board notes that the Veteran's reports of witnessing a boat fire and seeing child soldiers in El Salvador have not been corroborated; however, the February 2020 also opined that the Veteran's depression had been aggravated by his service-connected asbestosis and noted multiple instances in the record when the Veteran reported (and VA providers suggested) that his depression symptoms worsened after his lung disorder was diagnosed because the lung disorder was causing physical and financial difficulties. Resolving any remaining reasonable doubt in the Veteran's favor as required (see 38 U.S.C. § 5107; 38 C.F.R. § 3.102), the Board finds that the evidence persuasively shows that the Veteran's psychiatric disability was, at least in part, caused by his service-connected asbestosis. The requirements for establishing secondary service connection are met; service connection for a variously diagnosed psychiatric disability is warranted. 4. Entitlement to 10 percent (but no higher) rating for asbestosis prior to October 19, 2017 is granted from (the earlier effective date) of August 1, 2015. Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran filed the instant claim for increase on August 1, 2016. Consequently, the evaluation period begins August 1, 2015, one year prior. Under the General Rating Formula for Interstitial Lung Disease, a 10 percent rating is warranted for Forced Vital Capacity (FVC) of 75 to 80 percent predicted, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method) DLCO (SB) of 66 to 80 percent predicted; a 30 percent rating is warranted for FVC of 65 to 74 percent predicted, or; DLCO (SB) of 56 to 65 percent predicted; a 60 percent rating 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 cardiorespiratory limitation; and a 100 percent rating is warranted for FVC less than 50 percent predicted, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption with cardiorespiratory limitation, or; cor pulmonale or pulmonary hypertension, or; requires outpatient oxygen therapy. Id. at Codes 6825-6833. At the outset, the Board notes that, when evaluating disability under the General Rating Formula for both interstitial lung diseases, evaluation may be based on criteria other than DLCO (SB) as long as the examiner states why such testing would not be useful or valid in a particular case. Although the rating criteria refer to maximum exercise capacity tests, such tests are not required for evaluation. 38 C.F.R. § 4.96(d)(1)(i). VA must evaluate based on PFTs that are inconsistent with clinical findings, unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes, except when the results of pre-bronchodilator PFTs are normal, or when the examiner determines that post-bronchodilator studies should not be done and states why. When evaluating based on PFT's, use post-bronchodilator results in applying the evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, use the pre-bronchodilator values for rating purposes. When there is a disparity between the results of different PFT's (FEV-1 (Forced Expiratory Volume in one second), FVC (Forced Vital Capacity), etc.), so that the level of evaluation would differ depending on which result is used, use the test result that the examiner states most accurately reflects the level of disability. Id. at § 4.96(d)(2-6). On March 2015 VA respiratory conditions examination, chronic obstructive pulmonary disease (COPD), sarcoidosis, and asbestosis, were diagnosed. The Veteran reported that he utilized a combination steroid/long-acting bronchodilator inhaler, as well as another type of inhaler (Tiotropium) for bronchodilation. He related that he thought the inhalers helped, but he still has a chronic nonproductive cough. Available pulmonary function tests (PFTs) start in 2013, and show mild COPD. It was noted that the Veteran's respiratory disorder does not require use of oral or parenteral corticosteroid medications, but does require daily use of inhalational bronchodilator therapy and inhalational anti-inflammatory medication. Antibiotics or outpatient oxygen therapy were not required. March 2015 pulmonary function testing showed a pre-bronchodilator FVC of 85 percent predicted, an FEV-1 of 75 percent predicted, an FEV-1/FVC of 70 percent, and a DLCO of 64 percent predicted. Post-bronchodilator readings were an FVC of 86 percent predicted, an FEV-1 of 77 percent predicted, and FEV-1/FVC of 71 percent, and no DLCO reading. The examiner indicated that the test that most accurately reflected the Veteran's level of disability was FEV-1 percent predicted. A March 2015 high resolution chest CT scan showed the airway was patent, there was ground glass opacity in the left upper lobe/apical region, and there were multiple pulmonary opacities. There were no alveolar or interstitial infiltrates, no calcified pleural plaques, and no adenopathy. The examiner opined that COPD and fibrotic changes affected the Veteran's pulmonary stamina and that his past and current chest imaging did not support a diagnosis of sarcoidosis, but rather of asbestosis. On August 2016 VA respiratory examination, emphysema, COPD, chronic bronchitis, and asbestosis were diagnosed. It was noted that the respiratory disorders require use of oral or parenteral corticosteroid medications, and daily use of systemic high dose corticosteroids, inhalational bronchodilator therapy, inhalational anti-inflammatory medication, oral bronchodilators, and antibiotics. Outpatient oxygen therapy was not required. It was noted that the Veteran had 4 or more asthma attacks with episodes of respiratory failure in the last 12 months. Physician visits for exacerbations were less frequent than monthly, and his bronchiectasis was productive of a near constant daily cough with purulent sputum at times. Antibiotics were required at least twice a year, and the Veteran reported weight loss and weakness. A September 2016 PFT showed a pre-bronchodilator FVC of 85 percent predicted, an FEV-1 of 71 percent predicted, an FEV-1/FVC of 84 percent, and no DLCO reading. Post bronchodilator readings were an FVC of 72 percent predicted, an FEV-1 of 91 percent predicted, an FEV-1/FVC of 80 percent, and no DLCO reading. The examiner opined that the reading that most accurately reflected the Veteran's level of disability was the FEV-1/FVC and that his respiratory disorder did impact his ability to work because of his chronic cough, weight loss of more than 20 pounds in the last 6 months, daily shortness of breath, increased episodes of lung infections, and weakness requiring assistance with activities of daily living. At the January 2020 videoconference hearing, the Veteran's attorney asserted that the wrong pulmonary function tests were considered in rating the Veteran's asbestosis 0 percent. FVC numbers were noted in the rating decision, but the evaluators on VA examinations recommended that FEV values [best reflected] the Veteran's disorder. His attorney stated that according to the Code criteria, when the level of evaluation would differ depending on which test was used, the test result that the examiner states most accurately reflects the level of disability should be used. She related that the March 2015 and September 2016 examiners recommend the FEV rating be used, but the rating decision erroneously stated that the examiners recommended the FVC number, and when the numbers for the FVC and the FEV are utilized, the level of evaluation would be at least 10 percent for his asbestosis, not 0 percent. The Veteran testified that it had become more difficult for him to breathe. Considering all the probative evidence throughout the rating period on appeal, prior to October 19, 2017, the Board finds that the March 2015 VA examination report shows impairment most consistent with a 10 percent disability rating. [The Board notes that the March 2015 examination is prior to the period for consideration; however, it is competent evidence to help establish symptomatology during the period for review, specifically at the beginning of the 1-year "look back" period.] Post-bronchodilator readings reflected FVC of 86 percent predicted, and although there was a pre-bronchodilator DLCO reading, there was no post-bronchodilator DLCO reading. However, the examiner indicated that the test that most accurately reflected the Veteran's level of disability was FEV-1, which was 77 percent predicted, and warrants a 10 percent rating. The examination did not show impairment consistent with FVC of 65-74 percent predicted, or DLCO (SB) of 56-65 percent predicted, which is required for a 30 percent rating. As noted above, the evaluation period begins August 1, 2015, therefore, a 10 percent (but no higher) rating for asbestosis is warranted from (the earlier effective date) of August 1, 2015. The Board notes that the August 2016 VA examination did not include pre-bronchodilator or post-bronchodilator DLCO (SB) testing, and there was no explanation why it was not conducted. Consequently, that examination is inadequate for rating purposes, and the Veteran is not prejudiced by excluding this examination from consideration because the PFT results (or any other finding on the examination) would not have warranted a 10 percent or higher rating. REASONS FOR REMAND 5. Entitlement to service connection for OSA. The Veteran's STRs are silent for complaints, treatment, or a diagnosis of, a sleep disorder, to include OSA. He asserts that his OSA is related to his service or was caused or aggravated by his service-connected asbestosis. In a January 2020 private medical statement, the provider opined that it was at least as likely as not that the Veteran's OSA began during his military service. He indicated that he reviewed the Veteran's military (medical and personnel) and post service medical records and noted that the Veteran reported that during service he often woke up choking and coughing, that his snoring was so loud that fellow Coast Guardsmen complained about it, and that he experienced some daytime sleepiness. The provider noted that the Veteran related that after service his snoring and choking became worse with further daytime hypersomnolence and that he was finally received a diagnosis of OSA and a prescription for a BIPAP machine that he continues to use. The opinion is inadequate for rating purposes because although the provider notes the Veteran's lay reports of snoring and/or sleep difficulty during service and his current diagnosis of OSA, he did not discuss the more than 20-year interval between the Veteran's discharge from service and his diagnosis of OSA diagnosis or include any rationale to support his opinion. The Veteran has not been afforded an adequate VA examination in connection with this claim. Considering his contentions and the medical evidence, an examination and medical opinion are necessary. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 6. Entitlement to a rating in excess of 30 percent for asbestosis from October 19, 2017. The most recent VA examination to assess the severity of the Veteran's asbestosis was in October 2017. At the January 2020 videoconference hearing, he alleged that symptoms of that disability have increased in severity since that examination. He testified that he has more difficulty breathing. Considering the allegation of worsening and the (4-year) interval since he was last examined, a contemporaneous examination to assess the disability is necessary. The record suggests that the Veteran receives ongoing VA treatment for asbestosis and OSA. Records of such treatment may contain pertinent information, and outstanding records of the treatment must be obtained and considered. Notably, VA records are constructively of record. The matters are REMANDED for the following: 1. Secure for association with the record all outstanding records of VA treatment the Veteran has received for asbestosis and OSA, specifically any not already associated with the record (from May 2018). If any such records are unavailable, the reason for their unavailability must be explained for the record, and the Veteran should be so advised. 2. Then, arrange for the Veteran to be examined by an appropriate clinician (sleep specialist) to determine the likely etiology of his OSA. The Veteran's record (to specifically include his lay statements and testimony reporting difficulty sleeping during service, and his brother's testimony) must be reviewed by the examiner. On examination and interview of the Veteran and review of his record, the examiner should provide an opinion that responds to the following: (a) Identify the likely etiology for the Veteran's OSA. Specifically, is it at least as likely as not (a 50 percent or better probability) that it is related directly to his service (as due to disease, injury, or event, or by onset, therein)? (b) If the OSA is found to not be directly related to his service, opine further whether it is at least as likely as not that it was caused or aggravated by (increased in severity due to) the Veteran's service-connected asbestosis. [The opinion must address aggravation, regardless of permanence of any increase in disability found.] (c) Has the severity of the OSA varied or has it remained essentially unchanged/and unimpacted by his service-connected asbestosis? (d) If it is found that the service-connected asbestosis did not cause, but aggravated, the OSA, specify, to the extent possible, the degree of disability (symptoms/impairment) that has resulted from such aggravation. (e) If the Veteran's asbestosis did not cause or aggravate his OSA, identify the etiology for the OSA that is considered to be more likely (to the extent the record permits), and explain why that is so. If the more likely alternate etiology cannot be identified, explain why that is so. All opinions must include a complete explanation of rationale, with citation to supporting factual evidence and medical principles, as deemed appropriate. 3. Then, arrange for a respiratory examination of the Veteran by an appropriate clinician to assess the current severity of his asbestosis. The Veteran's claims file must be reviewed by the examiner. All indicated tests and studies should be completed, to PFTs. If DLCO testing and exercise capacity testing are not conducted, the examiner must indicate why the test would not be useful, valid, or a valid indication of respiratory functional impairment (other than an explanation that it is "[n]ot indicated for Veteran's condition"). The examiner should provide an accurate and fully descriptive assessment of all symptoms attributable to the asbestosis (any not separately and distinctly associated any nonservice-connected respiratory disability) and the impact of such on his ability to function. To that end, the examiner should: (a) Elicit from the Veteran all symptoms and impairment associated with his asbestosis. (b) Where medically possible, clearly distinguish between any symptoms and impairment that are not attributable to or associated with the asbestosis, and explain why that is so. (c) Comment on any of the asbestosis-related symptoms and impairment that are not specifically contemplated by the schedular criteria (as provided in 38 C.F.R. § 4.97, Diagnostic Code 6833); and (d) Describe the impact asbestosis has on the Veteran's occupational functioning, furnishing an assessment (without consideration of age and any nonservice-connected disabilities) as to the types of activities that remain feasible despite the asbestosis. The examiner must explain the rationale for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner determines that an opinion sought cannot be offered without resort to mere speculation, the examiner must explain why that is so. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bayles, 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.