Citation Nr: 21069098 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 14-15 686 DATE: November 17, 2021 REMANDED Entitlement to service connection for the Veteran's cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force during peacetime, the Korean conflict, and the Vietnam era from January 1948 to October 1954 and from May 1965 to September 1968. The Veteran died in May 2011, and the Appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). It was previously before the Board in January and August 2016 at which time it was remanded for further development. It was again before the Board in July 2017. At that time the claim was denied. Thereafter, the Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (CAVC), which resulted in a joint motion for remand (JMR) by the parties. A December 2018 Order by CAVC remanded the matter to the Board for compliance with the instructions of the JMR. Primarily, the JMR was agreed upon based on the inadequate reasons and bases provided to address the Veteran's exposure or lack thereof to asbestos while in active-duty service, and, if exposed, whether the Veteran's cause of death was related to that exposure. In July 2019, the matter was again before the Board, at which time it was remanded for consideration of the Veteran's exposure to asbestos while in active-duty service. However, the remand directives also called for nexus opinions regarding whether the Veteran's primary and contributary causes of death were manifestations of asbestos exposure, regardless of whether the Veteran was found to have been exposed in active-duty service or not, and whether the causes of death were otherwise attributable to that service. Thus, those questions must be addressed. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Additionally, a thorough and adequate examination must consider all other relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). An adequate medical opinion does not contain only data and conclusions, "but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Ultimately, if an examination report does not contain sufficient detail, "it is incumbent upon the rating board to return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2; see Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return inadequate examination reports); Hicks v. Brown, 8 Vet. App. 417, 421 (1995) (inadequate medical evaluation frustrates judicial review). Two VA medical opinions were obtained in response to the July 2019 remand. In the June 2021 opinion the examiner opined that the Veteran's pulmonary fibrosis, coronary atherosclerosis, carotid atherosclerosis, and chronic lymphocytic leukemia or small lymphocytic leukemia were not related to asbestos exposure because the Veteran's symptoms, including coughing and shortness of breath, appeared decades earlier than they would have if they were related to asbestosis. For a similar reason, the examiner opined that the Veteran was not exposed to asbestos, and his symptoms were more likely a consequence of cigarette smoking. This aspect of the opinion is cogent and fully developed, thus adequate for VA purposes. The examiner further opined that neither the Veteran's pulmonary fibrosis nor his chronic lymphocytic leukemia were related to his period of active service because no compelling probative evidence to support a causal nexus was found in the record. This aspect of the opinion is inadequate because of its conclusory nature. For example, the examiner does not explain the disease processes or what would be expected to be found in the record to support a causal nexus. Finally, the examiner opined that the Veteran's coronary atheroscleroses or carotid atherosclerosis at least as likely as not had its onset in the Veteran's period of active service. However, that aspect of the opinion is also inadequate because it was not specific to the Veteran or even his Air Force specialty. Instead, that aspect of the opinion was a mere recitation of study findings related to Veterans who served in a similar time period. See Mattern v. West, 12 Vet. App. 222, 227 (1999) (generally, generic information in a medical journal or treatise is too general and inconclusive to constitute the sole basis for establishing a medical nexus to a disease or injury). The examiner did not discuss the disease process or its risk factors and how those might relate to the Veteran's medical and social history, i.e., shortness of breath, smoking, etc. In the August 2021 opinion the examiner repeated his opinions and associated rationales, and the same analysis of its adequacy applies. Thus, although the Board regrets further delay, remand for an adequate opinion is necessary. The matter is REMANDED for the following actions: Forward the Veteran's claims file to an appropriate VA medical examiner to issue a medical opinion regarding the nature and etiology of the Veteran's cause of death. The Veteran's official death certificate indicates that pulmonary fibrosis was the immediate underlying cause of the Veteran's death and that coronary and carotid atherosclerosis was a contributing condition. Chronic lymphocytic leukemia/small lymphocytic lymphoma, noted during a May 2011 autopsy, has also been identified as a contributory cause of the Veteran's death. After a review of the record, the examiner should address the following questions: (a.) Whether it is at least as likely as not (50 percent probability or greater) that pulmonary fibrosis, coronary atherosclerosis, carotid atherosclerosis, and/or chronic lymphocytic leukemia/small lymphocytic leukemia are a manifestation/consequence of asbestos exposure. The examiner should provide a discussion as to whether the Veteran exhibited signs and symptoms of asbestos exposure. (b.) Whether it is at least as likely as not (50 percent probability or greater) that pulmonary fibrosis, coronary atherosclerosis, carotid atherosclerosis, and/or chronic lymphocytic leukemia/small lymphocytic leukemia had their onset in, or are otherwise attributable to, the Veteran's period of active service. In providing the requested opinions, the examiner should consider the entirety of the record, but primarily in-service complaints of dyspnea (in October 1954, September 1964, and March 1968); substernal discomfort (January 1959); pressure in his chest (September 1964); palpitation of his heart (September 1964); and very occasional slight dizziness (March 1968). The examiner should also consider the Appellant's lay claims that the Veteran was unable to "get a deep breath" as far back as the late 1950s or early 1960s, and that his symptoms continued over the years, but that he did not seek medical help. A complete rationale for all opinions rendered must be provided. Citation to relevant peer reviewed medical literature reviewed in rendering the opinion would be of considerable assistance to the Board. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate as such and provide a supporting rationale as to why that is so. If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Z. Sloley, 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.