Citation Nr: 21070056 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 08-33 198 DATE: November 22, 2021 ORDER Service connection for asthma is denied. REMANDED Service connection for hip disability is remanded. Service connection for heart disability is remanded. FINDING OF FACT The preponderance of the evidence against finding the Veteran's asthma manifested during service, is related to service, or is secondary to his service-connected disabilities. CONCLUSION OF LAW The criteria for service connection for asthma are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1979 to July 1990 with additional service in the Army Reserve. The Veteran appeared for a hearing before the undersigned in September 2012. The hearing transcript is associated with the claims file. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection for asthma The Veteran contends entitlement to service connection for asthma, to include as secondary to service-connected TB or related to environmental exposures during service. Service treatment records (STR) show September and October 1989 visits assessing chronic bronchitis. A November 1989 visit diagnosed URI. A December 1989 chest x-ray noted prominent vascular markings, no definite evidence of infiltrates, with no significant interval changes when compared to previous study. In January 1990, the Veteran was diagnosed with TB after sputum cultures were positive. He was treated with isoniazid, rifampin, pyrazinamide. Chest x-rays in January 1990 and May 1990 were normal. The June 1990 separation examination noted TB "medications started in January 1990 for 6 months, chest x-rays were clear, asymptomatic." The Medical History Report denied symptoms of asthma, shortness of breath, or chronic cough. Following separation from active duty service, a June 1996 examination noted a history of positive PPD test, status post 6 months of INH treatment, without sequelae. The Medical History Report denied asthma, shortness of breath, and chronic cough. A May 2002 separation examination noted past sinus surgery for frequent sinusitis, no longer with frequent sinus infections. The Report of Medical History denied asthma or any breathing problem, shortness of breath, bronchitis, wheezing, use of an inhaler, and chronic cough. A March 2005 treatment visit reported chronic cough for a year, getting worse. March 2005 pulmonary testing gave an impression of mild restrictive defect. An April 2005 treatment visit reported shortness of breath with cough and taking Prednisone for 3 to 4 weeks. The clinician reviewed ECHO, chest x-ray and PFTs, noting the only abnormality was mild restrictive defect on PFT that responded to bronchodilators. A June 2007 statement reported living in a motor bay with mold on walls and ceilings during service caused his respiratory illness. At a May 2009 DRO hearing, the Veteran contended exposure to mold on the walls and ceilings during service. He reported contracting TB and having respiratory issues since. The Veteran's friend, who reported being an RN for 15 years, stated she served with the Veteran and he had respiratory problems throughout his career. She noted he was exposed to dust and motor pool fumes during service. She stated his respiratory problems may be some kind of residual effect from TB. She noted an x-ray during service showed bronchial vascular markings. She stated she did not know what these mean because she was not part of his treatment, but thought the bronchial vascular markings were something that should have been investigated. At a September 2012 Board hearing, the Veteran asked for consideration of service connection for asthma on a direct and secondary basis. The Veteran reported his respiratory symptoms come with changes in the weather rather than the seasons. A March 2015 private treatment letter from Dr. K.D. stated that being in the barracks in Germany where there was a lot of mold may have led to his current asthma symptoms. The clinician said it is certainly not related to alcohol. A March 2017 VA medical opinion found the Veteran's respiratory disability was less likely than not incurred in or caused by service. The clinician stated STR do not show a diagnosis of asthma. The clinician noted STR listed chest pain, which was determined to be atypical chest pain consistent with costochondritis. The clinician noted a September 1999 visit noted allergic symptoms since his teens, an April 2002 visit diagnosed allergic rhinitis, a March 2005 PFT showed mild restrictive defect and stated no history of asthma, an August 2008 visit found alcoholic cirrhosis with ascites and noted he stopped smoking in 2008, and a March 2015 visit with a pulmonary specialist gave the diagnosis of asthma. The VA clinician noted there was no definitive diagnosis of asthma until 2015, with PFTs in 2005 showing restrictive not obstructive defect more consistent with restriction of his breathing capacity due to his cirrhosis and ascites. The clinician noted the Veteran detailed exposure to mold, dust, diesel fuels, and asbestos. The clinician stated there is no confirmed diagnosis of asbestosis or testing that demonstrated a severe mold allergy. The clinician noted an exposure to mold or other inhaled allergens could aggravate asthma, but there was not an active diagnosis until 2006 and a confirmed diagnosis by a pulmonary specialist until 2015. The clinician noted the May 2002 examination was negative for asthma or respiratory disability. The clinician stated she could not relate his current asthma to military service. A June 2017 private disability benefits questionnaire (DBQ) diagnosed asthma. The clinician opined the Veteran's asthma was more likely as not related to military service. A September 2021 VA medical opinion found the Veteran's asthma was less likely as not proximately due to or the result of his service-connected TB or sinusitis. The clinician opined asthma is a reactive airway disease characterized by reversible airway obstruction due to inhaled allergens and irritants. The clinician noted a chest x-ray in December 1989 showed "prominent bronchovascular markings" but the Veteran was not diagnosed with asthma at the time. The clinician stated that prominent bronchovascular markings are usually present in chest x-rays taken in an inspiratory (breathing in) phase when the blood vessels of your lungs are dilated, or alternatively, can also be seen in patients with congestive heart failure, pulmonary hypertension, or an infectious pulmonary process. The clinician stated if a radiologist reports increased bronchovascular markings, but the clinical situation is not supporting anything serious, the finding can be ignored. The clinician stated it is a non-specific finding and by saying prominent means it stood out to the radiologist, but would need to be compared to prior studies and have follow-up to determine any clinical significance. Regarding TB, the clinician stated his TB is inactive and not causing symptoms. The clinician noted he was treated with INH for 6 months during active duty in 1989, has not had any further treatment, and had no symptoms due to any residual of his treatment or initial diagnosis. The clinician noted the May 2002 examination was silent for asthma or any respiratory symptoms. A March 2015 chest CT scan was normal with no evidence of scarring or residuals of TB and May 2021 PFT studies and a chest x-ray were normal with no airspace disease, scarring or evidence of prominent bronchovascular markings. The clinician opined the Veteran's TB is inactive, has not been treated in years, and would not contribute to any active reactive airway disease. Regarding sinusitis, the clinician noted sinusitis was treated during active duty. The clinician noted a January 1998 evaluation reported sinus congestion and obstructed breathing, he was found to have chronic maxillary sinusitis and a deviated nasal septum. The evaluation stated no respiratory complaint or illness. The clinician noted the Veteran had sinus surgery in October 1998 with nasal septal correction, turbinate reduction and antral windows. The clinician noted a May 2002 examination stated he had sinus surgery for frequent sinusitis and no longer with frequent sinus infections. The VA clinician stated asthma is due to reactive airways disease triggered by inhaled allergens and irritants and sinusitis is an inflammation of the sinuses typically seen with nasal congestion related to allergic rhinitis and deviated septum which causes obstruction of the sinus passages and bacterial infection. She stated that sinusitis does not cause asthma or reactive airways disease. A September 2021 VA medical opinion found the Veteran's asthma was less likely as not aggravated beyond its natural progression by service-connected TB or sinusitis. The clinician stated there is no evidence for aggravation. Regarding his TB, the clinician stated his TB is inactive and not causing any symptoms, noting he was treated with INH for 6 months and has not had any further treatment or symptoms due to residual of his treatment or initial diagnosis. The clinician noted a March 2015 chest CT scan was normal with no evidence of scarring or residuals of TB. The clinician noted May 2021 PFT studies were normal. Regarding sinusitis, the clinician noted a January 1998 evaluation reported sinus congestion and obstructed breathing, was found to have chronic maxillary sinusitis and a deviated nasal septum. The evaluation stated there was no respiratory complaint or illness. The clinician noted he had sinus surgery in October 1998 with nasal septal correction, turbinate reduction and antral windows. The clinician noted a May 2002 examination stated he had sinus surgery for frequent sinusitis and no longer had frequent sinus infections. She stated asthma is due to reactive airways disease triggered by inhaled allergens and irritants and sinusitis is an inflammation of the sinuses typically seen with nasal congestion related to allergic rhinitis and deviated septum which causes obstruction of the sinus passages and bacterial infection. The clinician stated sinusitis would not affect the bronchial passages or aggravate asthma. There clinician stated there is no evidence the Veteran's asthma was aggravated and no evidence to show any aggravation related to his inactive pulmonary TB or sinusitis. Regarding direct service connection, the preponderance of the evidence is against finding the Veteran's asthma began during service or is related to service. The Board gives probative weight to the March 2017 VA medical opinion finding the Veteran's asthma was less likely than not incurred in or caused by service. The opinion is based on an accurate medical history and provided a clear conclusion and supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The clinician discussed STR, post-service records, and the Veteran's contention that his asthma could be related to environmental exposures during service. Regarding secondary service connection, the preponderance of the evidence is against finding the Veteran's asthma was proximately due to or aggravated beyond its natural progression by his service-connected TB or sinusitis. The Board gives probative weight to the September 2021 VA medical opinions finding the Veteran's asthma was less likely as not proximately due to or aggravated beyond its natural progression by service-connected TB or sinusitis. The opinions are based on an accurate medical history and provided a clear conclusion and supporting data. The clinician discussed the Veteran's contentions, to include the December 1989 chest x-ray showing prominent bronchovascular markings. The Board considered the Veteran's friend's testimony at the May 2009 DRO hearing. The friend reported being a RN for 15 years and serving with the Veteran. She thought his respiratory problems may be some kind of residual effect from TB. She noted the x-ray showing bronchial vascular markings was something that should have been investigated. The Veteran's friend is competent to provide medical opinions because of her experience as an RN. However, the Board gives low probative weight to her opinions at the DRO hearing because the statements were speculative. Medical opinions that use indeterminate language such as "possible," "may," or "can be" are speculative, and cannot suffice to support a claim. Bostain v. West, 11 Vet. App. 124, 127-28 (1998); McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). The Board considered the March 2015 private treatment letter from Dr. K.D. that stated being in the barracks in Germany where there is a lot of mold may have led to his current asthma symptoms. As is noted above, medical opinions that use indeterminate language such as "possible," "may," or "can be" are speculative, and cannot suffice to support a claim. The Board considered the June 2017 private DBQ opinion that the Veteran's asthma was more likely as not related to military service. The Board cannot weigh the probative value of a conclusory statement without supporting rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Board considered the Veteran's assertion that he had respiratory issues since service. The Board finds Veteran statements and examiner observations made contemporaneously at examinations during service and soon after separation from service more probative. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than subsequently reported history). The June 1990 separation examination noted TB "medications started in January 1990 for 6 months, chest x-rays were clear, asymptomatic." The Medical History Report denied symptoms of asthma, shortness of breath, or chronic cough. A June 1996 examination noted a history of positive PPD test, status post 6 months of INH treatment, without sequelae. The Medical History Report denied asthma, shortness of breath, and chronic cough. A May 2002 examination denied asthma or any breathing problem, shortness of breath, bronchitis, wheezing, use of an inhaler, and chronic cough. The clinician remarked the Veteran had a history of frequent sinusitis. In the case at hand, at separation from service and in the years after separation from service, the Veteran was noted to have a history of TB that was "asymptomatic" and "without sequalae." He affirmatively denied symptoms of asthma, shortness of breath, or chronic cough. Accordingly, the preponderance of the evidence against finding the Veteran's asthma manifested during service, is related to service, or is secondary to his service-connected disabilities. Service connection for asthma is denied. REASONS FOR REMAND Service connection for hip disability The Veteran contends entitlement to service connection for hip disability, to include related to jumping up and down off Bradley Fighting Vehicles for 12 years. See July 2007 statement, January 2012 statement, and November 2021 correspondence. VA medical opinions addressing the etiology of the Veteran's bilateral hip disability did not address this contention. Service connection for heart disability The Veteran contends entitlement to service connection for heart disability, to include experiencing chest pain since exposure to fumes, mold, and tank trail dust during service. See July 2007 statement and January 2012 statement. VA medical opinions addressing the etiology of the Veteran's bilateral heart disability did not address this contention. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hip disability. (a.) Identify any hip disability found during the appeal period. (b.) For each hip disability identified, is it at least as likely as not (50 percent or greater probability) the disability began during service or is otherwise related to service, to include jumping up and down off Bradley Fighting Vehicles for 12 years. See July 2007 statement, January 2012 statement, and November 2021 correspondence. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's heart disability. (Continued on the next page) (a.) Identify any heart disability found during the appeal period. (b.) For each heart disability identified, is it at least as likely as not the disability began during active service or is otherwise related to service, to include exposure to fumes, mold, tank trail dust during service. See July 2007 statement and January 2012 statement. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Winkler, 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.