Citation Nr: 21007342 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 13-10 131 DATE: February 9, 2021 ORDER Service connection for chronic obstructive pulmonary disease (COPD) is granted. FINDING OF FACT The Veteran’s COPD is at least as likely as not etiologically related to his service. CONCLUSION OF LAW Resolving all reasonable doubt in his favor, the criteria are met for entitlement to service connection for COPD. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from January 1952 to January 1956. Service connection for COPD is granted. The Veteran contends that his current respiratory disability, COPD, is etiologically related to his service, specifically, due to exposure to harmful fumes when working as a mechanic on diesel engines without proper ventilation. The evidence reflects that, during his 1952 military entrance examination, the Veteran was shown on chest x-ray to have multiple pulmonary calcifications in his right lung field. On December 1955 separation examination, a chest x-ray showed small calcifications, 2 millimeters in diameter, spread throughout his lungs. These findings were diagnosed as probable hematogenous histoplasmosis. His term of military service ended in January 1956, so the following month. Post-service treatment records, beginning in 1986, show ongoing treatment for respiratory related symptoms, variously diagnosed as reactive airway disease and/or COPD. When considering this relevant evidence, and all other evidence pertinent to this claim, including numerous VA and private medical opinions regarding the origins of the Veteran’s COPD, the Board finds that service connection for this disease is warranted. In so finding, the Board has considered the multiple medical opinions of record that weigh both in favor of and against the claim. Following such review, the Board finds, at the very least, that the evidence is in relative equipoise, meaning as supportive of the claim as it is against it. The most recent VA opinion obtained in May 2019 is supportive of the Veteran’s claim. This VA examiner concluded that it is at least as likely as not the Veteran’s COPD is due to his service. The examiner explained that the diagnosis in service of histoplasmosis and exposure to diesel fumes, asbestos, and environmental irritants could all be contributory to the Veteran’s progression of respiratory difficulties post service. This examiner surmised that, upon review of the Veteran’s medical records, it was evident that, while it was difficult to say with 100 percent certainty that the histoplasmosis was causative of his COPD, it was plausible that this finding in service and his exposure to fumes in service were etiological causes of his COPD. “Absolute” etiology is not a condition precedent to granting service connection, nor is “definite” or “obvious” etiology. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). So, notably, that VA examiner was not required to find with “100 percent certainty” that the Veteran’s COPD is attributable to his military service. Rather, this only needs to be an “as likely as not” plausibility, which that VA examiner confirmed it is. The Board affords this opinion significant probative weight because it took into consideration the Veteran’s contentions, the circumstances of his service, included a review of the relevant evidence of record, and contained the required discussion of the underlying reasoning or rationale, which was well-explained. And that is where most of the probative value of a medical opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Moreover, this supporting medical opinion also is consistent with the other evidence of record. In that regard, the Veteran’s treating physician also has submitted multiple supportive medical opinions in line with the May 2019 positive VA opinion. Most recently, in November 2013, this physician concluded that it is likely that the harmful fumes the Veteran inhaled in service, as well as the noted histoplasmosis in service, were likely aggravating causes of his current COPD. This physician had researched toxic fumes and fuels and determined that the type of substances to which the Veteran was exposed in service were known caustic chemicals that could cause long term effects of the lungs displayed in COPD. This physician noted that his practice had treated the Veteran since 1978 and that his office visits often related to respiratory illnesses.   The Board also has considered the medical opinions of record that conversely are against the claim. In November 2010, a VA examiner concluded that the Veteran’s COPD is less likely than not related to his history of histoplasmosis, stating that there was no evidence to suggest lung destruction due to this finding in service, and because the Veteran did not develop COPD for more than 50 years following his separation from service. This examiner concluded that the Veteran’s COPD, instead, was more likely related to his tobacco use. Precedent opinions of VA's General Counsel have discussed the cause-and-effect correlation between chronic smoking and the eventual development of respiratory disorders such as COPD/emphysema. See VAOPGCPREC 2-93 (Jan. 13, 1993) and VAOPGCPREC 19-97 (May 13, 1997). And indeed, as here, for claims filed on or after June 9, 1998, there is an express prohibition against granting service connection for any disability resulting from injury or disease attributable to chronic smoking. 38 U.S.C. § 1103; 38 C.F.R. § 3.300. In July 2012, a VA examiner concluded that the Veteran’s COPD was not related to the histoplasmosis shown in service, otherwise known as farmer’s lung. His COPD was diagnosed many years following his separation from service, and this was too remote from military service to be considered service related. In January 2018, a VA examiner agreed, also concluding that the Veteran’s COPD was likely related to his prior tobacco use. This examiner concluded that it was unlikely the Veteran’s histoplasmosis was aggravated by his service or that it caused or aggravated his COPD, explaining that histoplasmosis does not impact pulmonary function or cause airflow obstruction. After analyzing these several opinions that, as mentioned, are both for and against the claim, the Board sees that the three unfavorable opinions do not discuss the Veteran’s report of exposure to hazardous fumes while in service. Thus, while they provide competent and persuasive evidence that the in-service diagnosis of histoplasmosis was not aggravated by service and did not cause or aggravate the Veteran’s COPD, they are somewhat deficient when not discussing his contentions of in-service exposure to hazardous fumes. On the other hand, the 2019 VA opinion did consider these assertions and found it to be at least as likely as not that the in-service exposure contributed to the Veteran’s current COPD. However, the positive opinions did not discuss the substantial delay in diagnosis of COPD or the likelihood the eventual diagnosis, instead, was related to the Veteran’s tobacco use. Accordingly, in this circumstance, the Veteran is given the benefit of the doubt and the claim for service connection for COPD granted rather than denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Erdheim 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.