Citation Nr: 21011368 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 07-34 685A DATE: March 1, 2021 ORDER Service connection for a lung disability is denied. FINDING OF FACT The weight of the evidence of record fails to show that it is at least as likely as not that the Veteran’s current lung disability, to include mycotic lung disease, asthma, and chronic obstructive pulmonary disease (COPD), was incurred in, caused by, or otherwise is etiologically related to his active military service, to include exposure to dust in the California desert. CONCLUSION OF LAW The criteria for service connection for a lung disability have not been met. 38 U.S.C. § 1110, 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran honorably served in the Florida Army National Guard, to include a period of service on active duty with the U.S. Army Reserve unit from December 1990 to March 1991. In an August 2010 rating decision, the Regional Office (RO) denied his claim for service connection for a lung disability (originally claimed as lung condition). The Veteran appealed. In February 2013, the Veteran testified at a Travel Board’s hearing, a transcript of which is of record. The judge who conducted that hearing has since retired from the Board. The Veteran requested another hearing, and one was scheduled, but the Veteran failed to report to the hearing, and has not provided good cause for his absence. He was informed in a March 2019 Board decision that his hearing request was considered to have been withdrawn. By way of background, the Veteran’s VA treatment records showed that he was treated for recurrent hemoptysis (coughing up blood originating in the lungs or bronchial tubes) beginning in May 2008. In June 2009, having been diagnosed with aspergilloma, a form of mycotic lung disease, he underwent a right lung lobectomy (a resection of the upper lobe wedge of his right lung). In July 2009, he was noted to have developed postoperative shortness of breath, and then the following year was diagnosed with a COPD and a new asthma component with onset in May 2010. In August 2014, noting the Veteran’s report made at the hearing that he began to cough up blood during his training at Fort Irwin, California, from 1990 to 1991, and that a treating physician had reportedly informed him that his lung disorder was due to dust exposure in the California desert, the Board remanded his claim for an etiological opinion. In March 2019, the Board remanded the claim for a supplemental medical opinion which was obtained in October 2019. The October 2019 report confirmed a history of diagnosis of aspergilloma in 2009, and the subsequent development of COPD and asthma diagnosed in 2010, along with a negative medical opinion as to the causal link between this respiratory disability and service many years earlier. In August 2020, upon finding that the October 2019 VA examination report did not address the Veteran’s lay testimony and largely relied on the absence of the medical evidence of the associated complaints, treatment, or diagnosis in service, the Board remanded the claim for an addendum opinion to specifically consider the Veteran’s lay statements. In seeking service connection, the Veteran maintains that his current lung disability is the result of dust exposure during his military training in Fort Irwin, California, as told by his treating physician. Upon considering this contention in context of all evidence of record viewed as a whole and in light of pertinent laws, the Board has found that service connection for a lung disability is not warranted here. Service connection generally may be granted for a disability incurred in or due to service. See 38 C.F.R. § 3.303(a). “Service connection” is a term of art connoting many factors, but ultimately means that a particular disease or injury originated in service and caused a post-service disability, that is, a present disability as shown by the evidence to had been incurred in or coincident to service. Id. To that end, establishing an entitlement to service connection for a respiratory disability is subject to the three fundamental legal requirements that must be met with the requisite evidentiary standard of a 50-percent or greater probability showing: (1) the existence of the claimed disability; (2) a relevant traumatic event in service, such as an injury or disease, and (3) a causal link between the claimed disability and an event in service. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In this case, the existence of the current lung disability is not in dispute. Moreover, the Veteran has identified as a potentially relevant event in service, namely his exposure to dust during his training in the California desert, which the Board has conceded. However, the requisite causal link between his current lung disability and his exposure to dust many years earlier has not been shown. Such a causal link generally must be shown by the medical evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This is particularly true in this case involving the medical complex respiratory disability attenuated from service by many years. Absent any evidence that the Veteran has specialized knowledge, training, or experience in rendering medical opinions, he is said not to possess the requisite expertise to diagnose medically complex respiratory and pulmonary disabilities or competently discuss their etiologies. Id. Although the Veteran may competently report his conversations with medical staff, such reports must be corroborated. Of particular note here, the generalized conclusory statements, even if rendered by medical professionals, have no probative value. The Board must meaningfully understand whether, from a medical perspective, a pathophysiological mechanism linking the Veteran’s current lung disability to his exposure to dust in service actually exists and, if so, whether such a possibility arises to the requisite evidentiary standard of “at least as likely as not,” that is, a 50-percent probability or greater. Then, the Board must clearly understand why or why not. This is why the most value of any given medical opinion is derived from its rationale. By implication, even if true, the Board may not simply defer to the Veteran’s report of being told by his physician that his lung disability is due to dust exposure in the California desert. The record is devoid of any medical evidence reflecting the reported opinion and the Veteran has not reported being given any rationale for his physician’s opinion. Likewise, the record is devoid of any other documented medical opinion linking the Veteran’s lung disability to his service. The Board has endeavored to obtain a fully adequate medical opinion to assess the etiology of the Veteran’s lung condition, and remanded the claim on several occasions to ensure this was the case. The November 2019 report notes that the October 2019 report showed diagnosis of mycotic lung disease – aspergilloma. The examiner explains that aspergilloma is a mass caused by the aspergillus fungus. Aspergillus can be found throughout nature (outdoors), indoors and in water. Typically, they can be found indoors, in heating or cooling ducts or in insulation or dust exposure during building renovation or construction. Although the aspergillus mold spores are commonly found throughout nature, breathing in these mold spores normally does not cause problems in healthy individuals. However, inhaling those spores can cause infection in those with weakened immune system or underlying lung disease. The incubation period of invasive aspergillosis after exposure is highly variable, extending in documented cases from 2 to 90 days. The Veteran’s service treatment records (STRs) are silent for hemoptysis or chronic cough during service. His post-service occupation as a construction worker and underlying multiple pack-per-year smoking history are risk factors for the condition. His aspergilloma was diagnosed in 2008, 17 years post service, and thus is less likely than not to have had its onset in service or is otherwise related to service including due to dust exposure in the California desert. The examiner noted that the entire file was reviewed including lay statements. The Veteran’s testimony regarding coughing up blood during service from 1990 to 1991 and his treating physician informing him that his lung disorder was due to dust exposure in the California desert while training for Operation Desert Shield/ Desert Storm was also reviewed. But his STRs did not show evidence of asthma, hemoptysis, chronic cough, or aspergilloma during service. Based on the comprehensive review of all evidence of record, the examiner concludes that it is less likely as not that the Veteran’s current lung disability is etiologically related to service, to include his exposure to dust in the California desert. The Veteran has neither challenged the adequacy of this particular medical opinion or accuracy of the report, nor submitted any competent evidence to the contrary. As discussed, the Veteran does not possess the requisite expertise in rendering etiological opinions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). This leaves the Board with the medical evidence of record which fails to show that it is at least as likely as not that the Veteran current lung disability was incurred in or due to his active military service. Rather to the contrary, the first signs of hemoptysis were noted in May 2008, when the Veteran reported to an emergency room (ER). A May 2008 ER note reflects that the Veteran has a history of substance abuse (cocaine), long-standing tobacco use, and came into ER complaining of an acute onset of vomiting blood and chest discomfort with deep breathing. He described two episodes of coughing blood overnight, quantified at two teaspoons. At that time, the Veteran did not report any earlier history of coughing up blood. Of further note, a May 2008 ER addendum report reflects that hemoptysis in a non-acute infectious-looking presentation that raises concern for ruling out malignancies. Alternative diagnoses include vasculitis, coagulopathies, AVM (arteriovenous malformation), bronchiectasis, tuberculosis, and pseudohemoptysis (from gastrointestinal or nasopharyngeal tract). Of particular note is the May 2008 ER addendum report suggesting that the Veteran’s report of coughing up blood in service, presuming it to be true, may have been a pseudohemoptysis such as from nasopharyngeal tract dryness due exposure to desert dust or inflammation due to cold rather than true hemoptysis originating from his lungs. This suggestion is strengthened by his STRs, albeit appearing sporadic, reflecting a January 1991 in-service treatment note of the Veteran’s report of chest pain for 3 weeks, complaining of cold and runny nose. Of further note is the Board’s hearing transcript reflecting the following Veteran’s statements: “When I went to Desert Storm, I didn’t see it like with inhaling and all the dust and the mountains and the caves. I started to cough up blood. But I looked at it like if you have a bad cold, you start to cough sometimes and you get streaks of blood. So, I looked at it like that. I didn't know. And it got worse.” The Board also notes the Veteran’s statements made at his hearing that he was “young and gung-ho” doing “very high-speed . . . Special Forces, jungle training” and no one could tell him was not Superman. However, the Veteran neither actually “went to Desert Storm” nor has offered any adequate explanation as to why he did seek medical treatment for a runny nose, but not for coughing up blood. Further given that the Veteran had actually sought medical attention for chest pain, cold, and runny nose within three weeks of onset during his three-month-long active service, he likely would have sought medical attention for coughing up blood at some point within that timeframe, let alone in the next 17 years. The first documented reference to hemoptysis is the May 2008 ER report and a subsequent hospital admission for recurrent hemoptysis in October 2008, which is largely consistent with the Veteran’s testimony. However, in 17 years prior to the May 2008 ER visit, the record is devoid of any lay or medical evidence of any complaints, treatment, or diagnosis actually associated with any respiratory or pulmonary disorder. No evidence of record actually shows whether the Veteran’s report of coughing up blood was true hemoptysis or pseudohemoptysis, but the fact it had occurred 17 years prior to diagnosis of aspergilloma—that takes 2 to 90 days to develop—makes an onset of aspergilloma in service highly improbable. There is nothing in the record to suggest otherwise. Rather, a July 2009 pulmonology consultation note reflects an unequivocal statement that the Veteran’s hemoptysis is secondary to aspergilloma. The foregoing evidence, particularly when coupled with the scientific fact pointed out by the examiner that the incubation period of aspergilloma, meaning the time it takes for the disease to develop is from 2 to 90 days, not 17 years, tips the scales against the Veteran’s uncorroborated statements as to the onset of hemoptysis during service but made for the first time at the February 2013 Board’s hearing for the sole purpose of procuring VA benefits, while 10 years earlier he affirmatively denied any hemoptysis. For example, a June 2003 VA treatment progress note reflects an unequivocal statement the Veteran had affirmatively denied unusual shortness of breath, chronic cough, hemoptysis, or wheezing. Moreover, as noted in the November 2019 report, the Veteran has known post-service risk factors for developing respiratory disabilities, to include his work in construction and his heavy use of tobacco for many years (which he quit a day prior to lobectomy). This opinion considered in context of the fact his COPD and asthma were diagnosed only after lobectomy even more persuasively explains the likely etiology of his current lung disability less likely as not etiologically related to his service. As such, in weighing the Veteran’s uncorroborated statements as to the onset of his lung disability in service against the medical evidence of record viewed as a whole pointing to the opposite conclusion, the Board finds the medical evidence to be the most probative here and weighing heavily against the claim. In reaching this conclusion, the Board has considered the legal provisions allowing for the Veteran’s lay statements alone to serve as sufficient proof of an incurrence of the disability in service. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). But these legal provisions apply only to the circumstances of combat environment where a regular record-keeping may be impractical and must be consistent with all other circumstances of service, which is not the case here. Id. As noted, the Veteran did not serve in combat and in fact had access to a medical facility as evidenced in the January 1991 treatment note. In sum, the Board finds that the medical evidence of record fails to establish the requisite causal link between the Veteran’s current disability and active military service, which is the fundamental legal criterion for establishing an entitlement to service connection. As such, the legal criteria for establishing an entitlement to service connection have not been met. In reaching this conclusion, the Board has considered all legal bases for service connection, but ultimately has concluded that none are applicable to the factual circumstances of this case. 38 C.F.R. §§ 3.303(a), (b), (d), 3.307(a), 3.309(a), 3.310. Accordingly, absent any legal basis for a grant of the benefits sought here, service connection for a lung disability is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alex Bardin, 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.