Citation Nr: 21014322 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 18-14 050 DATE: March 11, 2021 REMANDED Entitlement to service connection for a respiratory disability, to include chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to special monthly compensation (SMC) based on aid and attendance/housebound status is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1973 to December 1974. This matter comes before the Board of Veterans’ Appeals (Board) from a March 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for COPD and SMC based on aid and attendance/housebound status. In April 2015, the Veteran timely filed a notice of disagreement (NOD). Following the issuance of a statement of the case (SOC) in February 2018, the Veteran perfected a timely appeal in March 2018. The Veteran was afforded a virtual hearing before the undersigned in January 2021. A transcript is of record. 1. Entitlement to service connection for a respiratory disability, to include COPD The Veteran contends that her COPD is caused or aggravated by her service-connected psychiatric disability. See e.g., Fully Developed Claim dated March 9, 2015, and January 2021 Board hearing transcript. The Veteran is currently service connected for depressive/anxiety disorder not otherwise specified (NOS) with a 100 percent rating, effective December 2, 2010. The Veteran’s service treatment records (STRs) contain no notation of COPD during her period of active service. The STRs, however, show complaints of and/or diagnoses for asthma, bronchiolitis and upper respiratory infection (URI). On September 8, 1974, the Veteran complained of bronchitis, cough, and chest pain. On examination, lungs were clear and pleuritic pain was noted. On October 1, 1974, the Veteran complained of severe bronchitis and cough. She reported no relief with Robitussin and Tedral tablets. The Veteran reported that she smoked a pack of cigarettes a day. On examination, her throat was slightly red and rhinorrhea/sinus congestion were noted. A chest x-ray was within normal limits. On October 7, 1974, the Veteran complained of bronchitis and sore throat, with slight red throat and productive cough since August 1974. The impression was URI with bronchiolitis, rule out asthma. During a follow-up visit the following day, the impression was pharyngitis secondary to smoking and “anxiety neurosis-asthma.” Post-service medical records include diagnoses for COPD, emphysema and hyperventilation. October 2016 VA primary care notes show complaints of “out of control” hyperventilation, and an assessment of hyperventilation from panic attacks. In September 2020, the Veteran was referred to a VA pulmonary consultation due to increased shortness of breath and dyspnea on exertion. She was noted as a “long term smoker (1ppd for > 50 yrs).” She reported symptoms of nasal congestion, frequent nose blowing, getting winded “very easily.” The Veteran also reported shortness of breath with long conversations, walking on flat surfaces at her own pace, and putting her dogs in crates. She reported an increase in shortness of breath with anxiety episodes, which limited her ability to perform basic activities of daily living. On examination, prolonged expiratory phase was noted. A computerized topography (CT) scan taken in August 2020 was noted to show significant emphysematous changes, most prominent in upper lobes, but persistent through mid-thorax. The Veteran was diagnosed with severe COPD/emphysema by CT scan, anxiety, and tobacco cessation for six days. The attending pulmonologist noted the Veteran “need[ed] to maintain optimal therapy since anxiety will increase respiratory rate and contribute to dyspnea on exertion and shortness of breath at rest. COPD also makes anxiety worse due to feelings of breathlessness and ‘not getting enough air.’” The post-service record on appeal includes lay statements indicating the Veteran’s belief that her service-connected psychiatric disability aggravates her COPD, as she experiences shortness of breath and hyperventilation during panic attacks. With regard to service connection based on a secondary basis, a February 2015 VA examiner reviewed the Veteran’s claim file and concluded that the Veteran’s COPD “is less likely than not (less than 50 percent) caused by, or as a result of the [service-connected] depressive anxiety disorder not otherwise specified.” The examiner explained that risk factors for COPD included in pertinent part cigarette smoking and second-hand smoke exposure. The examiner noted the Veteran was a cigarette smoker for approximately 40 years and worked in the casino industry, which exposed her to second-hand cigarette smoke. The examiner also explained there was no consensus of medical literature that showed that depressive anxiety disorder caused COPD. In addition, the Veteran has recently submitted a February 2020 opinion from her treating physician indicating that her COPD is most likely caused by or a result of her military service because “[the Veteran’s] anxiety is contributing to her shortness of breath.” The Board finds that although the October 2016 and September 2020 VA treatment records, as well as the February 2020 private medical opinion, raise an indication that the Veteran’s COPD is related to her service or a service-connected psychiatric disability, the opinions contained therein are inadequate to support a grant of benefits sought, as the February 2020 private opinion is conclusory and fails to provide an adequate rationale and the October 2018 medical opinion is speculative. Additionally, absent any information regarding the baseline of severity of the Veteran’s COPD prior to any aggravation by her service-connected psychiatric disability, these treatment records and private opinion are insufficient. Furthermore, the Board finds that the February 2015 VA examination is inadequate as the examiner failed to properly address the question of aggravation. The U.S. Court of Veterans Appeals (Court) has held that because there are two prongs to a secondary service connection claim--causation and aggravation in order to be adequate, a medical opinion must provide explanations for both prongs. Atencio v. O’Rourke, 30 Vet. App. 74 (2018); El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). The Board notes that a February 2018 VA examiner also found that the Veteran’s “COPD is less likely than not (less than 50 percent) incurred in or caused by the complaints/conditions noted during military service.” The examiner rationalized that the Veteran’s STRS did not demonstrate that a persistent respiratory condition was shown during active duty and no pulmonary function tests were undertaken. The examiner reported that the Veteran experienced minor, self-limiting conditions which resolved as expected, and thus it was unlikely that any resulting complications would resurface post service. Finally, the examiner attributed the Veteran’s COPD to her long-term cigarette consumption and workplace exposure to second-hand cigarette smoke. However, the examiner did not consider whether the Veteran’s COPD was caused or aggravated by her service-connected psychiatric disability. Thus, the evidence currently of record is inadequate to resolve the claim of service connection for respiratory disability. Remand of this matter for a new VA opinion is therefore warranted in order to address outstanding questions of nexus and aggravation. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made). 1. Aid and Attendance/Housebound As the Veteran has alleged that she is unable to perform necessary activities of daily living, such as bathing, shopping for food, cleaning, cooking, and walking any distances due to her currently diagnosed COPD, the issue of SMC is inextricably intertwined with the issue of service connection for a respiratory disability. Thus, the Board remands that issue for adjudication subsequent to adjudication of the issue of service connection for COPD. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: Refer the VA claims file to a medical professional with appropriate expertise to provide an opinion as to the currently diagnosed respiratory disabilities. The examiner is requested to review the claims file in its entirety. The examiner should then address the following: (a) Is it at least as likely as not that any current respiratory disability identified in the record, to include COPD and chronic hyperventilation syndrome, had its inception during her period of active duty or is otherwise causally related to her active duty? In providing this opinion, the examiner should address the service treatment records showing complaints of bronchitis, cough, and chest pain and notations of asthma, bronchiolitis and upper respiratory infection (URI), and “anxiety neurosis-asthma.” (b) If not, is it at least as likely as not that any current respiratory disability identified in the record, to include COPD and chronic hyperventilation syndrome is causally related to the Veteran’s service-connected depressive/anxiety disorder NOS? (c) If not, is it at least as likely as not that any current respiratory disability identified in the record, to include COPD and chronic hyperventilation syndrome is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by service-connected depressive/anxiety disorder NOS? If the Veteran’s diagnosed respiratory disability is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of her observable symptoms over time. Should the examiner decide that a physical examination of the Veteran is required to address these questions, such should be scheduled. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.N., 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.