Citation Nr: 21024615 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 13-09 778 DATE: April 23, 2021 REMANDED The appeal for entitlement to service connection for a pulmonary disability, to include chronic obstructive pulmonary disease (COPD), is remanded. REASONS FOR REMAND The Veteran had active service with the United States Navy from March 1964 to January 1968. This matter comes before the Board of Veterans’ Appeals (Board) from a February 2012 decision by the Agency of Original Jurisdiction (AOJ). It was remanded by the Board in March 2015, November 2019, and again in January 2021. The appeal has been advanced on the Board’s docket due to the Veteran’s advanced age, and as such will received expedited treatment until the appeal is finally resolved. The Veteran contends service connection for a pulmonary disability is warranted on the basis that he was exposed to asbestos during service. He is seeking service connection for asbestosis and for COPD as proximately caused or aggravated by asbestos exposure during service. He has submitted medical evidence showing a single diagnosis of asbestosis made by a physician who specializes in pulmonology in June 2008. This diagnosis was made in connection with a medical evaluation undertaken as part of class action litigation related to the Veteran’s post-service workplace asbestos exposure. The physician, however, attributes asbestosis to inservice and post-service exposure. The diagnosis rests in part upon a specialized B-reading of a November 2007 X-ray study, which was interpreted as showing small opacities in both middle and lower lung zones at a profusion rate of 1/1. Right and left chest wall pleural thickening consistent with asbestos exposure was noted as well. Based upon this evidence, the VA obtained further evaluation of the Veteran’s pulmonary status. According to the reports of multiple VA examinations, the Veteran has COPD related to his smoking history, but does not meet the criteria for a diagnosis of asbestosis, despite his demonstrated history of having been exposed to asbestos. In connection with the VA’s evaluation, a high-resolution computed tomography (CT) scan was performed in November 2011. The scan was interpreted as showing no evidence of asbestosis, with no pleural calcifications present. Despite obtaining several explanatory medical opinions over the years, the evidence still requires clarification for legal purposes before a fully informed decision may be reached. Therefore another remand is necessary. The most recent Board remand was aimed at clarifying the question of whether asbestos exposure could have aggravated the Veteran’s COPD. The examiner concluded that COPD was not aggravated by asbestosis, since the Veteran does not have asbestosis. The examiner did not directly answer the question as to whether COPD is an asbestos-related disease. Currently, the record contains a diagnosis of asbestosis from an expert B-reading x-ray interpretation by a pulmonologist. The evidence to the contrary mostly rests upon the interpretation of the high-resolution CT scan which is described by VA examiners as the “gold standard” for diagnosing; the record does not contain a satisfactory explanation as to why the interstitial markings, calcific densities, small opacities, and pleural thickening were not noted on the CT scan, which was taken three years after the B-reading X-ray study. The Board does not have a sufficient medical explanation as to whether the B-reading was incorrect, whether the CT scan would contain all findings that may be present on x-rays only, or whether the differential interpretations are based on the expertise of the interpretating physician. Lastly, the Veteran correctly asserts that the medical evidence he submitted in support of his claim was generated by a physician with particular expertise in pulmonology, whereas the VA medical opinions have not been authored by physicians with comparable expertise. Therefore, upon remand, the file should be reviewed, and further explanation provided specifically by a pulmonologist, thoracic surgeon or similarly qualified expert. As the appeal is being remanded, the Veteran’s VA treatment records should be updated for the file. IF the Veteran has received private medical care for his pulmonary complaints, subsequent to the June 2008 medical evaluation, he is encouraged to coordinate with the AOJ to obtain these records for review by adjudicators. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2021 to the Present. 2. After obtaining the records requested above, obtain an addendum opinion from a physician with expertise in pulmonology such as a pulmonologist, thoracic surgeon, B-reader certified physician or similarly qualified expert. The clinician should review and explain the significance of the findings on the 2008 B-reader X-ray interpretation, and contrast those with the findings on 2011 high resolution CT scan. The Board requires a medical explanation as to whether the B-reading was incorrect in light of the CT scan findings, whether the CT scan would contain all findings that would be present on x-rays only, or whether the differential interpretations are based on the expertise of the interpretating physician. As such, a complete explanation regarding the differential findings on these two different tests should be provided and the relative medical accuracy between the two types of tests and interpretations. For example, an explanation as to why the CT scan did not identify the findings from the November 2008 B-reader x-ray interpretation such as small opacities in both middle and lower lung zones at a profusion rate of 1/1, and right and left chest wall pleural thickening. It would be helpful from the Board’s lay perspective whether the interpretative differentials lie with the expertise of the interpretating radiologist, the type of technology utilized and/or both. It would also be helpful for the examiner to discuss whether the CT scan results, described as a the “gold standard” for diagnosing asbestos-related disease, is more precise than, and/or rules out the findings from the B-reader x-ray interpretation. Additionally, the examiner should provide explanation regarding the Veteran’s pulmonary function test results and the conclusions which may be drawn from these test results regarding asbestosis should be provided also, such as what type of PFT findings would be indicative of asbestosis if present. A complete rationale for the conclusions reached should be fully explained. The examiner should also clearly answer the question as to whether or not COPD would be classified as an asbestos-related disease. If any asbestos-related residuals are found, the examiner should answer the question of 1) whether these changes have caused COPD OR 2) whether the asbestos-related changes have caused a medically discernible worsening of functional impairment of COPD (e.g., worsening of pulmonary functioning or other aspects of COPD, even if temporary, beyond those associated with the expected baseline COPD effects). IF further tests or studies, or a clinical examination is deemed helpful by the expert, then such tests, studies, and/or examination should be scheduled. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Heather J. Harter, 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.