Citation Nr: 21024933 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 17-06 804 DATE: April 27, 2021 REMANDED Entitlement to service connection for respiratory disease to include chronic obstructive pulmonary disease (COPD) and asbestosis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1969 to October 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. The VLJ held the record open for an additional 60 days at the request of the Veteran and his representative to obtain supporting private medical evidence. Additional medical evidence was received In June 2020, the Board remanded these matters for additional development. Entitlement to service connection for respiratory disease, to include COPD and asbestosis, is remanded. Issues 1 & 2: The Veteran contends that he developed respiratory disorders due to or as a result of working as a boiler room technician aboard a naval ship. See e.g. Correspondence (October 2014) & (July 2020). His military occupational specialties (MOS) included fireman and boiler technician and his exposure to asbestos has been conceded by VA. A June 2020 Board decision remanded the claim for, among other things, an examination and medical opinion. Although a VA examination was obtained in November 2020, the Board finds the examination findings and medical opinion are inadequate for adjudicating the instant appeal and remand is again required. Once VA undertakes to provide an examination, it is obligated to ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). First, clarification is required to determine all of the Veteran’s current respiratory disorders. In this regard, the November 2020 VA examination report indicates the Veteran does not have multiple respiratory conditions and the examiner only noted the Veteran had “emphysema/COPD” while private medical records reflect a medical history or current diagnoses of pulmonary embolism, multiple lung nodules, pulmonary emphysema and COPD. See e.g. Medical Treatment Records (Dignity Health Medical Group Dominican Pulmonary and Critical Care Medicine) (May 2020). In addition, the Veteran’s private pulmonologist, Dr. Paul Godin, assessed the Veteran with pulmonary asbestosis based on his review of a chest CT scan obtained in November 2019. The doctor stated the x-ray “clearly shows pleural plaquing with associated increased interstitial markings at the right base and adjacent to his pleural plaquing consistent with asbestosis.” Dr. Godin further explained that the Veteran’s history of exposure to asbestos (during service), in addition to his prior physical exam findings and CT findings demonstrating pleural plaquing and associated fibrosis, are consistent with the diagnosis of pulmonary asbestosis. See Medical Treatment Records (Dignity Health Medical Group Dominican Pulmonary and Critical Care Medicine) (May 2020) & medical statement from Paul Godin, MD (June 2020). Additionally, a private chest x-ray, obtained in May 2019, revealed calcified pleural plaques which were assessed as consistent with asbestos exposure. See Medical Treatment Records (Dignity Health Dominican Hospital General Radiology) (May 2019). Notwithstanding Dr. Godin’s determination with respect to a current diagnosis of asbestosis, the Board finds his statements addressing the Veteran’s in-service asbestos exposure are insufficient to grant the claim for service connection for asbestosis. In this regard, the medical statements are not akin to a favorable medical opinion in which the correct legal standard has been applied to the facts of the case. Also, the pulmonologist made no attempt to provide any analysis or reasoned medical explanation to support his suggestion that there is a link between the Veteran’s pulmonary asbestosis and his history of in-service asbestos exposure. Significantly, Dr. Godin’s findings and conclusions are negative for any history detailing the Veteran’s possible exposure to asbestos following service discharge. Here, Social Security Administration (SSA) records show the Veteran worked as an auto mechanic from June 2000 to July 2012 when he stopped working due to a work-related injury to his right hand. In this case, Dr. Godin’s statements do not address the Veteran’s potential asbestos exposure while working as a full-time auto mechanic for 12 years following his separation in October 1973. It is noted that a medical opinion or "medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120 (2007) (when a medical examination or opinion is provided, the clinician must support conclusions with an analysis that is adequate for the Board to consider and weigh against contrary opinions). Second, the November 2020 VA CR chest (2 views) report, obtained in conjunction with the VA examination, notes an “indeterminate 1.8 cm nodular opacity in the left mid zone measuring 1.8 cm. Recommend further evaluation with chest CT.” The Board observes that no further imaging studies, procedures, or diagnostic tests were subsequently conducted by VA. Lastly, the VA medical opinion is inadequate because it does not reflect a full consideration of the Veteran’s complete medical records and medical history. The opinion is, in part, predicated on incomplete imaging studies and medical findings from the November 2020 chest x-ray. Specifically, the opinion states “The current chest x-ray dated November 16, 2020 shows a left sided nodule of unclear etiology. No current diagnosis of asbestosis is warranted therefore no opinion is needed.” Thus, in this case, the examiner provided a conclusory statement based on an inconclusive chest x-ray. Moreover, in an attempt to reconcile a previous diagnosis of asbestosis by a September 2016 treatment provider, the VA examiner determined the diagnosis was incorrect because imaging at the time did not show findings consistent with asbestosis. Additionally, the November 2020 opinion does not further address the positive medical evidence, discussed above, such as the May 2019 chest x-ray showing calcified pleural plaques suggestive of asbestos exposure and Dr. Godin’s May 2020 statement reflecting a diagnosis of asbestosis based on a November 2019 chest CT scan demonstrating pleural plaques. Finally, while the December 2016 VA respiratory examination report contains a diagnosis of asbestosis, the Board finds it of limited probative value in that it indicates no imaging studies, procedures or diagnostic tests were performed, and, further, the examiner provided no opinion or meaningful discussion as to whether the diagnosis of asbestosis was related to the Veteran’s in-service asbestos exposure. Based on the conflicting evidence above, it is unclear whether the Veteran has been diagnosed as having asbestosis during the appeal period. In determining the adequacy of a medical examination or opinion, an examination or opinion is considered adequate, "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's '"evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991))). Given the foregoing, the Board finds that the November 2020 examination and medical opinion are inadequate. As such, remand is required to obtain a new examination to clarify whether the Veteran is currently diagnosed with asbestosis or any asbestos-related respiratory disease that is related to his in-service asbestos exposure. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Obtain all VA treatment records dated from September 2020 to the Present. 2. Schedule an examination from an appropriate clinician, to determine the etiology of all respiratory disorders, to include asbestosis and/or any asbestos-related diseases, shown during this appeal period. Any and all diagnostic studies, tests, and evaluations deemed necessary by the clinician should be performed. The Veteran’s exposure to asbestos during his active service has been conceded by VA. The entire claims file, to include a copy of this REMAND, must be made available to and reviewed by the clinician. The medical opinion should, at a minimum, reflect consideration of (i) the documented history; (ii) the lay contentions, to include the Veteran’s theory that his current respiratory disorders are related to his in-service asbestos exposure; and (iii) medical evidence of record, to include evidence that is both favorable and unfavorable. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If another etiology is the more likely cause of the Veteran's respiratory disorders, the examiner must provide a complete explanation of his or her reasoning. Based on a review of the claims file, as well as an interview with the Veteran, the examiner should address the possibility of any post-service asbestos exposure, to include the likelihood of the Veteran’s exposure to asbestos while repairing cars during his employment as a full-time auto mechanic from June 2000 to July 2012. The examiner is asked to address the following: (a.) Identify all current respiratory disabilities. Consider the Veteran's December 2016 VA examination report showing diagnoses of asbestosis, COPD, emphysema, and chronic pulmonary embolism. The examiner must clarify whether the Veteran has been found to have asbestosis or any other asbestos-related disease during the appeal period. If any previously diagnosed respiratory disorder(s) are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. (b.) As to each diagnosed disability, detail the nature, onset, progression, and severity of the Veteran’s reported symptoms. (c.) As to each diagnosed disability, provide an opinion as to whether it at least as likely as not (i) had its onset during active service, or (ii) is related to an in-service injury or disease, to include the Veteran's conceded in-service asbestos exposure. (d.) Explain how asbestosis and asbestos-related respiratory/pulmonary diseases generally present or develop. The opinion should reflect consideration of the following evidence: (1) the non-VA provider radiology report dated May 2019 chest x-ray showing calcified pleural plaques suggestive of asbestos exposure, and (2) the medical statement and treatment records dated in May 2020 from the Veteran’s non-VA pulmonologist, Dr. Paul Godin of Dignity Health Medical Group Dominican Hospital, showing a diagnosis of asbestosis based on the Veteran’s history of in-service asbestos exposure, physical examination of the Veteran, and findings from a November 2019 CT chest scan demonstrating pleural plaques consistent with asbestos exposure. 3. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Krunic, 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.