Citation Nr: 21026659 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 16-27 219 DATE: May 3, 2021 REMANDED Entitlement to service connection for rheumatoid lung disease is remanded. Entitlement to service connection for mediastinal nodes enlargement is remanded. Entitlement to service connection for a lung condition, to include pulmonary fibrosis and interstitial lung disease is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1967 to September 1969, during the Vietnam Era, with service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The matter last appeared before the in December 2018, at which time the issues were remanded for further development. As a preliminary matter, the Board notes that the Veteran again filed a claim to reopen the claim for service connection for pulmonary fibrosis and interstitial pneumonitis in October 2018. As these claims were already substantively appealed to the Board, the RO notified the Veteran in a January 2019 rating decision and a February 2019 letter that they were unable to address his October 2018 service connection claims for pulmonary fibrosis and interstitial pneumonitis as the issues were currently under appeal and being handled through the VA appeals process. 1. Entitlement to service connection for rheumatoid lung disease is remanded. 2. Entitlement to service connection for mediastinal nodes enlargement is remanded. 3. Entitlement to service connection for a lung condition, to include pulmonary fibrosis and interstitial lung disease is remanded. In his May 2016 formal appeal to the Board, the Veteran stated that the VA medical center (VAMC) Tucson performed the Agent Orange registry examination and linked the disabilities to Agent Orange. He further stated that he has never been exposed to any other toxin that would have caused the enlarged mediastinal nodes or the interstitial lung disease. The Veteran's representative indicated that it is his position that his issues are directly related to his military service. In a September 2020 statement, the Veteran reiterated his belief that service connection is warranted for his lung conditions, to include pulmonary fibrosis and interstitial lung disease, and for rheumatoid lung and mediastinal nodes enlargement. He stated that his lung condition existed while on active duty or was a result of the exposure because he was treated and diagnosed with arthritis shortly after discharge. He stated that according to medical science, rheumatoid arthritis is often misdiagnosed and is only found through blood test and x-rays and these tests were never conducted on him in-service. He further cited a Mayo Clinic medical literature website regarding exposure to harmful chemicals causing interstitial lung disease and stated he has no family history of lung disease, has never been a smoker nor lived with a smoker, nor did his job post service expose him to harmful chemicals. The Veteran underwent a VA examination in November 2019. Although when asked to provide a diagnosis, the examiner did not provide a response, but noted the Veteran was diagnosed with interstitial lung disease secondary to rheumatoid arthritis in 2008 after a lung biopsy and he has other pulmonary conditions, pertinent physical findings, or scars due to pulmonary conditions. The examiner noted that the Veteran does not have multiple respiratory conditions. The examiner noted that the Veteran is not a smoker, has never smoked, and denied secondhand smoker exposure. The examiner opined that the Veteran's rheumatoid lung disease is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner rationalized that symptoms suggestive of rheumatoid arthritis are not documented on the January 1969 report of medical history nor on several undated reports of medical history reviewed in the service treatment records. The examiner indicated that there is no documentation of treatment for rheumatoid arthritis during military service nor in the twelve months immediately after military separation. The examiner noted that this evidence does not support a chronic condition of rheumatoid arthritis related to military service and, therefore, a nexus linking the current rheumatoid arthritis condition directly to military service cannot be established. The examiner further noted that rheumatoid arthritis is a generally progressive, systemic autoimmune process characterized by chronic symmetrical erosive synovitis. The examiner also opined that the Veteran's mediastinal nodes enlargement is less likely than not (50 percent or greater probability) incurred in or caused by the possible herbicide Agent Orange exposure during service. The examiner rationalized that a 2008 biopsy of the lung showed interstitial fibrosis with marked lymphoplasmacytic infiltrate. The examiner remarked that lung nodules were due to the interstitial fibrosis condition secondary to rheumatoid arthritis and not due to a separate and unrelated condition or herbicide Agent Orange exposure. The examiner lastly opined that the Veteran does not have a lung condition, to include pulmonary, that is at least as likely as not (50 percent or greater probability) incurred in or caused by possible herbicide Agent Orange exposure during service. The examiner rationalized that a review of the herbicide Agent Orange presumptive conditions fail to document rheumatoid arthritis as a VA approved presumptive condition secondary to Agent Orange exposure. The Board finds that the November 2019 VA examination and opinions are inadequate. Specifically, the examiner provided internally inconsistent findings regarding whether the Veteran has multiple respiratory diagnoses and did not address/reconcile the medical evidence showing additional diagnoses, other than rheumatoid lung disease and mediastinal nodes enlargement. Indeed, a February 2019 pulmonary clinic computerized problems list shows the Veteran's past medical history of various conditions including interstitial lung disease, pulmonary fibrosis, and rheumatoid arthritis while another February 2019 rheumatology clinic note also notes mediastinal lymphadenopathy probably related to rheumatoid arthritis. The examiner's opinions also fail to directly address whether the Veteran's rheumatoid lung disease is related to his conceded exposure to herbicides, as requested by the prior Board remand, or his service treatment records reflecting notations of chest pain (September 1968); chills, fever, nausea (February 1969); URI ward admission (December 1967); and malaria diagnosis (April 1969). Moreover, in regard to the rationalizations provided, the examiner failed to provide a factually accurate, fully articulated, sound reasoning for the conclusion as to whether the herbicide Agent Orange exposure has a causal relationship to the Veteran's claimed conditions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Illustratively, in regard to the rheumatoid arthritis and a lung condition, the examiner simply stated that the condition is not on the presumptive service connection and there is no in-service documentation of the condition and that there is no documentation of the rheumatoid arthritis in the STR's. Then, in regard to the interstitial fibrosis condition, the examiner noted that the condition is secondary to rheumatoid arthritis and not due to a separate and unrelated condition or herbicide Agent Orange exposure. Such explanation is insufficient to directly address why the condition is not casually related to the Veteran's herbicide exposure besides mentioning the June 2008 biopsy. Such opinions are a bare conclusion without supporting data. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Id. The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. Id. The Board is unable to conclude the examiner applied a well-reasoned analysis as bare and insufficient rationalization is given. The Board further notes that the December 2018 remand directed that the VA examination be conducted by a clinician with sufficient expertise to diagnose and determine the nature and etiology of the Veteran's conditions. The Board notes that the November 2019 VA examination was conducted by a physician's assistant of primary care service. However, the record reflects that the Veteran's respiratory conditions have been treated by the VA pulmonary and rheumatology clinics. The Board further notes that an examiner has not had the opportunity to address the Veteran's September 2020 lay statement and citation to the Mayo Clinic medical literature website. Hence, the Board finds that remand is warranted to obtain outstanding medical records and a new VA examination. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims. If any requested records are not available, the file should be annotated to reflect such, and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Then, schedule the Veteran for a VA examination by a physician with sufficient expertise to diagnose and determine the nature and etiology of the Veteran's claimed lung condition, enlarged mediastinal nodes, and rheumatoid lung disease. All pertinent evidence of record must be made available to and reviewed by the examiner. Any required studies should be performed, and all clinical findings should be reported in detail. The examiner is asked to address the in-service complaints of chest pain, chills, fever, nausea, URI ward admission, and malaria diagnosis, the Veteran's lay statements, including his September 2020 statement that his lung condition existed while on active duty or was a result of the exposure because he was treated and diagnosed with arthritis shortly after discharge, and his citation to the Mayo Clinic medical literature website. Based on a review of the evidence of record, lay statements and the examination results, the examiner should state an opinion with respect to: A. Whether the Veteran's rheumatoid lung disease is at least as likely as not (a 50 percent probability or greater) incurred in, or is otherwise etiologically related to his active service, to specifically include as a result of his exposure to herbicides. B. Whether any diagnosed lung condition, including pulmonary fibrosis and interstitial lung disease, is at least as likely as not (a 50 percent probability or greater) incurred in, or is otherwise etiologically related to his active service, to include as a result of his exposure to herbicides. C. Whether the Veteran's mediastinal nodes enlargement is at least as likely as not (a 50 percent probability or greater) incurred in, or is otherwise etiologically related to his active service, to include as a result of his exposure to herbicides. D. Whether the Veteran's mediastinal nodes enlargement is at least as likely as not proximately due to or aggravated by rheumatoid arthritis. For the purposes of these opinions, the examiner should note that exposure to herbicides has been conceded. The examiner must also note the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including events and symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner must provide a complete rationale for all proffered opinions. If the examiner cannot provide the required opinions without resorting to speculation, he or she shall provide a complete explanation as to why that is the case. Further, the examiner must state whether the inability to provide the required opinions is based on a personal limitation or on a lack of knowledge among the medical community at large. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Alli, 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.