Citation Nr: 21030703 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 15-40 487 DATE: May 19, 2021 REMANDED Service connection for a lung disability (to include bronchiectasis, COPD, emphysema, and chronic bronchitis, but not to include pleural thickening and pleural plaque formation associated with asbestos exposure) is remanded. REASONS FOR REMAND The Veteran honorably served on active duty from December 1967 to October 1971. This matter is back before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. This matter was previously remanded in August 2018 and August 2020 Board remands. The Veteran testified before the undersigned at a Board hearing in August 2016. A transcript of the hearing is of record. 1. Service connection for a lung disability (to include bronchiectasis, COPD, emphysema, and chronic bronchitis, but not to include pleural thickening and pleural plaque formation associated with asbestos exposure) is remanded. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete and accurate record upon which to decide the Veteran's claim so that every possible consideration is afforded. The Board finds that further development of the record is necessary to meet VA's duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully informed decision on the claim at this time because the record does not include an opinion that adequately addresses the facts and circumstances presented by the Veteran's case. Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Specifically, the October 2020 VA addendum medical examiner did not specifically address the particular facts and circumstances of the Veteran's case (i.e., his particular medical condition and circumstances). Instead, the only rationale provided for the secondary service connection causal link was that medical literature does not support pleural thickening or plaques as causing or aggravating COPD, chronic bronchitis, bronchiectasis or emphysema. Other causes were provided as explanation for the development of those conditions, but nothing specifically relating to this Veteran's conditions. Further, and importantly, the medical literature provided by the examiner consists of a Cleveland Clinic website link which appears to be for public consumption and not necessarily medical research into the potential causes of the Veteran's conditions. The matters are REMANDED for the following action: 1. Please note that, by law, ALL remanded claims must be processed expeditiously. 2. Provide the complete record to an appropriate clinician with expertise in pulmonary or respiratory diseases and conditions and obtain an addendum opinion. The clinician MUST indicate that she or he has reviewed the entire record. Based on the factual evidence of record, the clinician must provide an opinion that responds to the following: (a.) For the purposes of these medical opinions, the examiner is informed that the Veteran has current diagnoses of COPD, chronic bronchitis, bronchiectasis and emphysema. (b.) For the purposes of these medical opinions, the examiner is informed that the Veteran has conceded exposure to asbestos in service. (c.) For EACH of the Veteran's DIAGNOSED lung disabilities, is it at least as likely as not (defined as a 50% or better probability) that it was incurred in military service, to include as a result of exposure to asbestos, dust, bilge water, and smoke? (d.) For EACH of the Veteran's DIAGNOSED lung disabilities, is it at least as likely as not (defined as a 50% or better probability) that it was proximately caused by or aggravated by the Veteran's service-connected pleural thickening and/or pleural plaque formation? [The clinician is advised that AGGRAVATION is defined as any increase in severity of the disability beyond its natural progression, regardless of measurability OR permanence.] (e.) SPECIFICALLY, does pleural thickening or pleural plaques contribute ANY increase in severity beyond its natural progression, regardless of how small or incremental such increase could be, to the Veteran's symptoms of difficulty breathing and other symptoms associated with his conditions? (f.) IF the answer to 2.(e) is YES, does this indicate that the Veteran's service-connected pleural thickening or pleural plaques (caused by asbestos exposure in service) causes some increase in the severity of his symptoms associated with COPD, chronic bronchitis, bronchiectasis and emphysema? In other words, does the Veteran's pleural thickening or pleural plaques make the other conditions worse or are there overlapping symptoms? If the examiner cannot provide answers because further information, examination of the Veteran, or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies or testing should be exhausted before concluding that the answer cannot be provided. The examiner's attention is drawn to the following records (the following is a brief factual background and not intended to be a substitute for your review of the Veteran's claims folder): (g.) A September 1967 pre-induction naval examination reveals no notation of a lung or chest abnormality. (h.) A January 1968 service treatment note where the Veteran reported trouble breathing with a coughing spell, but that he did not feel sick. Diagnosis was an upper respiratory infection with bronchitis. (i.) An August 1970 service treatment note where the Veteran reported pain with deep breathing for two weeks with no other symptoms. Consultation report notes increased fibrosis in his chest. (j.) A September 1970 service treatment note where the Veteran reported pain in the left chest area for approximately one month. Notation includes "old gran. Disease -? asthma." (k.) A May 1971 service treatment note where the Veteran reported painful inspiration with a hard time breathing. Notation includes "chronic changes and evidence 'Nd' granulomatous disease." (l.) An October 1971 service release examination reveals no notation of a lung or chest abnormality. (m.) The Veteran has reported difficulty breathing beginning at least as early in 2010. [The Board notes that, by law, an extensive time gap between service and initial diagnosis is but one factor to consider.] The examiner is advised that, BY LAW, the particular facts and circumstances of the Veteran's case (i.e., his particular medical condition and circumstances) must be addressed. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. [CONTINUED ON NEXT PAGE] If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the clinician (that is, the clinician does not have the required knowledge or training). VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Williams, 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.