Citation Nr: 22013363 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 17-25 895 DATE: March 9, 2022 ORDER Entitlement to service connection for chronic obstructive pulmonary disease (COPD), claimed as due to asbestos exposure, is denied. Entitlement to service connection for asthma, claimed as due to asbestos exposure, is denied. FINDINGS OF FACT 1. The Veteran's January 1958 entrance examination did not diagnose asthma or COPD despite his later reporting a history of a pre-service respiratory condition (asthma) and the record does not contain medical evidence that demonstrates that asthma or COPD was diagnosed prior to service. 2. The evidence shows that asthma and COPD were not present in service or until many years thereafter and are not related to service or to an incident of service origin, to include asbestos exposure, as well as environmental hazards to include diesel fumes, paint particles "from dusting paint and rust," and potentially mold. CONCLUSION OF LAW The criteria for service connection for asthma and COPD have not been met. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Navy from January 1958 to February 1961. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision and April 2015 notification letter of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2017, the Board remanded the Veteran's claim for additional development. The Board in a March 2018 decision denied the claim for service connection for asthma and COPD. The Veteran appealed the March 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a subsequent November 2018 order, which incorporated the parties Joint Motion for Remand (JMR), the Court vacated and remanded the Board decision. In May 2019 and January 2021, the Board remanded the Veteran's claim for further development. It has now returned to the Board for further appellate review. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). 38 U.S.C. § 7107(b)(1). Post-Remand Compliance and the Concerns Raised by the JMR As to post-remand compliance, as well as the concerns raised by the JMR, the Board notes that the post-remand record shows that the Veteran was provided a VA notification letter in September 2019 formally notifying him of the unavailability of medical records from the Loma Linda VA Medical Center (VAMC) prior to May 1999, in accordance with 38 C.F.R. § 3.159(e)(1). See November 2018 JMR. Further, the Board finds that the post-remand etiology VA examinations provided in January 2020 and September 2021 and addendum opinions in January 2020, October 2020, April 2021, September 2021 are adequate, when taken together, to adjudicate the claim and substantially comply with the May 2019 and January 2021 Remands, as well as satisfy the concerns raised in the November 2018 JMR. The Board has reached the above conclusion because after a review of the record on appeal and multiple examinations of the Veteran and numerous medical opinions on the issues on appeal, many VA examiners have collectively provided an opinion as to the etiology of the claimant's asthma and COPD in this claim, which are supported by the evidence found in the record, to include service treatment records and post-service diagnostic reports, as well as lay testimony regarding asbestos exposure, potential environmental exposures, and internet and lay evidence provided by the Veteran. Context in this case is important: The Board now has several medical opinions providing evidence against this claim. Accordingly, because the above VA examiners, when opining that the Veteran's current asthma and COPD was not due to his military service, weighed the totality of the medical and lay evidence found in the claims file, the Board finds the etiology opinions are, as a whole, adequate to adjudicate this claim. In other words, as will be discussed in more detail below, because negative service treatment records were not the sole basis for the opinions provided by the examiners in rendering the negative etiology opinions, the Board finds they are, as a whole, adequate to adjudicate the claim. Furthermore, not only does the record reveal that VA has obtained and associated with the claims file available and identified service and post-service treatment records, the Veteran has not provided VA with an authorization to request any additional records despite being asked to do so by the RO on a number of occasions. Therefore, the Board finds the required development has been completed and the matters are properly before the Board at this time. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). SERVICE CONNECTION 1. Entitlement to service connection for COPD 2. Entitlement to service connection for asthma The Veteran and his representative, in many writings to VA, claim, in substance, that the Veteran's asthma and COPD either pre-existed military service and was aggravated by his service or started due to an injury while on active duty (i.e., due to asbestos and/or environmental exposure) and continued to the current time. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). In this regard, in order to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). If a pre-existing disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under 38 U.S.C. § 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417. In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Lynch v. McDonough, No. 2020-2067 (Fed. Cir. Dec. 17, 2021) (en banc). a. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b) Initially, the Board notes that the examiner that conducted the Veteran's January 1958 entrance examination specifically opined that he had normal lung and chest with negative chest x-ray and the Veteran expressly reported on his January 1958 entrance Report of Medical History that he did not have "asthma", "shortness of breath", "pain or pressure in chest", or "chronic cough" despite the fact that he later reported a history of asthma prior to service. See October 2017 Statement in Support of Claim (Veteran asserts that he had asthma since age 7 (i.e., 1947)); Cf. September 2021 VA Respiratory Conditions Examination (Veteran reports that he started having respiratory problems in 1972). Therefore, because the Veteran's asthma and COPD was not "noted" on his entrance onto active duty, the Board finds that presumption of soundness attaches to this claim unless there is clear and unmistakable evidence of it preexisted military service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). As to whether there is clear and unmistakable evidence of asthma and COPD preexisted military service, the Board finds that the normal January 1958 chest and lung examination with normal chest x-ray and the Veteran's January 1958 own lay testimony of not having asthma at entry to service are the most competent and credible evidence of record because they took place at the time the Veteran entered onto active duty and considered his reports of a pre-service conditions. See Owens, supra. Therefore, the Board finds that there is not clear and unmistakable evidence that the Veteran's asthma and COPD preexisted military service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Accordingly, the Board finds that presumption of soundness attaches to this claim. Id. b. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The remaining question before the Board is whether a current asthma and COPD is due the Veteran's military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Initially, as to current disabilities, the Board notes that there is no dispute that the Veteran has a current diagnosis of COPD and asthma. See September 2021 VA Respiratory Conditions Examination. Additionally, the Veteran's service personnel records show that the Veteran served aboard the USS Perkins. As such, asbestos exposure is conceded. However, service treatment records, including the February 1961 separation examination, are negative for an injury, history, complaints, diagnoses, or treatment for COPD and asthma. In this regard, the Board finds it significant that the Veteran did not report having any history of chronic or frequent colds, asthma, shortness of breath, pain or pressure in chest, and/or a chronic cough during service. See Chronological Care Notes, Service Treatment Records, 1958 to 1961. The Board also finds it significant that when examined in February 1961 it was opined that his lungs and chest examinations were normal and that his chest x-ray was negative for abnormalities at separation. In this regard, the Board also finds it significant that service treatment records do not document the Veteran's complaint or treatment for signs or symptoms of COPD and asthma despite the records containing detailed reports of other problems. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not develop COPD and asthma while on active duty and did not demonstrate symptomatology of COPD and/or asthma while in service despite any claim to the contrary. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Overall, the Board finds the service records provide highly probative evidence against any claim that the Veteran's current asthma and COPD are directly related to service. Similarly, the post-service record does not show the Veteran being diagnosed with COPD and/or asthma in the first post-service year. Therefore, the Board finds that the presumptions found at 38 C.F.R. § 3.309(a) do not help the Veteran establish service connection for COPD and asthma. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. § 3.307. More importantly, the record does not show that the Veteran had a continued problem with COPD and asthma in and since service. In fact, as noted above, the February 1961 separation examination was negative for a signs, symptoms, or diagnoses of COPD and asthma despite the conceded asbestos exposure; providing highly probative evidence against the claim. Likewise, and more importantly, the post service treatment records show the Veteran being initially diagnosed with COPD in approximately 2000 and for asthma in approximately 1972. Tellingly, the Board notes that the first documented evidence of asthma following the Veteran's service was more than a decade after discharge and almost four decades for COPD. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(b). This fact would seem to support the findings of the February 1961 examiner in service who provided evidence against the claims, by opining that this Veteran's lungs and chest examinations were normal and that his chest x-ray was negative for abnormalities at separation, as noted above. Given this record, the Board finds that the service medical records and the post-service medical evidence provides highly probative evidence, overall, against these claims. The Board also finds it significant that the Veteran specifically reported his problems started after he worked as a truck driver for 10 years after leaving service (i.e., a post-service). See September 2021 VA Respiratory Conditions Examination. The record clearly shows that the Veteran was not diagnosed with asthma for more than 10 years following his separation from active duty. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not have a continued problem (i.e., continuity of symptoms) with COPD and asthma in and since service despite the conceded asbestos exposure while serving on board the U.S.S. Perkins on active duty. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(b). For the reasons noted above, the Board finds that the service and post-service medical records provide highly probative evidence against these claims. Accordingly, competent evidence linking the current asthma and COPD to service is needed to substantiate these claims. In this regard, the Veteran contends that he was exposed to asbestos while his ship, the U.S.S. Perkins, was docked in Japan under repair in 1959. See April 2015 Notice of Disagreement (NOD). The Veteran also reported that he grinded, sanded and painted asbestos covered equipment while serving on board the U.S.S. Perkins and that he breathed in fumes without protective gear. See Statement in Support of Claim, June 2019, March 2020, May 2020, February 2022. He believes his respiratory conditions are directly resulting from "breathing lead paint dust for long periods of time" while in service more than one-half-century ago. See June 2019 Statement in Support of Claim. Alternatively, the Veteran's attorney asserts the Veteran's asthma and COPD are due to alleged environmental exposures, while on board the U.S.S. Perkins, to include diesel fumes, paint particles "from dusting paint and rust," and potentially mold. See July 2020 Attorney Brief. The attorney makes no reference to the Veteran's clear post-service work history as a truck drive, where he would presumably have been exposed to diesel fumes as well. Importantly, the Veteran asserts (as do his fellow servicemembers and representative) that he was exposed to asbestos continuously, 24 hours a day, 7 days a week, while serving aboard the U.S.S. Perkins, for two years. See April 2015 Notice of Disagreement (NOD); see also August 2017 Attorney Brief; February 2022 Buddy Statements from K.M.D. and R.C. However, while exposure to asbestos has been conceded in this case, the Board finds the Veteran and his friends are not competent to provide evidence of the amount, or time, that servicemembers serving aboard the U.S.S. Perkins over 60 years ago were exposed to asbestos. The Board has reached this conclusion because the Veteran and his friends have not demonstrated that they have the required training or expertise to be able to determine asbestos levels, or to have tested the air quality diagnostically, on board the U.S.S. Perkins from 1959 to 1961. Moreover, there is no diagnostic report in the Veteran's military personnel or service treatment records indicating any level of asbestos exposure. Accordingly, the Board finds the Veteran's statements (and those of his friends and attorney) regarding the amount and time of exposure to asbestos while in service are of little probative value in this claim. Nonetheless, the Board finds the Veteran is competent and credible to report the type of activities he performed while aboard the U.S.S. Perkins, such as sanding, grinding, painting and working with equipment. See Davidson, supra. There is no reason to discount the probative value of the Veteran's statements regarding the duties that he performed while serving on the U.S.S. Perkins from 1959 to 1961, more than one-half a century ago. Such facts do not provide a basis to diagnose the Veteran with asbestosis. On VA examination in January 2015, the examiner (a chief of pulmonary and critical care) opined that it was less likely as not that the Veteran's COPD or asthma were caused by or a result of asbestos exposure in service. The Veteran reported that in approximately 1972 he began to experience trouble with his breathing. The examiner noted that the Veteran had reportedly smoked between a half and one whole pack of cigarettes for approximately 8 to 10 years from about 1955 to 1965. The Board cannot overlook the Veteran's history of smoking. The examiner acknowledged that while there was probable exposure to asbestos fibers during service, he said that "at present" there was "no good evidence that this exposure led to his subsequent breathing difficulties." However, as noted in the November 2018 JMR, the examiner also opined that a chest CT would be most helpful in diagnosing Appellant's exposure to asbestos. Private medical records show the Veteran underwent a chest x-ray in March 2015 that showed no active disease process, no fibrosis noted, and no pleural thickening or pleural plaques. Based on his chest x-ray, the private examiner opined that he did not see any evidence of asbestosis or mesothelioma. See February 2016 Beaver Medical Group Pulmonology Department Follow Up Notes, providing highly probative evidence against this claim. In a December 2016 VA examination addendum opinion, the same January 2015 VA examiner reviewed private treatment records, noted above, received by VA in April 2015. After reviewing the March 2015 chest x-ray and February 2016 Beaver Medical Group progress notes he opined that there is nothing that would change his previous medical opinion in this case. That is, there is no evidence for asbestosis. The VA examiner pointed out that the March 2015 private treatment record containing a chest radiograph report "does not suggest any asbestosis." However, the examiner noted again that a plain chest radiograph (CXR) is not the ideal imaging modality to diagnose asbestosis and that a chest CT (HRCT) would be a better way to assess this problem. In a March 2017 VA examination addendum opinion, the same January 2015 VA examiner found that the evidence for asbestos exposure was minimal. Additionally, the examiner found that the Veteran had no other pulmonary indications for having had long-term exposure to asbestos fibers. The examiner, after reviewing the March 2015 and February 2016 private treatment records, noted above, reported that the Veteran did not have asbestosis. The VA examiner opined that it is less likely than not that the Veteran's COPD and asthma were caused by or are due to any asbestos exposure that he may have had during active military service. He noted that asbestos exposure often occurs in conjunction with other exposures, such as cigarette smoke. He explained that asbestos fibers typically can cause interstitial pulmonary fibrosis (asbestosis), as well as pleural effusions, pleural plaques, mesothelioma, and can contribute to lung cancer. The examiner observed that "long-term exposure to asbestos fibers may, in fact, contribute to COPD." However, the examiner stated "[t]his is not the case with [the Veteran]. He does have a history of smoking, but minimal, at best, exposure to asbestos fibers." The examiner found that it "certainly is plausible that asbestos exposure contributes to COPD and/or asthma; however, in the case of [the Veteran], the exposure, if any, is considered minimal." As indicated in the November 2018 JMR, the VA examiner did not provide adequate support for his conclusion that the Veteran's exposure to asbestos was felt to be minimal. Accordingly, in May 2019, the Board remanded the Veteran's claims for another addendum opinion on the etiology of the Veteran's asthma and COPD in compliance with the JMR that stipulated the 2015 opinion with December 2016 and March 2017 addenda opinions were inadequate because they "did not include a reasoned medical explanation connecting the supporting data therein to the conclusion provided." This finding was made notwithstanding the facts of this case. The Board also notes that the January 2015, December 2016 and March 2017 VA medical opinions were found to be inadequate where the examiner noted that a "chest CT would be most helpful in diagnosing [the Veteran's] exposure to asbestos," but such was not ordered/conducted. The parties to the JMR agreed that on remand, "the Board should also consider whether VA, as part of its duty to assist [the Veteran], should attempt to obtain a chest CT, or similar diagnostic test.". See November 2018 JMR; May 2019 Board Remand. It is important for the Veteran to understand at this point, even if a medical opinion is "inadequate" to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight. If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). However, if the opinion is merely lacking in some detail, as is the case here, then it may be given some weight based upon the amount of information and analysis it contains. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). Thus, VA is not permitted to completely ignore even an "inadequate" opinion or examination, whether it is in favor or against a veteran's claim. Context and the circumstantial evidence in this case is important. In this regard, in a non-precedential Memorandum Decision, Judge Toth of the United States Court of Appeals for Veterans Claims (Court) emphasized that it is the Board's duty to determine whether evidence shows that the principal fact is true with a degree of certainty that satisfies the requisite standard of proof. See Davis v. McDonough, No. 20-3267 (September 22, 2021). As noted by Judge Toth, mere circumstantial evidence such as this can be compared with the annotations of Henry David Thoreau, who observed of "unscrupulous dairymen who diluted their milk with water to increase its volume, '[s]ome circumstantial evidence is very strong, as when you find a trout in the milk.'" See id. (citing Journal, 11 Nov. 1850, in 2 Journal of Henry D. Thoreau 94 (Bradford Torrey & Francis H. Allen eds., 1962)); Also see Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). In this case, beyond the medical opinions, the "circumstantial evidence" against this claim is especially strong against this claim: The service records provide highly probative evidence against this claim, the post-service medical records provide highly probative evidence against this claim, and the Veteran's history of smoking and his exposure to his pets (addressed below) provides some circumstantial evidence against this claim. The Board cannot disregard the facts of this unique case. In any event, the Board finds the January 2015, December 2016 and March 2017 medical opinions are still probative as to whether the March 2015 and February 2016 private medical treatment records show interstitial pulmonary fibrosis (asbestosis) in this Veteran. In January 2019, the Veteran submitted a private November 2018 chest CT report. See November 2018 Redlands Community Hospital Report. A December 2019 VA addendum opinion provided a negative nexus (to service) but noted that the November 2018 Chest CT report was not located in the records and therefore was not reviewed. As such, the Board finds this opinion lacks some probative value because it is not supported by the clinical data of record. See Black v. Brown, 5 Vet. App. 177, 180 (1995) (holding that a medical opinion is inadequate when it is unsupported by clinical evidence); Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (an adequate examination "must rest on correct facts and reasoned medical judgement so as to inform the Board on a medical question and facilitate the Board's consideration and weighing of the report against any contrary reports."). In a July 2020 statement, the Veteran's attorney argued that asbestos exposure increases a person's risk of developing COPD and may be a risk factor for the development of asthma. In support of his argument, he cited several medical websites/journal articles and included their respective web addresses. He also raised a new contention, i.e., that by virtue of his service aboard the U.S.S. Perkins (a Gearing-class destroyer), the Veteran was exposed to diesel fumes, paint particles "from dusting paint and rust," and potentially mold, which caused him to develop asthma and/or COPD. Another addendum opinion was obtained in October 2020 in which a different VA physician opined, inter alia, that the November 2018 CT scan evidence of asbestos exposure does not contain evidence (on CT or PFTs) of asbestosis. Specifically, the examiner noted that the body of the November 2018 diagnostic report includes the statement "there is a tiny calcific pleural plaque at the anterolateral right mid thorax" which represents objective evidence of definitive asbestos exposure. However, the examiner opined that this is not asbestosis. In support, the examiner noted that asbestosis is an interstitial disease and pointed to the fact that there is no mention of interstitial disease on the CT scan or on findings cross-referenced from pulmonary function tests (PFTs) of record. In addition to rendering a competent, credible and highly probative analysis on the November 2018 CT scan report, the examiner also highlighted the fact that the Veteran has a smoking history and had 4 cats and 2 dogs in the home and is allergic to animal dander. Citing to Up-To-Date, a medical journal, the examiner reported that asbestos exposure is not a risk factor for developing or aggravating asthma or COPD. Moreover, Up-To-Date also shows that "[n]umerous epidemiologic studies indicate that tobacco smoking is overwhelmingly the most important risk factor for COPD." Therefore, the examiner opined, based on all of the reasons already stated, it is less likely than not that the Veteran's COPD and asthma were caused by or are due to any asbestos exposure that he may have had during active military service. In January 2021, the Board remanded the claims once again, but only because the October 2020 medical advisory opinion apparently did not consider (or reconcile) the journal articles cited by the attorney regarding asbestos exposure or address the additional/new contentions raised by the Veteran's attorney in July 2020 regarding environmental exposures. An addendum opinion was again obtained in April 2021 to address the concerns of the January 2021 Board Remand. The same examiner that rendered the October 2020 medical opinion, addressed each of the attorney's arguments, to include citing to the websites noted in the July 2020 Attorney Brief, and potential environmental exposures. In short, the examiner concluded that the articles were either not relevant, too speculative and/or only contained generic information that was not helpful in showing a nexus exists between the Veteran's current asthma (diagnosed in 1972) and COPD (diagnosed in 2000) and service (ending 1961). Tellingly, in citing to the Mayo Clinic article, the examiner noted it provided probative evidence against the Veteran's claim because it lists pet dander as a cause or trigger for asthma. See October 2020 VA Examination. Moreover, the examiner noted that the Mayo Clinic article mentions air pollution and fumes, but the Veteran's ten-year history of smoking outweighed any potential contribution from the conceded exposure in the military. Additionally, the examiner added that the Veteran was exposed to fumes from jet fuel during pilot training in the 1970's, as well as exposure to pollution while working as a truck driver (including truck exhaust, road pollution, etc.) after leaving service. In this regard, the examiner opined that any exposure to environmental substances in-service was more than matched by post-service exposures as a truck driver, during pilot training in the 1970's, and/or potential pollen via his documented daily golf outings. Finally, the examiner opined that exposure to mold is so ubiquitous that any determination relating it to a specific event would need to happen at the time of an ongoing exposure and the Veteran's service treatment records do not reflect that any such determination was made for this Veteran while in service. The examiner concluded that the most likely etiology for the Veteran's COPD was smoking, and the most likely etiology for his asthma was his pets living in the home (4 cats and 2 dogs) with pet dander as well as environmental triggers after service to include pilot training, truck driving and daily pollen exposure playing golf. Importantly, the examiner noted that while exposure to asbestos is conceded, the CT scan report from November 2018 shows it was not very significant. In this regard, the Board finds the examiner's opinion competent, credible and highly probative as to demonstrating through medical findings the fact that the Veteran's exposure to asbestos in service was minimal. Therefore, the examiner opined, based on all of the reasons already stated, it is less likely than not that the Veteran's COPD and asthma were caused by or are due to any asbestos and/or environmental exposure that he may have had during active military service. In a September 2021 addendum opinion, the VA examiner opined that the claimed conditions (asthma and COPD) are less likely as not incurred in or caused by the event, injury or illness during military service to specifically include environmental exposures to include asbestosis, diesel fumes, and mold exposure. In support, the examiner explained that asthma is a chronic inflammatory disorder of the airways and triggers include allergens, some medications particularly aspirin and nonsteroidal anti-inflammatory drugs, environmental factors such as tobacco smoke and occupational exposures. However, the "triggers" are well-known, and require a diagnosis of underlying asthma, which this Veteran did not have during his military service (i.e., after exposure). Moreover, the examiner explained that smoking is the most common risk factor for COPD worldwide but that other risk factors can include occupational exposures. The examiner pointed out that the Veteran's occupational exposures certainly could have made his pulmonary system vulnerable to illness, disease and loss of function as he aged, but a significant 10 pack year history of daily cigarette smoking would most likely have damaged his lungs at an early age and impacted the functional capacity and functional reserve of his respiratory system (citing to Up-to-Date medical journal). This case has become increasing multifaceted because, considering the JMR and some argument raised by the Veteran's advocate, the Board has been implicitly obligated to not only determine what did not cause the Veteran's disabilities, but in a sense is being asked to determine what caused these problems. The Board cannot unfortunately do that. Context in this case is again important: Based on the facts of this case the contentions regarding exposure to diesel fuel in service and other contaminants more than one-half a century are ago found to be tenuous in the extreme. The Board cannot remand this case once again in light of these, and other, contentions. The Board finds the October 2020, April 2021 and September 2021 VA examiner's negative etiology opinions, along with the January 2015, December 2016 and March 2017 medical opinions, together as a whole, provide the most probative evidence of record to the extent these opinions are found to be adequate, as outlined above. The Board has reached this conclusion because the opinions were developed over multiple remands for the express purpose of obtaining a range of etiology opinions regarding the Veteran's asthma and COPD claims. Moreover, they were provided after multiple reviews of the record on appeal, private treatment records and multiple examinations of the Veteran during the appeal, as well as because the VA examiner's opinions were supported by evidence found in the record, their findings at the examinations, medical journals cited by the Veteran and prior VA examiners, and controlling medical principles, as well as because the examiner's specifically considered the Veteran's lay statements regarding the history of his disease, asbestos exposure and occupational hazards while in service. Tellingly, at this time, the negative nexus opinions are not contradicted by any other medical evidence of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Therefore, the Board finds that the VA opinions, taken together, provide highly probative evidence against the claims. See Owens, supra. The Board also finds that the Veteran is not competent to provide the missing nexus opinion because he does not have the required medical expertise to provide an answer to this complex medical question (i.e., what caused his current asthma and COPD). See Davidson, supra. Significantly, there is no competent medical opinion of record linking the Veteran's diagnosis of his asthma or COPD disorder to his service. The Board acknowledges that the Veteran's representative, who has done a commendable job representing his client's interest, in its most recent brief, requested the Board remand this case for a new examiner and a new examination to consider additional generic internet evidence relating to "leaded paint" exposure and asthma and COPD. See February 2022 Attorney Brief. However, the Board must note the extensive development in this case (discussed above). The Board has considered this request but finds another remand on these matters unnecessary as the Board has a full and complete record on which to base its decision. Specifically, the Veteran already submitted testimony throughout the appeal as to his exposure to "leaded paint". See e.g., April 2015 Notice of Disagreement (NOD); Statement in Support of Claim, June 2019, March 2020, May 2020, February 2022. Moreover, multiple VA examiners have already considered the Veteran's lay statements regarding his lead exposure in service and rendered negative nexus opinions, despite acknowledging such exposure. Furthermore, the internet articles submitted by the Veteran's representative provide only general information regarding health and exposure to lead paint. For example, the first internet article discusses a generic study on occupational risks of lead exposure at military firing ranges. A second article discusses high hematocrit and hemoglobin, while the third and fourth articles discuss general principles around lead exposure. Importantly, the articles are not accompanied by any corresponding clinical evidence specific to the Veteran, and do not suggest a relationship between the Veteran's asthma or COPD and his time on board the U.S.S. Perkins with a degree of certainty such that, under the facts of this specific case, reflects plausible causality based upon objective facts. As such, the Board places little probative weight on the most recent internet evidence submitted by the Veteran. Nonetheless, in this case, the Board finds it is able to render a decision without another remand for a VA examiner to consider additional generic internet articles related to lead pain exposure. While it is clear that the Veteran clearly suffers from his disabilities, he has not established a link between his current COPD and asthma and his active service, to include exposure to asbestos and environmental hazards. There is no significant evidence against this claim. Therefore, although the Veteran's competent and credible reports of symptoms have been considered and are probative, for the reasons outlined above, the best evidence of record shows that the Veteran's in-service exposure to asbestos and occupational/environmental exposures over 60 years ago is not etiologically related to his current COPD and asthma. The Board attaches greater probative weight to the clinical findings and opinion of skilled, unbiased professionals as to the relationship between asbestos and the environment and the Veteran's current disabilities. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Importantly, where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. The Veteran does not meet this burden by merely presenting his lay opinion because such evidence does not constitute competent medical authority in this claim. The only evidence of record linking the asthma and COPD to service is the Veteran's own assertions. The Veteran has not been shown to have the requisite medical training to opine as to the diagnosis or the etiology of the claimed condition. He is clearly asserting a fact that is beyond his competence to do so. The Veteran's statements, standing on their own, are insufficient upon which to establish a (causal) relationship between his current disability and a period of active service. Therefore, the Board finds that the claim of service connection for asthma and COPD is denied. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In reaching the above conclusions the Board has considered the applicability of the benefit of the doubt doctrine. However, as there is not an approximate balance of positive and negative evidence regarding the claim that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, No. 2020-2067 (Fed. Cir. Dec. 17, 2021) (en banc). John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Davidson 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.