Citation Nr: 24013158 Decision Date: 03/28/24 Archive Date: 03/28/24 DOCKET NO. 16-63 958 DATE: March 28, 2024 REMANDED Entitlement to service connection for pulmonary sarcoidosis is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1974 to November 1977. In December 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. The record was held open for 90 days following the hearing to allow the submission of additional evidence; however, no additional evidence was submitted. A July 2022 Board decision, in pertinent part, reopened the claim of service connection for pulmonary sarcoidosis and remanded the underlying service connection claim for additional development. Entitlement to service connection for pulmonary sarcoidosis is remanded. The Veteran seeks service connection for pulmonary sarcoidosis, which he contends is related to his active duty service. Specifically, the Veteran contends that he started having breathing problems about a week after being ordered to clear out a cave in Panama that had bats and bat droppings. The Veteran was denied service connection for pulmonary sarcoidosis in a November 1977 rating decision. The basis of the denial was that the Veteran's pulmonary sarcoidosis preexisted his active duty service and was not aggravated by his active duty service. However, in its July 2022 decision, the Board found that the Veteran's induction examination did not clearly and unmistakably show that the Veteran's pulmonary sarcoidosis preexisted the Veteran's service. Subsequently, the Board found that remand was warranted to obtain a VA examination to determine the nature and etiology of the Veteran's pulmonary sarcoidosis. Pursuant to the July 2022 remand, a VA opinion was obtained in December 2022. The examiner's opinion was: "Medical records during the service period between 1974-1977 were reviewed. The [service treatment records (STRs)] have been silent for any condition of pulmonary condition including sarcoidosis during this period. Thus, the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." The examiner also provided a negative secondary service connection opinion stating that it was not medically well-known that hearing loss or tinnitus trigger sarcoidosis. Finally, the December 2022 VA examiner also stated that "The STRs have been silent for any condition of pulmonary condition including sarcoidosis during this period and prior to service. Thus, the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness." In February 2023, an addendum opinion was obtained from the VA examiner as she did not address the Veteran's bat cave contentions in her prior opinion. The examiner then provided the following opinion and rationale: "It is NOT medically well known what is the exact cause of pulmonary sarcoidosis. Exposure to virus or bacteria by CLEARING OUT A CAVE IN PANAMA WITHOUT USING A RESPIRATOR, as the Veteran states, could be A cause of pulmonary sarcoidosis, but it is very hard to confirm that the episode is the MAIN cause of pulmonary sarcoidosis. Moreover, after review of EVIDENCE OF RECORD, the exposure happened in 1977 which is a couple of decades before he was found with pulmonary sarcoidosis. Thus, it is reasonable to keep the negative opinion." (Emphasis original.) Additionally, in the July 2022 Board remand, the examiner was asked to determine whether there is clear and unmistakable evidence that the Veteran's pulmonary sarcoidosis existed prior to service, and if it is determined that his pulmonary sarcoidosis existed prior to service, the examiner was asked to determine whether there is clear and unmistakable evidence that the preexisting disorder was not aggravated beyond the natural progression of the disorder. The examiner stated: "The STRs have been silent for any condition of pulmonary condition including sarcoidosis during this period and prior to service. Thus, the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness." The Board finds the above VA medical opinions to be insufficient for rating purposes because the examiner's rationale was conclusory, did not provide a well-reasoned medical explanation, and was based on the absence of documentation. While the examiner addressed the Veteran's bat cave contention in her February 2023 addendum opinion, her rationale was internally inconsistent. The examiner first stated that the cave could be a cause of pulmonary sarcoidosis but then stated that after reviewing the record, the exposure happened decades before diagnosis, so it is reasonable to keep the negative opinion. It is unclear, however, what significance temporal proximity between exposure and diagnosis has in determining service connection in this diagnosis. In its prior decision, the Board found that the Veteran's induction examination did not clearly and unmistakably show that the Veteran's pulmonary sarcoidosis preexisted the Veteran's service. Although she stated that the Veteran's STRs were silent for a pulmonary condition, including during service and prior to service, the examiner concluded that the Veteran's pulmonary sarcoidosis clearly and unmistakably existed prior to service. The Board finds this premise and conclusion contradictory. Moreover, the Board emphasizes that an opinion based on the absence of documentation in the record is inadequate if it fails to take into account the Veteran's reports of symptoms and history. Dalton v. Peake, 21 Vet. App. 23 (2007). Accordingly, the Board finds another remand is regrettably necessary to obtain a VA medical opinion consistent with the directives herein. Finally, the Board acknowledges the Veteran's representative's objection to the VA examiner being a family medicine doctor who has not been shown to have any particular expertise, experience, training, or competence in commenting on pulmonary disorders. See February 2024 Brief. However, the fact that the examiner specialized in family medicine, rather than pulmonology, does not render her unqualified or render the opinion inadequate. See, e.g., Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (finding that VA satisfied its duty to assist when it provided a medical examination performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions able to provide competent medical evidence, whether that is a doctor, nurse practitioner or physician's assistant). As such, in the absence of any specific objection to the competence of the VA examiner's qualifications (other than that the physician did not specialize pulmonology), the Board finds no reason to remand on the basis that the prior VA examiner was unqualified to provide a medical opinion in this case. See id. at 569; Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019). Subsequently, the Board elucidates that the present decision remands the claim for another medical opinion based on the prior opinion's inadequacy rather than any VA examiner's alleged lack of qualification. The matter is REMANDED for the following action: Obtain a VA examination from an appropriate examiner to determine the nature and etiology of the Veteran's pulmonary sarcoidosis. All indicated tests and studies should be undertaken. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner as part of the examination. a) To the extent that the medical evidence suggests the Veteran's currently diagnosed pulmonary sarcoidosis existed prior to service, the examiner must determine whether there is clear and unmistakable (obvious, manifest, or undebatable) evidence that the Veteran's pulmonary sarcoidosis preexisted his active duty service. b) If it is determined that the Veteran's pulmonary sarcoidosis existed prior to service, the examiner must determine whether there is clear and unmistakable (obvious, manifest, and undebatable) evidence that the preexisting disorder was not aggravated beyond the natural progression of the disorder. The term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. c) If the Veteran's pulmonary sarcoidosis did not clearly and unmistakably preexist service, the examiner should provide an opinion as to whether it is at least as likely as not that the pulmonary sarcoidosis had its onset during, or is otherwise related to, his active duty service. In rendering the above opinions, the examiner should consider and discuss the Veteran's contention that his pulmonary sarcoidosis is due to clearing out a cave in Panama without using a respirator. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Coburn 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.