Citation Nr: 0007562 Decision Date: 03/21/00 Archive Date: 03/28/00 DOCKET NO. 98-12 478 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an increased evaluation in excess of 30 percent for status post right upper lobectomy for adenocarcinoma of the lung. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD Amanda Blackmon, Counsel INTRODUCTION The appellant served on active duty from April 1953 until his retirement from service in April 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 1998 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to an increased evaluation in excess of 30 percent for right upper lobectomy for adenocarcinoma of the lung. The appellant filed a notice of disagreement with this rating determination in June 1998. A statement of the case was forwarded to the appellant in July 1998. The appellant filed a substantive appeal in this matter later that month in July 1998. The record reflects that the appellant requested a hearing in connection with this claim. However, in September 1998, he withdrew his hearing request. Moreover, to the extent the appellant has initiated a "new claim" for an increased evaluation in excess of 40 percent for post operative degenerative disc and degenerative joint disease of the lumbosacral spine, as indicated by the VA examination report dated June 1999, see 38 C.F.R. § 3.158(b)(1) (1999), this matter is referred to the RO for appropriate action. See also Drosky v. Brown, 10 Vet. App. 251, 254 (1997). FINDINGS OF FACT 1. All available, relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the RO. 2. The appellant's status post right upper lobectomy for adenocarcinoma of the lung is currently manifested by diffusion capacity of the lungs evaluated on forced expiratory volume in one second (FEV-1) of 94 percent, forced expiratory volume in one second as percent of forced vital capacity (FEV-1/FVC) of 112 percent, and diffusion capacity of the lung for carbon monoxide by the single breath method (DsB) of 54 percent, as well as subjective complaints of dyspnea on exertion. CONCLUSION OF LAW The criteria for an evaluation in excess of 30 percent for status post right upper lobectomy for adenocarcinoma of the lung, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.2, 4.3, 4.7, 4.10, 4.96, 4.97, Diagnostic Codes 6819, 6844 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the appellant's claim for an increased evaluation for his right upper lobectomy, adenocarcinoma of the lung, is well-grounded pursuant to 38 U.S.C.A. § 5107(a), in that the claim is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78 (1990). This finding is predicated upon the evidentiary assertions by the appellant, and medical evidence of record documenting medical treatment. See Drosky v. Brown, supra (citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992)). The Board is satisfied that all procurable data have been assembled for appellate review, and that no further assistance to the appellant is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). Factual Background Entitlement to service connection for status post right upper lobectomy for adenocarcinoma of the lung was granted in a September 1995 rating decision, and a 30 percent evaluation was assigned (effective from June 1994). The evidence reviewed in conjunction with this rating determination included service medical records, VA medical examination, and outpatient treatment reports. The RO, in a subsequent rating decision dated in April 1996, confirmed and continued the currently assigned 30 percent evaluation pursuant to 38 C.F.R. § 4.97, Diagnostic Codes 6816 and 6819 (1996). The appellant filed a new claim for an increased evaluation for the status post right upper lobectomy for adenocarcinoma of the lung in December 1997. See Drosky, supra. In support of that claim, the appellant submitted private hospital and medical reports, dated between October 1992 and November 1997, which were received by the RO in January 1998. See 38 C.F.R. § 3.157(b)(2)-(3) (1999). These medical data reflect that the appellant was evaluated with adenocarcinoma of the lung, upper right lobe in October 1992. At that time, he underwent right upper lobe anterior segmental resection. The medical report noted that the appellant was asymptomatic. At the time of this procedure, it was noted that computerized tomography (CT) scan of the abdomen showed an isolated lesion without any evidence of metastasis to the liver or mediastinum. A pathology report disclosed adenocarcinoma, moderately differentiated, involving the anterior segment of the upper lobe of the right lung with no extension to surgical margins or evidence of lymphatic or venous invasion. The medical report further noted that pathological studies revealed peribronchial lymph nodes, without evidence of metastatic carcinoma. Subpleural emphysema (focal), and emphysematous blebs were also detected. The medical report indicated that while the histologic pattern on the material biopsied was suggestive of lung primary, the better-fixed material from the excised nodule was somewhat less suggestive of lung primary. Further diagnostic evaluation was recommended for work up for pancreatic or colon primary. The medical report indicated that the appellant did well postoperatively. Clinical reports reflect that the appellant reported intermittent complaints of breathing difficulties, with occasional complaints of cough and dyspnea. When evaluated in December 1992, the appellant was noted to be doing well following the resection. Clinical reports disclose subsequent treatment for complaints of dyspnea on exertion, among other symptoms, which was opined to be related to a combination of the appellant's emphysema and ischemic heart disease. It was noted that the appellant's history was significant for cigarette smoking, and that he had a familial history of emphysema. A January 1993 ultrasound of the abdomen was normal. X-ray studies of the chest, also conducted in January 1993, revealed essentially complete resolution of the post surgical changes in the right hemithorax from resection of carcinoma in October 1992. There was no acute process detected on evaluation. A March 1993 radiology report indicated that studies of the chest for post surgical changes revealed no change in the linear strands of the right midlung field. There was no evidence of active pulmonary disease. On physical examination in April 1993, the appellant was assessed with prolonged expiratory phase due to emphysema. It was noted that the lungs were clear. In his assessment, the examiner indicated that the appellant's condition was stable. When seen in June 1993, the lungs were noted to be quite clear on physical examination. There were a few expiratory wheezes detected at the bases. However, it was noted that air was moving "ok." X-ray studies of the chest, conducted in November 1993, showed no interval changes when compared to earlier (March 1993) studies. Radiographic evaluation of the chest, conducted later that month, in November 1993, revealed no change when compared to earlier studies. The examiner indicated that the chest was stable. There were no changes suggestive of acute trauma observed in conjunction with these studies. On physical evaluation, the lungs showed mild pleuritic rub on deep inspiration in the mid axillary line lower lung zone on the left side, but were otherwise quite clear. The appellant was hospitalization for surgical treatment of a hernia in December 1993. The medical report disclosed that the appellant underwent bronchoscopy during this hospitalization to evaluate his complaints of dyspnea. It was noted that the anterior segmental bronchus to the right upper lobe, showed no evidence of tumor. A January 1995 radiology report indicated that studies of the chest revealed it to be stable, with no significant change observed since November 1993. There was no active disease process detected. A March 1995 clinical report indicated that there was no evidence of recurrence of the appellant's lung cancer. It was noted that the appellant experienced no chest pain, pleurisy, or increasing shortness of breath. Physical examination showed the lungs to be clear to auscultation and percussion. There was no wheezing, rhonchi, or rales detected. On VA examination in June 1995, the appellant was evaluated with adenocarcinoma of the right upper lung. It was noted that the appellant reported symptoms of dyspnea on exertion following the 1992 procedure. In this context, he noted that he required rest after climbing two to three flights of stairs. He also reported occasional right chest pain, but denied phlegm production. The lungs were clear to auscultation and percussion on physical examination. Pulmonary function studies revealed spirometry improved post bronchodilator. Based upon this evidence, service connection for adenocarcinoma of the right upper lobe, status post lobectomy was granted in September 1995. A 30 percent rating evaluation was assigned for this disability under Diagnostic Code 6816-6819. It was noted that there was no evidence of recurrence or metastasis, or other pulmonary impairment shown on examination at that time. A February 1996 radiology report indicated that studies of the chest revealed interval infiltrate and linear densities in the right upper lobe, noted to have been occurring since March 1992. The examiner recommended comparison with more recent studies to verify stability of changes observed in the right upper lobe. It was noted that the remainder of the evaluation remained unchanged, with status post coronary bypass surgery and pleural-diaphragmatic left adhesion. An April 1996 VA medical examination report referenced a diagnostic assessment of status post adenocarcinoma of the right lung and status post right upper lobectomy in 1992. The examiner indicated that there was no history of recurrence since that time. The medical report indicated that the appellant did not undergo radiation treatment or chemotherapy. The appellant noted a history of cigarette smoking of 1 to 11/2 packs of cigarettes daily for a period of 30 years. The appellant denied any chronic cough or hemoptysis. The appellant reported his weight to be stable. It was noted that his medical history was not significant for tuberculosis or fungal pneumonitis. There was no history of pneumoconiosis. The appellant did report a history of exertional dyspnea since 1992, particularly with walking up inclines. The examiner indicated that there was no history of orthopnea or paroxysmal nocturnal dyspnea (PND), or chest wall pain. It was noted that a recent x-ray study of the chest, performed three months earlier, was negative. On physical evaluation, auscultation revealed good air entry. There were no rales or rhonchi detected on physical examination. A May 1996 CT scan revealed faint infiltrate seen in the right mid lung in the region of the minor fissure. There was no evidence of hilar or mediastinal adenopathy. Small nonspecific precarinal nodes were detected. It was noted that the appellant was status post cardiac surgery. A June 1996 clinical report indicated that the appellant's medical history was significant for mild emphysema. The appellant reported a couple episodes of wheezing. It was noted that obstructive lung disease was opined to be a component of his emphysema. Evaluation of the lungs showed crackles at the bases. The examiner indicated that the appellant presented with progressive shortness of breath on exertion. The examiner noted a differential diagnoses of obstructive lung disease, reactive airways disease, and infiltrative lung disease. The appellant was referred for further diagnostic evaluation. When seen in July 1996, the appellant noted continued complaints of shortness of breath at rest and upon exertion. He reported that he was able to walk 150 yards, and then experienced sensation that his legs burned. The examiner noted that pulmonary function test (PFT) results were good. It was noted that x-ray studies of the chest revealed infiltrate type process in the right upper lung zone. These results were noted to be consistent with clinical findings noted in May 1996. The examiner opined that this circumstance represented either metastases tumor from his previous adenocarcinoma or residual scar. It was noted that PFTs did not show any significant amount of obstructive lung disease. The examiner indicated that malignant dysrhythmias would be considered in the context of the differential diagnosis with respect to his subjective complaints of shortness of breath on exertion. An April 1997 clinical report indicated that the lungs were clear to auscultation and percussion on examination. There was no evidence of rubs, rhonchi, or rales. The report indicated that the appellant presented with complaints of chest pain in the right chest. The assessment was "costochondritis severe, but greatly improved, pleurisy without effusion, improved." A radiology report indicated that x-ray studies of the chest revealed pulmonary and pleural inflammatory residuals. These studies also showed previous thoracotomy. The examiner noted that a comparison of these studies with earlier (July 1996) studies revealed no interval change. The examiner noted that x-ray studies also showed no evidence of recurrence of tumor, with only chronic scars from the previous lobectomy. It was noted that there was no pleural effusion or infiltrate detected. An October 1997 radiology report indicated that studies of the chest revealed right upper lobe infiltrate, which the examiner noted might represent postsurgical scarring, although an infiltrate was not entirely excluded. When compared with earlier (August 1992) studies, it was noted that a pulmonary nodule which was previously identified in the right mid lung was no longer visualized on recent radiographs. Studies were noted to be suggestive of postsurgical scarring rather than an active infiltrate. A November 1997 clinical notation indicated that the appellant presented with complaints of continued shortness of breath, although reported to be less severe. It was noted that the appellant's medical history was significant for upper lobe resection, and that x-ray studies of the chest revealed some scarring in the right upper lung zone, with some question of pneumonia. On physical examination, the lungs were fairly clear and clean in the right upper lung zone anteriorly and posteriorly. In his assessment, the examiner opined whether the appellant experienced a recurrence of lung cancer, or whether another type of viral condition had developed. A February 1998 VA medical examination report indicated that the appellant was status post right upper lobectomy for adenocarcinoma of the lung. It was noted that the appellant reported no radiation or chemotherapy following the 1992 surgery. He reported subjective complaints of dyspnea after walking two to three level blocks, or one flight of stairs. The appellant was noted not to have a productive cough, or use medications. On physical examination, the appellant was evaluated with a well-healed nontender right thoracotomy scar. The examiner noted that there was chest expansion and diaphragm excursion with good air exchange without wheezes, rales, or rhonchi. Spirometry was conducted in conjunction with this examination. The report indicated that the results were within normal limits. Pulmonary function studies showed forced expiratory volume in one second (FEV-1) of 94 percent, forced expiratory volume in one second as percent of forced vital capacity (FEV-1/FVC) of 112 percent, and diffusion capacity of the lung for carbon monoxide by the single breath method (DsB) of 54 percent. X-ray studies of the chest revealed status post right upper lobectomy, and coronary artery bypass graft and tinting of the left hemidiaphragm secondary to pleural disease. The diagnostic impression was status post upper lobectomy for adenocarcinoma. In correspondence, dated in June 1998, the appellant indicated he continues to experience severe dyspnea upon even mild exertion. He attributed the normal results on recent PFT studies, conducted during (February 1998) VA examination, with his being able to sit "completely still while [he] waited to be called in for the examination," and being in a seated position without moving during the course of the examination. In this context, he noted that having to perform activities that require any level of exertion, will result in his being scarcely able to catch his breath. In correspondence, dated in July 1998, the appellant indicated that his service-connected lung disorder is more appropriately rated under Diagnostic Code 6844, based upon post surgical residuals, and under Diagnostic Code 6816, based upon the unilateral lobectomy. He maintained that separate rating evaluations are warranted under these diagnostic codes. In addition, the appellant maintained that his symptoms of dyspnea should be considered only with respect to his lung condition, rather than in conjunction with his leukemia and coronary artery disease. The remainder of these clinical records document treatment for various disorders to include probable myelodysplastic syndrome of the chronic myelomonocytic leukemia subtype, mitral valve prolapse and coronary artery disease, colitis, peripheral vascular disease, marked by subjective complaints of fatigue and shortness of breath on exertion. Analysis Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Although the regulations do not give past medical reports precedence over current findings, it is the present level of disability that is of primary concern where entitlement to compensation has already been established; and, as such, the Board is required to consider the applicability of a higher rating for the entire period in which the appeal has been pending. See Powell v. West, 13 Vet. App. 31, 34-34 (explaining the Court's decision in Francisco v. Brown, 7 Vet. App. 55 (1994)). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (1999). Therefore, the Board will consider the potential application of the various other provisions of the regulations governing VA benefits, whether or not they were raised by the appellant, as well as the history of the appellant's disability in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49 (1990), the United States Court of Appeals of Veterans for Claims ("the Court") stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." Id. at 53. To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). The appellant's status post right upper lobectomy for adenocarcinoma of the lung is currently evaluated as 30 percent disabling under Diagnostic Codes 6819-6816. 38 C.F.R. 4.97 (1996 & 1999). Effective October 7, 1996, the schedular criteria by which respiratory system disorders are rated changed. See 46 Fed. Reg. 46728 (1996). The amendment, among other changes, deleted Diagnostic Code 6814 (pneumothorax) and Diagnostic Code 6816 (lobectomy), and added Diagnostic Code 6844 (post-surgical residuals). 38 C.F.R. § 4.97 (1999). Regarding the question of whether the former or newly revised schedular criteria for evaluating respiratory system disorders apply to the appellant's case, the Board notes that where a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant applies, unless Congress provided otherwise or permitted the Secretary to do otherwise and the Secretary does so. See Marcoux v. Brown, 9 Vet. App. 289 (1996); Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991); see also VAOPGPREC 11-97 (VA O.G.C. Prec 11-97). However, the appellant filed his new claim for increase in December 1997, which is well after the October 7, 1996 effective date. Therefore, the claim at issue was not pending at the time of the regulation change, and, hence, only the newly revised schedular criteria for evaluating respiratory system disorders are for application in this appeal. Under 38 C.F.R. § 4.96 (1999), ratings for coexisting respiratory conditions under diagnostic codes 6600 through 6817, and 6822 through 6847 may not be combined. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 may not be combined with each other, or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating is to be assigned under the diagnostic code that reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Id. (the regulatory changes, which became effective October 7, 1996, did not change the rule against combined ratings). Therefore, while the appellant has asserted that the assignment of a separate rating is warranted under Diagnostic Codes 6819 and 6844 for his status post right upper lobectomy for lung cancer, a separate evaluation in this instance is not permitted under § 4.96. Under applicable criteria, a 100 percent is warranted under Diagnostic Code 6819 for neoplasms, malignant new growths of any specified part of the respiratory system exclusive of skin growths. Note: A rating of 100 percent shall continue beyond the cessation of any surgical, x-ray, antineoplastic chemotherapy, or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. In the absence of local recurrences or metastases, the rating will be made based upon residuals. 38 C.F.R. § 4.97 (1999). Post surgical residuals of lobectomy are rated under the General Rating Formula for Restrictive Lung Disease. 38 C.F.R. §§ 4.96, 4.97, Diagnostic Codes 6844 (lobectomy, pneumonectomy, etc.) (1999). Under these regulatory criteria, a 30 percent evaluation is warranted when pulmonary function tests show a forced expiratory volume in one second (FEV-1) of 56- to 70-percent of predicted; or show the ratio of forced expiratory volume in one second to forced vital capacity (FEV-1/FVC) of 56- to 70-percent of predicted; or show a diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO (SB)) of 56- to 65-percent of predicted. Id. A 60 percent evaluation is warranted when pulmonary function tests show a FEV-1 of 40- to 55-percent of predicted; or show a FEV-1/FVC of 40- to 55-percent of predicted; or show a DLCO (SB) of 40- to 55-percent of predicted; or when there is maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). Id. A 100 percent evaluation is warranted when pulmonary function tests show a FEV-1 of less than 40 percent of predicted; or a FEV-1/FVC of less than 40 percent of predicted; or show a DLCO (SB) of less than 40 percent of predicted; or when there is maximum exercise capacity of less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or when there is cor pulmonale (right heart failure); or when there is right ventricular hypertrophy; or when there is pulmonary hypertension (shown by Echo or cardiac catheterization); or when there is an episode or episodes of acute respiratory failure; or when outpatient oxygen therapy is required. Otherwise, the primary disorder is rated. Id. In this case, the appellant underwent right upper lobectomy in 1992 for excision of a nodule in the right upper lung. Pathology of the excised material confirmed adenocarcinoma. The appellant was not treated with a chemotherapy or radiation treatment following the 1992 surgery. The appellant was noted to do well postoperatively, but has reported continued complaints of dyspnea on exertion. The medical evidence reflects that the appellant's history is also significant for cardiac disability requiring surgical treatment, leukemia, and emphysema which are manifested by complaints of fatigue and dyspnea as well. There is no evidence of metastases or recurrence of the appellant's lung cancer. The Board is of the opinion that the preponderance of the pertinent evidence in evaluating the severity of the appellant's service-connected respiratory disability is against finding that the criteria for an evaluation in excess of 30 percent are met under the current provisions of Diagnostic Code 6844. In this regard, clinical evidence shows that the appellant's lungs have been evaluated as stable on physical examination. Diagnostic evaluation has shown good results on PFT, with no significant obstructive lung disease shown. Clinically, the lungs are evaluated as clear to auscultation and percussion, without wheezes, rales, or rhonchi. Radiographs of the chest conducted in 1993 showed resolution of post surgical changes, and have subsequently been noted to remain unchanged with no evidence of interval change since the right upper lobectomy. The clinical reports document that the appellant's continued subjective complaints of dyspnea have been variously considered in the context of differential diagnoses made relative to his cardiac disorder, as well as among symptomatology evaluated relative to his leukemia condition. Moreover, diagnostic evaluation has been negative for any evidence of recurrence or metastases of the appellant's lung cancer. On the most recent VA examination in 1998, pulmonary function tests showed that FEV- 1 was 94 percent or more of its predicted value and the FEV- 1/FVC ratio was 112 percent, and DsB was evaluated as 54 percent. Further, there is no probative evidence such as objective medical evidence, that DLCO is less than 56-percent predicted; that the appellant's maximum oxygen consumption is 15 to 20 ml/kg/min (with cardiorespiratory limit); that his maximum exercise capacity is less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); that there is cor pulmonale (right heart failure), right ventricular hypertrophy or pulmonary hypertension (shown by Echo or cardiac catheterization), an episode(s) of acute respiratory failure; or that he requires outpatient oxygen therapy. Thus, the Board finds that the criteria for an evaluation in excess of 30 percent under the criteria of Diagnostic Code 6844 based upon post surgical residuals of the right upper lobectomy are not met in this instance. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.97. The Board further notes that VA examination revealed a surgical scar secondary to the appellant's right upper lobectomy. The Board has considered whether a separate rating is warranted for residuals of the surgical scar. In this regard, the Board notes that applicable regulations permit consideration of the assignment of a separate rating evaluation for any distinct and separate symptomatology present. See Esteban v. Brown, 6 Vet. App. 259 (1994). In this case, however, the appellant's thoracotomy scar has been clinically evaluated as well-healed, with no tenderness noted. Thus, the evidence does not show that the scar is disfiguring, poorly nourished with repeated ulceration, painful on objective demonstration, or that it causes any functional limitation. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (1999). The Board finds, therefore, that the criteria for an additional rating for the scar are not met. Finally, the Board notes that pursuant to 38 C.F.R. § 3.321(b)(1), an extra-schedular rating is in order where there exists such an exceptional or unusual disability picture as to render impracticable the application of the regular schedular standards. However, the record does not reflect periods of hospitalization because of the appellant's service-connected lung cancer, and there is no showing that this service-connected disability has significantly interfered with the appellant's employment status. Thus, the record does not present an exceptional case where his currently assigned rating evaluation is found to be inadequate. See Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (noting the disability evaluation itself is recognition that industrial capabilities are impaired). Accordingly, the Board finds that the criteria for submission for an extra- schedular rating under 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board has considered in the appellant's assertions in this case, particularly with respect to the severity of his symptomatology. In this regard, the Board notes that where the issue is factual in nature, that is, whether an incident occurred during service or whether a clinical symptom is present, the appellant is competent to made assertions in that respect. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). However, where the determinative issue involves a question of medical causation or a medical diagnosis, the appellant is not qualified to make assertions in this regard as he lacks the necessary medical expertise or experience. King v. Brown, 5 Vet. App. 19, 21 (1991); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In this case, the appellant has reported increased symptomatology associated with his service-connected lung cancer. Objective medical evidence, however, has not been found to support the assignment of a higher rating evaluation in this instance. For the reasons discussed, the Board finds that the preponderance of the evidence is against the appellant's claim for entitlement to an increased evaluation for adenocarcinoma of the lung, status post right upper lobectomy. The evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 5107(b). ORDER An increased evaluation for status post right upper lobectomy for adenocarcinoma of the lung is denied. Deborah W. Singleton Member, Board of Veterans' Appeals