Citation Nr: 0007413 Decision Date: 03/20/00 Archive Date: 03/23/00 DOCKET NO. 97-10 195A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for a pulmonary disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. M. Fogarty, Associate Counsel INTRODUCTION The veteran served on active duty from July 1974 to July 1977. This matter is before the Board of Veterans' Appeals (Board) on appeal of a March 1996 rating decision from the Department of Veterans Affairs (VA) Houston, Texas Regional Office (RO), which denied entitlement to service connection for sarcoidosis. At his February 2000 hearing before a member of the Board, the veteran stated that he wished to withdraw the issues of entitlement to increased evaluations for bilateral tinea pedis and for plantar callosities from appellate consideration. Thus, those issues are no longer before the Board. Following the same hearing, the veteran submitted additional evidence consisting of articles regarding diagnoses of sarcoidosis among military personnel. The veteran also submitted a statement waiving RO consideration of this additional evidence. Accordingly, the evidence has been considered by the Board in this decision. FINDINGS OF FACT 1. Competent medical evidence of sarcoidosis manifested to a compensable degree within one year of the veteran's discharge from service has not been presented. 2. Competent medical evidence of a nexus between sarcoidosis and any other pulmonary disorder and an incident of service has not been presented. CONCLUSION OF LAW The claim of entitlement to service connection for a pulmonary disorder, including sarcoidosis, is not well grounded. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 4.97, Diagnostic Code 6600 (1995); 38 C.F.R. §§ 3.303, 3.309, 4.97, Diagnostic Codes 6600, 6846 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background Service medical records reflect that upon enlistment examination dated in July 1974, the veteran's systems were clinically evaluated as normal. The veteran reported no complaints or defects in a July 1974 report of medical history. A June 1977 separation examination reflects the veteran's systems were clinically evaluated as normal with the exception of plantar calluses. In a June 1977 report of medical history, the veteran reported experiencing occasional pericardial pains. An October 1977 VA record reflects that the veteran sought VA hospital treatment at that time for chest pains as well as foot and throat problems. A VA examination report dated in March 1978 is silent for complaints or diagnoses related to chest pains or a pulmonary condition. A chest x-ray was noted as normal. Physical examination of the chest revealed symmetrical bilateral expansion and breath sounds were noted as bronchovesicular without rales or wheezes. A VA examination report dated in December 1978 is silent for complaints or diagnoses related to chest pains or a pulmonary condition. A VA clinical record dated in August 1979 reflects complaints of dizziness and occasional chest pains. A chest x-ray was noted as normal with no evidence of cardiomegaly, infiltrates, or pleural effusion. An additional August 1979 record reflects complaints of dizzy spells when standing or straightening up. A diagnosis of hypotension was noted. A VA examination report dated in December 1980 is silent for complaints or diagnoses related to chest pains or a pulmonary condition. VA outpatient treatment records dated from 1981 to 1982 reflect a normal chest x-ray in April 1981. The veteran complained of chest pain, a dry cough, dizziness, and a headache. A relevant diagnosis of an upper respiratory infection was noted. A December 1981 clinical record reflects complaints of painful breathing. A December 1981 chest x-ray was noted as normal. A VA examination report dated in November 1983 is silent for complaints or diagnoses related to chest pains or a pulmonary condition. A March 1985 statement from a private physician reflects that the veteran was hospitalized in March 1985 for treatment of a progressive pulmonary condition that probably began several months prior to his evaluation. The physician opined that although he had not seen the veteran prior to March 1985, it was conceivable that he may have been quite symptomatic and partly incapacitated from this disorder for months prior to his evaluation. A VA chest x-ray dated in March 1985 reflects a diagnosis of diffuse bilateral parenchymal abnormalities of uncertain etiology and significance. It was noted that a very tiny left pleural effusion was demonstrated. A subsequent March 1985 chest x-ray revealed a diffuse reticular nodular pattern in each lung of uncertain etiology and significance. A December 1985 clinical record reflects complaints of chest pain for four to five days with numbness in the left arm. A diagnosis of atypical chest pain, probably musculoskeletal, was noted. It was also noted that a chest x-ray revealed diffuse fine nodular infiltrates prominent in both lower lung fields. A private radiologic report dated in October 1988 reflects an impression of an abnormal chest exhibiting an increased reticular pattern in both lower lung fields as well as the right upper lobe that could be due to either sarcoidosis or occupational disease. It was also noted that idiopathic pulmonary fibrosis was not completely ruled out. A private radiological impression of a reticular infiltrate in both lower lung fields with some honeycomb pattern compatible with a history of sarcoidosis was noted in May 1989. That impression was essentially confirmed in a September 1989 private radiologic report. October 1991 private radiology reports reflect a conclusion of extensive chronic interstitial changes consistent with sarcoid and no evidence of a superimposed infection. It was also noted that the reticular infiltrate was minimally more pronounced than in September 1989. Clinical records dated from 1988 to 1991 reflect complaints of chest pain, shortness of breath, and wheezing. An impression of stable sarcoid was noted in October 1989. Relevant VA treatment records dated from 1994 to 1996 reflect complaints of shortness of breath and chest pains. A June 1995 chest x-ray reflects diffuse interstitial infiltrate findings noted as consistent with pulmonary edema versus inflammation. A diagnosis of sarcoidosis was noted in February 1996. A statement from a private physician dated in June 1996 reflects that the veteran suffered from an advanced stage of an interstitial lung disease process, possible sarcoidosis, which currently required high doses of corticosteroids to control the activity of the pulmonary process. It was also noted that the veteran had been under his care since November 1995. The physician opined that upon review of the veteran's medical records dating as far back as 1985, he was able to establish that the veteran's medical illness apparently started in early 1978 given the chest radiographic abnormalities noticed at that time. The physician further opined that the veteran suffered from a disabling illness which would likely progress despite therapy, although no definite prognosis could be drawn at that time. At his October 1996 RO hearing, the veteran testified that he experienced trouble breathing and chest pains in service but thought he was just overexerting himself or run down. The veteran also testified that after his discharge from service, his chest pains became worse and he sought treatment at a VA facility. The VA facility told him he had a spot on his lungs but it was nothing to worry about. (Transcript, page 2). The veteran reported he was diagnosed with sarcoidosis in 1985 after he sought treatment for his chest pains from another doctor. (Transcript, page 3). The veteran submitted a statement from his physician in support of his claim. (Transcript, page 3). A private medical statement signed by two physicians and dated in August 1997 reflects that the veteran was seen in May 1997 for a second opinion regarding his pulmonary condition. The physicians opined that upon reviewing records from the VA hospital dated in 1979 and from a private hospital dated in 1985, it appeared that the veteran's medical problems started to manifest in 1978 or 1979 when he presented at the VA hospital with a chest x-ray that may have been abnormal. The veteran's current condition was noted as stable. At his February 2000 hearing before a member of the Board, the veteran testified that he was first diagnosed with sarcoidosis in 1985. The veteran reported that during his military career, he was in the field artillery division and part of his duties included removing paint from the vehicles with a sander. (Transcript, pages 3-4). The veteran stated that he began to experience chest pains or some kind of pulmonary dysfunction in October 1977. (Transcript, page 5). The veteran also stated his contentions that the 1978 and 1979 VA chest x-rays were misread by the VA and had he been referred to a pulmonary specialist at that time, his disability would have been diagnosed earlier. (Transcript, pages 8-11). At his hearing before a member of the Board, the veteran submitted articles regarding a trend of sarcoidosis diagnoses among U.S. military personnel and discussed an association with environmental factors and military personnel who served as "deck grinders." Pertinent Law and Regulations Basic entitlement to disability compensation may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Service connection connotes many factors but basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a) (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic disabilities, such as sarcoidosis, will be presumed to be related to service if manifested to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. § 3.309 (1999). The threshold question that must be resolved with regard to each claim is whether the veteran has presented evidence of a well-grounded claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). A well-grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. See Murphy, 1 Vet. App. at 81. An allegation of a disorder that is service-connected is not sufficient; the veteran must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability; lay or medical evidence of incurrence or aggravation of a disease or injury in service; and competent medical evidence of a nexus between the in-service injury or disease and the current disability. Caluza v. Brown, 7 Vet. App. 498 (1995). Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Lay assertions of medical causation cannot constitute evidence sufficient to render a claim well grounded under 38 U.S.C.A. § 5107(a); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). When all evidence is assembled, the Secretary is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The veteran contends that his sarcoidosis developed within one year of his discharge from service and he is therefore entitled to service connection for that disability. Clinical and radiological records dated in May 1989, September 1989, October 1989, and October 1991 reflect various impressions of interstitial changes consistent with sarcoidosis and stable sarcoid. Sarcoidosis is a disease for which presumptive service connection may be granted. The regulations provide that a chronic disability such as sarcoidosis will be presumed to be related to service if manifested to a compensable degree within one year of discharge from service. See 38 C.F.R. § 3.309. As the record reflects diagnoses of sarcoidosis, the Board must consider whether the veteran's sarcoidosis was manifested to a compensable degree during the one-year period after his discharge from service. The regulations provide that sarcoidosis is rated pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6846 (1999), which provides for a noncompensable rating for sarcoidosis manifested by chronic hilar adenopathy or stable lung infiltrates without symptoms or physiologic impairment. A 30 percent rating is warranted for sarcoidosis manifested by pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. Additional ratings are warranted for more severe symptomatology. The regulation also provides that sarcoidosis or the residuals thereof may be rated as chronic bronchitis and extrapulmonary involvement under the specific body system involved. See 38 C.F.R. § 4.97, Diagnostic Code 6846. The rating criteria for chronic bronchitis, 38 C.F.R. § 4.97, Diagnostic Code 6600 (1999), provides that a 10 percent evaluation is warranted for chronic bronchitis manifested by FEV-1 (forced expiratory volume in one second) of 71 to 80 percent predicted, or FEV-1/FVC (forced vital capacity) of 71 to 80 percent, or DLCO (SB) (diffusion capacity of carbon monoxide in a single breath) 66 to 80 percent predicted. A 30 percent disability evaluation is warranted for FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent, or DLCO (SB) 56 to 65 percent predicted. Additional ratings are warranted for more severe symptomatology. See 38 C.F.R. § 4.97, Diagnostic Code 6600. The Board recognizes that the Court has held that where the law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted the VA Secretary to do otherwise and the Secretary did so. Karnas v. Derwinski, 1 Vet. App. 308 (1991). The regulations regarding the evaluation of chronic bronchitis were revised effective October 7, 1996. As the veteran's claim was filed prior to 1996, the Board must consider the evaluation criteria for bronchitis in effect at the time the veteran's claim was filed. The criteria for the evaluation of bronchitis in effect prior to October 7, 1996 provide that a noncompensable evaluation is warranted for mild chronic bronchitis manifested by slight cough, no dyspnea, and few rales. A ten percent evaluation is warranted for moderate chronic bronchitis manifested by considerable night or morning cough with slight dyspnea on exercise and scattered bilateral rales. Additional ratings are warranted for chronic bronchitis manifested by more severe symptomatology. See 38 C.F.R. § 4.97, Diagnostic Code 6600 (1995). The veteran was discharged from the service in July 1977. The record is silent for any competent medical evidence showing that the veteran's sarcoidosis was manifested to a compensable degree under the rating criteria for sarcoidosis or bronchitis, old or new, within one year of his discharge from service. Although the record reflects private medical opinions to the effect that the veteran's medical problems apparently began in 1978 or 1979, the statements do not report any symptomatology manifested at that time other than possible chest radiographic abnormalities. Other medical evidence of record dated within one year of the veteran's discharge reflects normal chest x-rays and a complaint of chest pain in October 1977. This symptomatology does not meet the aforementioned requirements for a compensable evaluation under the criteria for sarcoidosis or chronic bronchitis. Thus, in the absence of competent medical evidence reflecting that the veteran's sarcoidosis was manifested to a compensable degree within one year of July 1977, entitlement to presumptive service connection for sarcoidosis is not warranted. See 38 C.F.R. § 3.309. The veteran may nonetheless establish a well-grounded claim of entitlement to service connection for sarcoidosis on a direct basis if competent medical evidence meeting the criteria set forth in Caluza has been established. See Caluza, 7 Vet. App. at 506. A comprehensive review of the record reflects that the veteran's claim of entitlement to service connection for sarcoidosis is supported by statements from private physicians dated in June 1996 and August 1997. As previously noted, the June 1996 statement reflects that the physician reviewed the veteran's medical records as far back as 1985 and determined that his medical illness apparently started in early 1978 given the radiographic chest abnormalities noted at that time. The August 1997 statement reflects that VA hospital records dated in 1979 were reviewed and it appeared that the veteran's medical problems started to manifest in 1978 or 1979 when the veteran presented with a chest x-ray that may have been abnormal. (emphasis added). However, the Board notes that the statements do not state whether the actual chest x-rays were reviewed. Additionally, the June 1996 statement reflects that only records dated back to 1985 were reviewed, it is not clear whether any records dated in 1978 or 1979 were reviewed by that physician. Finally, the private medical opinions do not state that the veteran's sarcoidosis was incurred as a result of an incident of service. The record is silent for any competent medical evidence of a nexus between sarcoidosis and an incident of service. In fact, the record does not universally confirm the diagnosis of sarcoidosis. The Board is cognizant of the articles submitted regarding a trend of sarcoidosis diagnoses among military personnel and an association with environmental factors, especially those who served as "deck grinders." However, a treatise that contains generic statements regarding a "possible link" does not satisfy the nexus element of a well-grounded claim. See Sacks v. West, 11 Vet. App. 314, 316-317 (1998). Additionally, there is no evidence in the record that the veteran served in the capacity of a "deck grinder." Thus, in the absence of competent medical evidence of a nexus between sarcoidosis or any other pulmonary disorder and an incident of service, the claim is not well grounded and must be denied. ORDER Entitlement to service connection for a pulmonary disorder, including sarcoidosis, is denied. John E. Ormond, Jr. Member, Board of Veterans' Appeals