Citation Nr: 0634409 Decision Date: 11/07/06 Archive Date: 11/16/06 DOCKET NO. 00-12 954 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 (West 1991) for chronic granulomatous disease with cervical myelopathy for purposes of accrued benefits. 2. Entitlement to Dependency and Indemnity Compensation (DIC) under 38 U.S.C.A. § 1151 (West 1991) or (West 2002). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael A. Pappas, Counsel INTRODUCTION The veteran served on active duty from October 1953 to July 1957. He died in November 1999. The appellant is his surviving spouse. At the time of the veteran's death, he had pending an appeal of the denial of a claim of entitlement to disability benefits under the provisions of 38 U.S.C.A. § 1151 (West 1991) for cervical nerve damage. In February 2000, that appeal was dismissed by the Board of Veterans Appeal (Board) based upon the death of the veteran. When this matter was last before the Board in July 2003, it was remanded to the Department of Veterans Affairs (VA), Louisville, Kentucky, Regional Office (RO) for development and readjudication of the appellant's claims of entitlement to disability benefits under the provisions of 38 U.S.C.A. § 1151 for cervical nerve damage for accrued benefits purposes, and entitlement to DIC benefits under the provisions of 38 U.S.C.A. § 1151. Following the completion of the requested development, a supplemental statement of the case was issued in December 2005, and the case was returned to the Board for further appellate review. After the claims file was returned to the Board, additional pertinent medical evidence was submitted by the appellant in the form of a medical opinion in support of her claims. Normally, such evidence would have to be remanded to the RO for initial review. 38 C.F.R. § 20.1304 (2006). In this case, however, the appellant's representative waived that initial review. FINDINGS OF FACT 1. All evidence necessary for review of the issues on appeal has been obtained, and VA has satisfied the duty to notify the appellant of the law and regulations applicable to her claims and the evidence necessary to substantiate them. 2. The competent and probative evidence in this case supports the finding that chronic granulomatous disease with cervical myelopathy was aggravated as a result of treatment received by the veteran at the VA Medical Center in 1988. 3. The competent and probative evidence in this case supports the finding that chronic granulomatous disease with cervical myelopathy caused or contributed substantially or materially to cause the veteran's death. CONCLUSIONS OF LAW 1. The criteria for entitlement to compensation, for purposes of accrued benefits, for additional disability, classified as chronic granulomatous disease with cervical myelopathy, as a result of VA treatment received in a VA Medical Center in 1988, have been met. 38 U.S.C.A. § 1151 (West 1991). 2. The criteria for the award of DIC benefits pursuant to 38 U.S.C.A. § 1151 for death due to VA treatment have been met or approximated. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.310, 3.358 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is seeking entitlement to compensation under 38 U.S.C.A. § 1151 for chronic granulomatous disease with cervical myelopathy for purposes of accrued benefits, and entitlement to DIC under 38 U.S.C.A. § 1151, based upon whether she can establish the former claim, that is, whether she can establish benefits for the veteran's chronic granulomatous with cervical myelopathy. In the interest of clarity, the Board will initially address the matter of whether these issues have been appropriately developed for appellate purposes. In order to facilitate understanding of its decision, a pertinent factual background will be set forth. Finally, the Board will analyze the appellant's claims. Preliminary Matter: Duties to Notify & to Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002), and its implementing regulations, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2003), are applicable to this appeal. The VCAA and the implementing regulations provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. In the appellant's case, the RO notified her of the requirements for her to be successful in her claims, and obtained the veteran's service medical records and all private and VA treatment records that were identified by the appellant. The RO also obtained medical opinions in March 2001 for the express purpose of determining whether the evidence was supportive of the appellant's claims. In view of the fact that this decision is a complete grant of the benefits sought on appeal, further notification and development pursuant to the VCAA is not required. Factual Background The medical evidence in the claims file shows that the veteran was admitted to the Lexington, Kentucky, VA Medical Center, (VAMC) on November 4, 1987 with onset of right arm heaviness, numbness, and pain in the entire right arm in August 1987. He denied any precipitating event. The condition had progressively increased since that time. Electromyograms (EMGs)and nerve conduction studies performed prior to hospitalization had revealed findings consistent with a right C8 or T1 radiculopathy. The veteran was admitted for cervical myelogram that showed mild anterior extradural defects at all the intervertebral disc space levels from C3-4 through C6-7. These mild anterior defects appeared to be due to both a combination of bulging discs and bony hypertrophy. There was some bony compression of the anterior subarachnoid space but there was no spinal stenosis or compression of the cervical spinal cord. Hypertrophic degenerative changes were seen in the cervical spine but no other bony lesions. No surgical intervention for the degenerative spine disease was recommended at that time. The veteran was scheduled for additional EMG/nerve conduction studies that were performed on November 24, 1987, and that confirmed radicular injury. The veteran canceled a Neurosurgery Clinic appointment scheduled for February 5, 1988. When seen on June 3, 1988, he reported pain on the right side of his neck radiating into the right arm. He was readmitted to the VAMC on June 14, 1988, where CT scan of the cervical spine revealed surgical causes of the veteran's pain. Consequently, an attempt at cervical traction was made. The veteran responded with cervical traction with the pain being relieved with 8 to 10 pounds, twice a day. The veteran was discharged on June 24, 1988, to continue traction with a home traction device. The veteran was seen in the VA Neurosurgery Clinic on August 26, 1988, for follow-up. He reported improvement in symptoms with home cervical traction. Subsequent VAMC reports reflect complaints of low back pain but no specific complaints relating to the cervical spine. Of record is the report of the veteran's hospitalization at Paul B. Hall Regional Medical Center on October 2, 1991, for complaints of back and leg pain. He was shown to be status post surgery on the low back. The hospital report does not reflect complaints of or treatment for any disability relating to the cervical spine. VAMC notes dated January 7, 1992, and February 7, 1992, reflect concerns about the veteran's eligibility for treatment. He apparently was found not to be eligible for long-term epidural catheter treatment. There are no reports of VAMC treatment between February 7, 1992, and June 13, 1994. Of record is the report of a cervical spine x-ray performed at a private facility on May 27, 1994, in connection with the veteran's complaints of gradual right arm paralysis. Highlands Regional Medical Center report dated June 7, 1994, showed the veteran was seen with decreased reflexes in both upper arms and profound weakness of the proximal musculature of the right arm. The veteran was seen in the Neurosurgery Clinic of the VAMC on July 8, 1994. At that time he reported a four year history of symptoms of right arm numbness, weakness and pain, as well as neck pain. The veteran underwent MRI of the cervical spine on July 20, 1994, which revealed a posterior vertebral body soft tissue mass compressing on the cord which had diffuse spinal stenosis throughout. Cardiac catheterization revealed single vessel coronary artery disease; he was deemed fit for surgery. On September 26, 1994, he underwent anterior cervical dissection and corpectomy C3-C6 with neck spine fusion fibular strut graft and synthesis plates with spinal fixation for diagnosis of cervical myelopathy. The pathology report showed fragments of cartilage with crystalline deposits with an appearance and refraction pattern consistent with calcium pyrophosphate. Similar appearing crystals were shown to be found in chondrocalcinosis and pseudogout. When seen for follow-up on October 14, 1994, strength was improved in all extremities. The veteran continued to be followed in the VAMC system. When seen in Neurosurgery on January 10, 1996, he was shown with progressive increase in neck and shoulder pain. An MRI performed in November 1995 was shown to have been distorted secondary to Motrin and repeat was planned to evaluate strut graft/granulomatous disease. MRI performed on February 6, 1996, showed cervical spine stenosis and abnormal cord signal from the C3-C7 level. There was no evidence of recurrent tumor. When seen in the Orthopedics Clinic on March 25, 1996, the veteran reported shoulder pain which awakened him at night. He also reported incontinence. As a result, the veteran was immediately referred to Neurosurgery for progression of chronic granulomatous disease of the neck and a chronic myelopathy. On May 14, 1996, the veteran filed a claim for compensation under 38 U.S.C.A. § 1151 (West 1991) for chronic granulomatous disease with cervical myelopathy. His claim was denied by the RO in January 1997. The veteran ultimately perfected an appeal of that decision. In May 1997, D.A.B., M.D., an Associate Professor at the University of Kentucky Chandler Medical Center, and Section Head of the Division of Neurosurgery of the VAMC, submitted a statement regarding the veteran's claim. In the statement, Dr. D.A.B. provided a pertinent history of the veteran's treatment by VAMC beginning with the treatment for his complaints in 1988 for right upper extremity pain and weakness, continuing to the diagnosis of granulomatous disease of the cervical spine, and concluding with the results of her examination of the veteran as of the date of the statement. In the statement, Dr. D.A.B. concluded that the veteran was completely and irrevocably disabled from his cervical spine disease. She opined that "according to the records and history, signs [of granulomatous disease] were present in 1988 and early intervention certainly would have positively impacted on his present state [in May 1997]." The veteran was admitted to the VAMC in January 1999 with melena. In February 1999, he had a pacer placed and was noted to have decreased blood pressure. He received coronary artery stents time two. He then underwent surgical repair of the aorto-enteric fistula and axillary bifemoral bypass, after which he spent three months in the intensive care unit. The veteran was discharged from the VAMC in May 1999, but returned in July 1999 with nausea and vomiting. On September 2, 1999, the veteran was transferred from the VAMC to the University of Kentucky Hospital with diagnoses of status aspiration pneumonia, oralpharyngeal dysphagia, and feeding tube. The veteran was hospitalized at the University of Kentucky Hospital Chandler Medical Center from September 2, 1999, to November 15, 1999. In the Discharge Summary of that hospitalization, it was noted that the veteran's diagnoses during the hospitalization included aspiration pneumonia, coronary artery disease, and peripheral vascular disease. Procedures during hospitalization included tracheostomy and percutaneous endoscopy. In early November 1999, the veteran was felt to be stable for transfer to a nursing home or to home with home health care. The veteran was discharged in stable condition on November 15, 1999, to be transferred to St. Catherine Care Center. A Certificate of Death is of record that documents that the veteran died on November [redacted], 1999. The immediate cause of death listed on the Certificate is coronary artery disease. There is nothing else listed on the Certificate as a "cause leading to the immediate cause of death". In December 1999, the appellant filed the current claims for entitlement to compensation under 38 U.S.C.A. § 1151 for chronic granulomatous disease with cervical myelopathy for purposes of accrued benefits and entitlement to DIC benefits under 38 U.S.C.A. § 1151. These claims were denied in rating decisions dated in March 2000 and June 2000. The appellant has perfected appeals of these decisions. In September 2000, D.A.B., M.D., the Associate Professor and Section Head of the Division of Neurosurgery of the VAMC, submitted a second statement, this time regarding the appellant's claim. In the statement, Dr. D.A.B. recalled that the veteran first presented to the VAMC Neurosurgery Clinic in 1994 secondary to progressive cervical myelopathy. It was noted that the veteran had reported having problems dating back at least 6 years, however, extensive investigation had not been done. Dr. D.A.B. noted that a cervical MRI was performed that was significant for a mass compressing the cervical spine. She noted that surgical intervention resulted in pathologic interpretation consistent with granulomatous disease. Dr. D.A.B. stated that because of the severity of the lesion and involvement of the spinal cord, complete extirpation of the lesion could not be accomplished. It was noted that the veteran enjoyed improved neurologic status for approximately four years. Dr. D.A.B. then noted that the veteran ultimately succumbed on November [redacted], 1999, after a long hospitalization. She stated that at the time of his last hospital admission, the veteran's neurologic status had deteriorated significantly and he was showing signs during his hospitalization of central cord syndrome and brainstem dysfunction. She noted that because of the presence of the veteran's pacemaker, a MRI could not be done, but that she suspected that the veteran had recurrence of the granulomatous process with probable secondary vascular insufficiency to the spinal cord and brainstem. Dr. D.A.B. opined that this ultimately led to respiratory insufficiency and contributed to the veteran's death. She concluded by stating her belief that the veteran's neurologic status played a much larger role in hastening his death than the listed cause of death, coronary artery disease. In November 2000, D.R., M.D., of the Department of Internal Medicine at the University of Kentucky Medical Center, provided a statement in support of the appellant's claim. In the statement, Dr. D.R. indicated that the examination of the veteran during hospitalization in September 1999 indicated that the veteran had suffered a brain stem insult with a differential diagnosis that included a stroke or the progression of the granulomatous process to the cervical spinal cord. Dr. D.R. related his suspicion that, whatever the etiology, the veteran's death was related to some sort of respiratory difficulty due to this neurological insult. In December 2000, the RO requested a medical opinion from the VAMC regarding whether the veteran's granulomatous disease with cervical myelopathy was due to the failure of the VAMC to treat the veteran's condition, and whether that disability was a cause of the veteran's death. In response to that request, L.C., M.D. provided an opinion dated in March 2001 that was subsequently modified by two separate addendums. In the March 2001 opinion and subsequent addendum opinions, Dr. L.C. indicated that the veteran's claims file had been reviewed. In the second addendum opinion, Dr. L.C. opined that although it was unclear whether granulomatous disease was present in 1988, the veteran's eventual pathologic diagnosis of granulomatous disease raises a question that such disease was present in 1988. In the third and final addendum opinion, Dr. L.C. stated that although it is unclear whether the granulomatous disease was present in 1988, it is as likely as not possible it was present and as likely as not possible treatment in 1988 would have prevented eventual myelopathy. He noted that converse possibilities are also as likely as not given the uncertainties. Dr. L.C. opined further that there appeared to be no evidence to decide whether an extension of the veteran's granulomatous disease occurred near the time of the veteran's death so as to be a factor in his death. He opined, however, that it is as likely as not possible granulomatous disease spread was a factor leading to his death, for instance causing brainstem or worsened cervical cord injury. In April 2006, C.N.B., M.D., a neuro-radiologist, provided an "Independent Medical Evaluation" in support of the appellant's claim. In the opinion, Dr. C.N.B. states that it is his opinion that if the veteran had received a more accurate diagnosis and aggressive cervical decompression surgery in 1988, he would not have had his progressive permanent cervical myopathy, and he would have been healthier and more able to tolerate the medical insults of his abdominal vascular surgery in 1999 and would have likely been a better candidate for aggressive cervical decompression of his neck, and therefore, would have likely had fewer respiratory and coronary complications during his last hospitalization and would have lived longer. Accrued Benefits under 38 U.S.C.A. § 1151 Analysis At the time of the veteran's death, he had pending a claim of entitlement to compensation under 38 U.S.C.A. § 1151 (West 1991) for chronic granulomatous disease with cervical myelopathy. Although the veteran's claim terminated with his death, the regulations set forth a procedure for a qualified survivor to carry on, to a limited extent, a deceased veteran's claim for VA benefits by submitting a timely claim for accrued benefits. 38 U.S.C.A. § 5121 (West 2002); see Landicho v. Brown, 7 Vet. App. 42, 47 (1994). Thus, while the claim for accrued benefits is separate from the claim for compensation under 38 U.S.C.A. § 1151 filed by the veteran prior to his death, the accrued benefits claim is derivative of the veteran's claim and the appellant takes the veteran's claim as it stood on the date of his death. See Zevalkink v. Brown, 102 F.3d 1236, 1242 (Fed. Cir. 1996); Jones v. West, 146 F.3d 1296 (Fed. Cir. 1998). In the instant case, the veteran died in November 1999, and the claim for accrued benefits was received in December 1999. The law applicable to this claim for accrued benefits provides that certain individuals may be paid periodic monetary benefits (due and unpaid for a period not to exceed two years) to which the veteran was entitled at the time of his death under existing ratings or based on evidence in the file at the time of the veteran's death. 38 U.S.C.A. § 5121(a); 38 C.F.R. § 3.1000. Here, the appellant, as the veteran's spouse, is advancing essentially the same claim for compensation under 38 U.S.C.A. § 1151, for accrued benefits purposes, which the veteran had pending at the time of his death. With respect to the appellant's claim for benefits under 38 U.S.C.A. § 1151, the Board pointed out in the July 2003 remand, that the RO had erroneously applied the wrong version of 38 U.S.C.A. § 1151 in its prior decisions. It was noted that because the veteran had filed his claim for entitlement to compensation under 38 U.S.C.A. § 1151 (West 1991) for chronic granulomatous disease with cervical myelopathy on May 10, 1996, which was prior to October 1, 1997, that claim was not subject to more recent [and more restrictive] amendments to that law, and that the only issue before VA was whether the veteran's chronic granulomatous disease with cervical myelopathy was the result of VA treatment, without regard to fault or whether the resulting disability was reasonably foreseeable. VAOPGCPREC 40-97, 63 Fed. Reg. 31263 (1998). Since the appellant's claim for accrued benefits is derivative of the veteran's claim, the issue that remains before VA is the same that existed when the veteran advanced his claim as just described. Title 38, United States Code § 1151, as in effect in May 1996, provides that, where a veteran suffers an injury or an aggravation of an injury resulting in additional disability or death by reason of VA hospitalization, or medical or surgical treatment, compensation shall be awarded in the same manner as if such disability were service connected. Amendments to 38 U.S.C.A. § 1151 made by Public Law 104-204 require a showing not only that the VA treatment in question resulted in additional disability or death but also that the proximate cause of the additional disability or death was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability was an event which was not reasonably foreseeable. However, those amendments apply only to claims for compensation under 38 U.S.C.A. § 1151 which were filed on or after October 1, 1997. VAOPGCPREC 40-97, 63 Fed. Reg. 31263 (1998). Therefore, as the veteran filed his claim prior to October 1, 1997, and as the appellant's claim for accrued benefits is derivative of the veteran's claim, the only issue before the Board is whether the veteran's chronic granulomatous disease with cervical myelopathy was in any way the result of VA treatment. In the instant case, considerable effort was made on the part of the appellant, as well as on the part of the RO in the development of the appellant's claim, to determine whether the veteran's chronic granulomatous disease with cervical myelopathy could have been detected and potentially corrected by the VAMC in 1988. Focus was placed in this development upon whether the neck and upper extremity symptoms reported by the veteran in 1988 should have been more aggressively studied by the VAMC. Essentially, the questions posed and then answered in these opinions were whether the veteran's chronic granulomatous disease was aggravated by the negligent failure of the VAMC to timely diagnose and treat the disease. Clearly, by proceeding in this manner, the question of whether there was fault on the part of the VAMC was interjected by the RO into the issue of entitlement to compensation under 38 U.S.C.A. § 1151. As emphasized above, however, the only question that needs to be answered is whether the veteran's chronic granulomatous disease with cervical myelopathy was the result of VA treatment, without regard to fault or whether the resulting disability was reasonably foreseeable. This question was not specifically answered in the medical opinions provided by the appellant in support of her claim or in the medical opinions obtained by the RO in March 2001. Based upon an overview of all of the medical opinions found in the record, however, it can be concluded that during the veteran's treatment at the VAMC in 1988, it was as likely as not that he had chronic granulomatous disease that was left untreated. Significantly, in the March 2001 VA medical opinion and subsequent addendum opinions, Dr. L.C. concluded that it is as likely as not possible granulomatous disease was present in 1988. It is true that in stating only that such a result was "possible," the probative value of the opinion is significantly diluted. It is also noted, however, that the only other medical opinions offered in this case were in direct support of the appellant's claim (and the veteran's claim during his lifetime), and were more emphatic in the belief that the disease was present in 1988. Applying the law of the case as it existed for claims such as this one filed prior to October 1997, it matters not whether chronic granulomatous disease was left undetected and untreated through the fault of the VAMC or for any other reason, including whether it was totally undetectable regardless of the medical treatment applied. The fact that chronic granulomatous disease as likely as not existed in 1988 is key; the fact that it was not treated by the VAMC in 1988 is undisputed. The failure to treat the disease regardless of the reason is what led to its aggravation, and it was that aggravation which resulted in the veteran's ultimate development of cervical myelopathy and other complications; complications that were eventually detected in 1996. As noted above, it is irrelevant whether more aggressive treatment by the VAMC in 1988, or indeed after 1988, could have resulted in the resolution of his granulomatous disease. The Board finds that the competent and probative evidence in this case supports the finding that the veteran's chronic granulomatous disease with cervical myelopathy was aggravated as a result of VA medical treatment in 1988. Consequently, the Board can conclude that the appellant has satisfied the criteria for compensation under 38 U.S.C.A. § 1151 for accrued benefits purposes, for the veteran's chronic granulomatous disease with cervical myelopathy. The benefit- of-the-doubt doctrine has been considered and found to be for application in this case. 38 U.S.C.A. § 5107. DIC Benefits under 38 U.S.C.A. § 1151 Analysis At the time of the veteran's death, service connection was not in effect for any disability. In fact, the appellant does not claim, and the evidence does not suggest that the veteran's death was related to his period of service in any way. The appellant's claim for DIC has always turned upon the threshold establishment of benefits under 38 U.S.C.A. § 1151 for accrued benefits purposes. In other words, if benefits under 38 U.S.C.A. § 1151 for chronic granulomatous disease with cervical myelopathy for purposes of accrued benefits could be established under the non-fault standard, and if chronic granulomatous disease with cervical myelopathy can be shown to have contributed substantially or materially to the cause of the veteran's death, then entitlement to DIC benefits could also be established without regard to fault on the part of VA. 38 C.F.R. § 3.312 (2006). A service-connected disability (or in this case a disability established under 38 U.S.C.A. § 1151) will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other conditions, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b); see Ashley v. Brown, 6 Vet. App. 52, 57 (1993). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service- connected disability (or in this case a disability established under 38 U.S.C.A. § 1151) contributed to death, it must be shown that it contributed substantially or materially, that it combined to cause death, or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c); see Schoonover v. Derwinski, 3 Vet. App. 166, 168-69 (1992). It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c); see Ventigan v. Brown, 9 Vet. App. 34, 36 (1996). The regulation points out that "[t]here are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions." 38 C.F.R. § 3.312(c)(4). The regulation further notes that, "even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was itself of a progressive or debilitating nature." 38 C.F.R. § 3.312(c)(3), (4) (2005); Lathan v. Brown, 7 Vet. App. 359 (1995). As decided above, the appellant can be awarded benefits under 38 U.S.C.A. § 1151 for chronic granulomatous disease with cervical myelopathy for purposes of accrued benefits. The dispositive question thus presented in her DIC claim is whether chronic granulomatous disease with cervical myelopathy can be shown to have contributed substantially or materially to the cause of the veteran's death. Just as it was for the issue of accrued benefits, considerable effort was made on the part of the appellant, as well as on the part of the RO in the development of the appellant's claim, to determine whether the veteran's chronic granulomatous disease with cervical myelopathy could have contributed substantially or materially to the cause of the veteran's death. To that end, several medical opinions were obtained. Based upon an overview of all of these medical opinions, it can be concluded that it was as likely as not that the veteran had active chronic granulomatous disease at the time of his death, and that disease as likely as not contributed substantially to the veteran's demise. Significantly, in the March 2001 VA medical opinion and subsequent addendum opinions, Dr. L.C. concluded that "it is as likely as not possible granulomatous disease spread was a factor leading to his death, for instance causing brainstem or worsened cervical cord injury." It is true once again that in stating only that such a result was "possible" the probative value of the opinion is significantly diluted. It is also noted once again, however, that the only other medical opinions offered in this case were in direct support of the appellant's claim (and the veteran's claim during his lifetime), and were more emphatic in the belief that active chronic granulomatous disease was present at the time of his death, and that the disease contributed substantially to the veteran's demise. The Board finds that the competent and probative evidence in this case supports the finding that the veteran's chronic granulomatous disease with cervical myelopathy contributed substantially to the veteran's demise. Consequently, the Board can conclude that the appellant has satisfied the criteria for DIC benefits under 38 U.S.C.A. § 1151. The benefit-of-the-doubt doctrine has been considered and found to be for application in this case. 38 U.S.C.A. § 5107. ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 (West 1991) for chronic granulomatous disease with cervical myelopathy for purposes of accrued benefits is granted. Entitlement to Dependency and Indemnity Compensation (DIC) under 38 U.S.C.A. § 1151 (West 1991) or (West 2002) is granted. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs