Citation Nr: 1308076 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 06-11 062 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Sean A. Ravin, Attorney WITNESS AT HEARING ON APPEAL The Appellant-Widow ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from August 1948 to May 1952 and received the Combat Infantryman Badge and Purple Heart Medal. He died in September 2004. The appellant is his surviving spouse. She appealed to the Board of Veterans' Appeals (Board/BVA) from a March 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire, which denied her claims for service connection for the cause of the Veteran's death (one basis for Dependency and Indemnity Compensation (DIC)) and for DIC benefits alternatively under 38 U.S.C.A. § 1318. In January 2007, as support for these claims, the appellant testified at a videoconference hearing before the undersigned Veterans Law Judge of the Board. Subsequently, in September 2007, the Board issued a decision denying these claims, and the Appellant appealed to the U.S. Court of Appeals for Veterans Claims (Court/CAVC). In a November 2009 Single Judge, Memorandum Decision, the Court vacated the portion of the Board's decision that had denied service connection for the cause of the Veteran's death. The Court remanded this claim to the Board for further development and readjudication consistent with its decision. Regarding the claim for DIC under 38 U.S.C.A. § 1318, the Court deemed that claim had been abandoned in the absence of any dispute of the Board's decision denying that claim. See Ford v. Gober, 10 Vet. App. 531, 535 (1997) (claims not argued on appeal are deemed abandoned); Bucklinger v. Brown, 5 Vet. App. 435, 436 (1993). In August 2010, the Board remanded the remaining cause-of-death claim to the RO for further development and consideration - in particular, to try and obtain other volumes of the claims file (c-file) that at the time apparently were missing and to have a physician review the file and provide a medical opinion indicating the likelihood (very likely, as likely as not, or unlikely) that the Veteran's service-connected status post hemothorax of the right lung or medications used to treat this disability either had caused or contributed substantially or materially to his death. On remand, two additional volumes of the claims file were located and associated with the other volume, for a total of three, so there are no longer any missing volumes. Since, however, the medical opinion also obtained on remand was inadequate, in June 2012, the Board again remanded this cause-of-death claim to the RO for still further development and consideration. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (indicating a claimant is entitled to compliance with remand directives, as a matter of law, and that the Board itself commits error in failing to ensure this compliance). The Board is now satisfied there has been compliance with its remand directives so is proceeding with its readjudication of this claim. Id. In February 2012, because of the Appellant-widow's age, the Board advanced this appeal on the docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002) and 38 C.F.R. § 20.900(c) (2012). FINDINGS OF FACT 1. The Veteran's death certificate indicates he died in September 2004 from a subdural hematoma following a closed head injury from a fall in his home. 2. At the time of his death, his service-connected disabilities were: status post traumatic hemothorax of the right lung with retained foreign bodies (rated as 100-percent disabling effectively since January 16, 2002); a scar on his face as a residual of a shell fragment wound (SFW), rated as 10-percent disabling; hearing loss (rated as 0-percent disabling, so noncompensable); and a scar on his back, also a residual of a SFW (and also rated as 0-percent disabling). 3. The most persuasive and probative (meaning competent and credible) medical and other evidence of record does not show a service-connected disability either caused or contributed substantially or materially to his death. CONCLUSION OF LAW A service-connected disability was not a principal or contributory cause of the Veteran's death. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 1310 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits upon receipt of a complete or substantially complete application. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). To this end, VA must provide notice informing the claimant of any information and medical or lay evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). So, ideally, this notice should include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Additionally, in claims for DIC benefits, VCAA notice must include: (1) a statement of the conditions, if any, for which the Veteran was service connected at the time of his death; (2) an explanation of the evidence and information required to substantiate the claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate the claim based on a condition not yet service connected. See Hupp v. Nicholson, 21 Vet. App. 342 (2007). Also, ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated, rather preserved, and the claimant is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, a November 2004 letter from the RO advised the appellant of the type of evidence needed to substantiate her claim for DIC, prior to initially adjudicating her claim for service connection for the cause of the Veteran's death in March 2005, so in the preferred sequence. The letter also informed her of her and VA's respective responsibilities in obtaining this supporting evidence. That letter did not specifically mention the conditions for which the Veteran was service connected at the time of his death, pursuant to Hupp, supra, as that letter pre-dated the Court's decision in Hupp. But the evidence shows that omission did not preclude the appellant from meaningfully participating in the adjudication of her claim, as she already was aware of the Veteran's service-connected disabilities. This is evident from the essential basis of her argument - that medications (Coumadin, Lasix, etc.) taken for his service-connected lung condition (status post traumatic hemothorax with retained foreign bodies of the right lung), made him dizzy, which, in turn, caused him to fall and sustain the terminal head injury. Clearly then, she has actual knowledge of and thus is well aware of the requirement to somehow link his death to his military service, including especially by way of his service-connected lung disability. Actual knowledge is established by statements or actions by the claimant or the claimant's representative demonstrating an awareness of what is necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007)). She is not alleging, and the evidence does not otherwise suggest, that the Veteran's death was in any way related to a condition not yet service connected at the time of his death. So not receiving additional VCAA notice, concerning a circumstance not claimed, is not prejudicial, meaning harmless error. 38 C.F.R. § 20.1102. The Board also notes that, since the November 2004 letter was issued prior to the Court's decision in Dingess/Hartman, this pre-adjudication letter did not inform the appellant how "downstream" disability ratings and effective dates are assigned and the type of evidence impacting those determinations. But this is inconsequential - and therefore at most harmless error - because the Board is denying her underlying claim of entitlement to service connection for cause of death, so the downstream effective date element of her claim is ultimately moot, and there is no downstream disability rating element of a cause-of-death claim. Additionally, consideration also should be given to "whether the post-adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre-adjudicatory section 5103(a) notice error non-prejudicial." Vazquez-Flores v. Peake, 22 Vet. App. 37, 46 (2008). The appellant and her attorney have had a meaningful opportunity to participate effectively in the development and adjudication of her claim, and she is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). As the pleading party, she, not VA, has the evidentiary burden of proof of showing there is a VCAA notice error in timing or content and, moreover, that it is unduly prejudicial, meaning outcome determinative of her claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading or allegation in this instance, and moreover, she has been represented throughout this appeal, first by a veterans service organization (VSO) and currently by a private attorney. VA also has fulfilled its duty to assist the appellant by obtaining all relevant evidence in support of this claim that is obtainable. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). The RO obtained the Veteran's available service treatment records (STRs), VA treatment records, and private treatment records. As well, the appellant has submitted personal statements and testimony, VA and private medical records, a letter from the Veteran's physician, a letter from the chief of staff of a VA Medical Center (VAMC), and a copy of the Veteran's death certificate. In DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008), the Federal Circuit Court held that 38 U.S.C. § 5103A(a) does not always require VA to assist the claimant in obtaining a medical opinion or examination for a DIC claim, but that it does require VA to assist a claimant in obtaining such whenever it is necessary to substantiate the DIC claim. The Federal Circuit Court added that there was no duty to provide a VA opinion in a DIC claim under 38 U.S.C.A. § 5103A(d) since this provision is explicitly limited to claims for disability compensation, which is defined as a monthly payment made by VA to a Veteran, and therefore does not pertain to a DIC claim. Id. But see also Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008) (holding that, in the context of a DIC claim, VA must also consider that 38 U.S.C. § 5103A(a) only excuses VA from making reasonable efforts to provide an examination or opinion when no reasonable possibility exists that such assistance would aid in substantiating the claim). Here, as already alluded to, VA obtained three medical opinions regarding this cause-of-death claim, in January 2011 and July 2012, as to whether the Veteran's terminal head injury was related to a service-connected disability or to the medication used to treat a service-connected disability as is being alleged. See 38 U.S.C. § 5103A(a); DeLaRosa, supra. The claimant's attorney has contended that all of these VA medical opinions are inadequate. In its June 2012 remand, the Board also found the two January 2011 VA medical opinions were inadequate because of a lack of supporting rationale and therefore remanded this claim for yet another medical opinion. However, the Board finds that the additional July 2012 VA medical opinion since obtained is indeed adequate as it is responsive to this determinative issue of causation and supported by rationale and, thus, in compliance with this remand directive. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Veteran's attorney argues that July 2012 medical opinion was based on an inaccurate factual predicate, but for the reasons and bases discussed below, the Board disagrees with this notion. The Board consequently is satisfied that the duty to assist the appellant with her cause-of-death claim has been satisfied. 38 U.S.C.A. § 5103A. She has received all required notice and assistance with this claim and has had a meaningful opportunity to participate effectively in the development of this claim It is difficult to discern what additional guidance VA could have provided her regarding what further evidence she should submit to substantiate this claim. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."). See also Reyes v. Brown, 7 Vet. App. 113, 116 (1994) and Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances when a remand would not serve any useful or meaningful purpose or result in any significant benefit to the claimant). In deciding this claim, the Board has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the claimant or obtained on her behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Analysis Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. At the time of his death, the Veteran's service-connected disabilities were: status post traumatic hemothorax of the right lung with retained foreign bodies (rated as 100-percent disabling effectively since January 16, 2002); a scar on his face as a residual of a SFW, rated as 10-percent disabling; hearing loss (rated as 0-percent disabling, so noncompensable); and a scar on his back, also a residual of a SFW (and also rated as 0-percent disabling). The basis of the appellant-widow's claim for service connection for the cause of the Veteran's death is that he was taking medication for his service-connected lung disability, and that medication in turn caused dizziness that resulted in his September 2004 fall and terminal head injury. She does not contend, and the evidence does not reflect, that his death was related in any way to his service-connected scars of the face or back or to his service-connected hearing loss. The law provides DIC benefits for a spouse of a Veteran who dies from a service-connected disability. See 38 U.S.C.A. § 1310. A service-connected disability is one that was incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). The death of a Veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. See 38 C.F.R. § 3.312(a). For a service-connected disability to be considered the principal or primary cause of death, it must singly, or with some other condition, be the immediate or underlying cause, or be etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which contributed substantially or materially to cause death, or aided or lent assistance to the production of death. See 38 C.F.R. § 3.312(c). 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. Id. It is recognized there are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated regardless of coexisting conditions, but, 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 of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4). The Veteran's September 2004 death certificate lists the manner of his death as an accident, specifically, an unwitnessed fall, after which he was found in the bathroom by his wife. The cause of his death was listed as a subdural hematoma following a "cleared" (presumably, closed) head injury. The evidence of record reflects that the Veteran fell in the bathroom of his home, where the appellant found him unconscious. He succumbed within hours without regaining consciousness as a result of the head injury he sustained in the fall. During the January 2007 hearing, the appellant's then representative argued the claim was denied without adequate medical evidence to support the decision. He asserted that the medications the Veteran was prescribed for - at least in part, his service-connected lung condition (status post hemothorax) caused him to become very dizzy and fall, sustaining the terminal head injury. The appellant testified that had occurred on several prior occasions, but fortunately the Veteran had previously always either fallen backwards onto a couch or his bed - so he was unharmed on those earlier occasions. On this particular day in question, however, the representative asserted the Veteran walked approximately 10 steps to the bathroom and then fell and hit his head, this time resulting in the fatal injury. See Transcript, pp. 1-6. In other testimony, the appellant asserted that the Veteran had become dizzy or passed out on at least three occasions during the prior year, but that she never took him to a hospital or otherwise helped him seek medical attention for this. She said that, instead, she would just sit him up and allow him to recover. She stated that when he arose to go to the bathroom, she was in the living room, and that he just went around the corner to access the bathroom, where she heard him fall. She entered the bathroom and tried to pick him up but, understandably, was unable to. She requested, through her representative, that VA obtain a medical opinion on whether the Veteran's medications contributed to his fall, noting the RO had adjudicated her claim on the basis of his VA and private treatment records without obtaining further medical review. The Veteran had several what could be considered serious non-service-connected disabilities, including hypoxemia, coronary artery disease (CAD) - status post coronary artery bypass graft (CABG), and congestive heart failure (CHF). Records from Concord Hospital in Concord, New Hampshire, and from American Medical Response and Massachusetts General Hospital show the Veteran was picked up at his home and initially transported to Concord. September 2004 documents of the ambulance service prepared the day of his death indicate he had collapsed at home the prior evening and was taken to the emergency room at Concord Hospital. There it was determined he had sustained an intracranial subdural hematoma. He was placed on a ventilator and assessed as ventilator dependent. After intubation, he was transferred to Massachusetts General Hospital where his family gave instructions not to resuscitate him. Later that same day, physicians at Massachusetts General diagnosed a large right subdural hemorrhage and determined that no intervention was possible, and he was transferred back to Concord for terminal care. Ambulance records reflect that he died en route. There are no entries in any of these records to the effect that the appellant or anyone else told responding or treating personnel the Veteran had experienced dizziness or any other difficulty prior to his fatal fall, including as a result or consequence of his service-connected lung disability, such as from the medications he had been treating it with. Earlier dated records show the Veteran had sustained his SFWs in service during the Korean Conflict, but that he did not apply for service connection until the 1980s. A February 1989 rating decision assigned an initial 0 percent (i.e., noncompensable) rating for the traumatic hemothorax of his right lung, as he had denied any problems from the wounds and the examination had shown his scars as the primary active residual, although an X-ray had shown a fragment of metal retained in his right lung. VA outpatient records show the Veteran was presenting with complaints of dyspnea beginning in the summer of 1989. A February 1989 chest X-ray showed a fragment of metal in the right lung. There was no other pulmonary abnormality. There was some widening of the right pleural margin inferolaterally possibly on the basis of previous trauma or gunshot wound. A July 1989 entry listed his complaint as being all out of breath if he had to hurry, and that this problem had started in 1987. He was on medication for hypertension, and his pulmonary function tests (PFTs) were reported as either good or very good. Findings on examination included a systolic murmur. No edema was noted. The diagnosis was non-pulmonary dyspnea on exertion. An October 1989 entry noted his hypertension was deemed borderline, but due to the notation of brisk and small carotid pulses, he was diagnosed with mild aortic stenosis. In October 1991, the VA medical facility where the Veteran received his treatment referred him for a fee-basis evaluation to determine if decreasing lung function was related to the shrapnel in his lung. The report shows the appellant was present at that examination. The Veteran had been able to walk two miles a day until 6 to 12 months prior to that examination, when he had to stop because of dyspnea. He told the examiner that he could only walk about 20 or 30 feet before he had to stop due to dyspnea associated with burning across his chest. He denied nausea, vomiting, diaphoresis, or chest pain and said his symptoms went away after resting for several minutes. He described the same feeling when he bent over such as to tie his shoes. The examiner noted a 15-year one-pack-a-day smoking history that had ceased 30 years earlier, and the Veteran told him that he was diagnosed with hypertension approximately two and one-half years before the then current evaluation, for which he had taken three medications - first Lisinopril, then Acebutolol, and Nifedipine as of the time of that examination. He had worked in a tannery for 35 years as a buffer, where he had used a mask, until it closed. His last employment before retiring was with a bay window building. Also noted was a history of possible environmental allergies with occasional post nasal drip. Objective physical examination noted no adenopathy or thyroid. Lung sounds were diminished with crackles at both bases, and cardiac was significant for diastolic sound, which the examiner assessed as a possible murmur versus S4. The examiner noted that he had insufficient records or data on the Veteran to assess how much cardiac or pulmonary disease he had, but he noted the Veteran felt better after using an inhaler during the pulmonary function testing. It showed possible mild restriction and normal arterial blood gases. The February 1992 rating decision determined the Veteran's lung sounds were associated with advanced age rather than the retained foreign body, but that the February 1989 rating decision contained clear and unmistakable error (CUE), in that a compensable rating was not granted on a presumptive basis for the retained foreign body in the right lung. From 1992 onwards, the treatment records show the Veteran progressively developed more cardiac symptoms. In May 1992, he complained of wheezing and voiced concern that he might again have pneumonia. Based on a chest X-ray, an upper respiratory infection was diagnosed, and the examiner noted rule out right pneumonia and left ventricle failure. In July 1992 he was noted to have severe uncontrolled hypertension. It was noted that his lungs were "very clear." In August 1993, he still had dyspnea on exertion, and on examination his lungs were again "very clear." In September 1994, he presented with complaints of shortness of breath and increased chest pressure after slight exertion over the prior three days. His blood pressure was 192/90. His chest X-ray revealed congestive heart failure. A May 1997 chest X-ray was performed for complaints of difficulty breathing. A metallic foreign body was noted within the right chest. Pulmonary congestion was absent, and there was no pleural effusion or acute pulmonary disease. The diagnostic impression was no evidence of pulmonary congestion, and the overall heart size, which in the past had been enlarged, was then currently within normal limits. May 1997 PFTs showed restrictive lung disease. A June 1997 VA discharge summary shows the Veteran was admitted with diagnoses of atrial fibrillation, CAD, and chronic obstructive pulmonary disease (COPD). The summary lists his history of those conditions, and that he was admitted for shortness of breath. An extensive workup included a ventilation perfusion scan and non-invasive venous studies, all of which were negative. He was found in paroxysmal atrial fibrillation, but rapidly converted. He was initially admitted to a private hospital, but was transferred to the VA facility. The initial sense was that his symptoms were secondary to bronchospasm from beta blocker that had been recently started, so it was discontinued. He was discharged to home where he was doing well, until he developed 7/10 chest pain with nausea, shortness of breath, and diaphoresis. He took no nitroglycerin, but after presenting at the emergency room his pain was relieved after two sublingual nitroglycerin. While in the emergency room he was found to be in rapid atrial fibrillation. After being loaded with Digoxin and started on Heparin, his symptoms improved. During the inpatient treatment, a heart attack was ruled out, but an echocardiogram showed mild left atrial enlargement, borderline atherosclerosis with mild mitral regurgitation. After an exercise thallium stress test was stopped due to chest pain and dizziness and showing a moderate-sized inferior defect, the Veteran agreed to undergo a cardiac catheterization, which required transfer to an outside private facility. The summary noted he would be restarted on his Coumadin for anticoagulation after the procedure, and that he would seen for possible cardio-conversion for his atrial fibrillation after he was anticoagulated for three weeks. He was to avoid beta blockers, since he did not tolerate them well during a previous admission for a bronchospasm. The summary specifically noted that his pulmonary condition and other medical problems were stable. He was transferred to CMC, a private hospital for catheterization at his request. Private medical records from CMC dated in June 1997 reflect that he underwent a CABG. Other documents show he was unable to appear for an examination in July 1997, as he underwent the CABG during that month. A September 1997 cardiology note reflects that he was diagnosed with ischemic heart disease with coronary atherosclerosis, recent onset atrial fibrillation, hypertension, dyslipidemia, remote history of tobacco abuse, abstinent for more than 30 years, and mild chronic lung disease. Several medications were prescribed for his heart disease. A September 1997 lung examination report noted he was found to be grossly obstructed in August 1997 after being placed on Atenolol. It was stopped and Prednisone started, and his shortness of breath improved. He was then diagnosed with ischemia and underwent a CABG. Since the CABG he had noted increasing shortness of breath on exertion, such that he could not climb more than two flights of stairs. Objective physical examination showed an irregular pulse of 80 and a clear chest. PFTs showed mild restrictive disease without evident obstruction, and the chest X-ray showed the metallic foreign body within the right chest. The examiner indicated the Veteran's chest symptoms were multifactorial. In addition to the restrictive disease, the examiner indicated that underlying asthma and beta blocker treatment caused some of the asthmatic symptoms, and that the Veteran was moderately disabled from the symptoms. The treatment records show the Veteran's cardiac disorder continued to develop more severe symptoms, including congestive heart failure. A May 2001 X-ray taken at Concord Hospital showed that, as compared to a 1997 study, his heart was enlarged, interstitial and alveolar edema were present, as well as a small right effusion. The impression was congestive heart failure with right pleural effusion and developing interstitial edema. Private medical records dated in 2001 from Concord Hospital reflect treatment for heart disease. In July 2001, the Veteran presented at the Concord Emergency Room in congestive heart failure, and he was given diuretic therapy, which led to an improvement in his symptoms. He was admitted. In a July 2001 note, his treating cardiologist, Dr. K., observed that the exact contribution to the Veteran's congestive heart failure was somewhat perplexing, but he noted evidence of aortic outflow obstruction versus aortic stenosis that was difficult to evaluate. Dr. K.'s main concern, however, was potential worsening valvular disease, and that the prospect of coronary disease contributing to the recent congestive heart failure could not be excluded. He scheduled a cardiac catheterization. As noted in the discharge summary, that procedure revealed no significant obstruction of the Veteran's grafts and native three vessel coronary disease was noted. In the report of the cardiac catheterization, Dr. K. indicated that the presence of significant pulmonary hypertension suggested the Veteran's mitral stenosis was hemodynamically significant. On discharge, after discussion of the alternatives, he elected to continue with intensive medical therapy to manage his condition. His Coumadin was restarted. Dr. K.'s discharge diagnoses were: mild aortic stenosis, CAD, moderate to severe mitral stenosis, chronic atrial fibrillation, renal insufficiency, and pulmonary hypertension. The discharge medications included Verapamil, Mevacor, nitroglycerin, Coumadin and Demadex, but the "Demadex" is partially lined through and Lasix written above it. In November 2001, the Veteran experienced an acute ischemic left leg. Upon presentation at the Concord Emergency Room he was missing his left groin pulse. He was admitted and underwent a diagnostic arteriography which revealed a large embolus involving the distal external iliac artery. The discharge diagnosis was acute arterial embolus of the left leg. A February 2002 VA pulmonary clinic note reflects the Veteran had postoperative CHF, hypoxemia, now doing well. A chest X-ray revealed normal lung fields. PFTs revealed normal lung function except for a diffusion impairment, which had been essentially stable since 1997. The doctor (the pulmonary chief) said he suspected the diffusion defect was due to mitral stenosis. At the Veteran's follow-up visit in March 2002, Dr. K. noted the Veteran continued to be limited by exertional dyspnea, but that the condition was stable and he was doing well overall. The Veteran told him that he had felt occasional light-headedness, particularly when he took a medication that was added for his blood pressure control, and that he had since stopped taking it. Dr. K. noted the Veteran's then current medications as Lovastatin 20 mg, Verapamil 240 mg, Lisinopril 20 mg, Demadex 40 mg, Coumadin, and Allopurinol. Dr. K. emphasized the importance of fluid management if the Veteran developed orthopnea or lower extremity edema. In September 2002, Dr. K. noted the Veteran was seen for follow up of his cardiovascular condition. He reported dyspnea at times and occasional lower extremity edema, but there had been no dizziness, palpitations, presyncope or sensation of sustained tachycardia. Dr. K. again emphasized the importance of fluid management, and he asked the appellant to confirm the Veteran's current dose of Demadex, as he might consider asking him to take a slightly higher dose. The Veteran, through his representative, requested an increased rating in April 2002 for his lung disorder (status post hemothorax), stating he was having difficulty breathing. The August 2002 VA examination report states the examiner noted the Veteran's history and his medical difficulties in late 2001. The Veteran reported that he had sustained a shrapnel wound of the chest with a pneumothorax during the Korean War in 1950. Following that, he really did not have many symptoms. He complained of some shortness of breath, and about 15 years ago he had developed more symptoms. Examination revealed his heart murmur. His lungs were clear to auscultation and percussion. No rales or rhonchi were heard. The lower extremities showed 2+ edema. The examiner interpreted the PFTs as showing a diffusion defect and mild restrictive pulmonary disease. The diagnosis was remote hemothorax with retained foreign body, by chest film, right lung. The RO requested further medical clarification on whether the Veteran's diffusion defect was caused by his service-connected lung disorder (status post hemothorax) or instead his non-service-connected heart disease. The VA examiner who reviewed the claims file in December 2002 indicated it was due to both, as it was not due solely to the prior pneumothorax with retained foreign body or solely to the heart condition. The examiner provided no supporting rationale for his opinion. The examiner noted the Veteran had severe CAD and atrial fibrillation and had CABG'g and CHF. The examiner indicated that the results of August 1997 PFTs showed diffusion effect with restrictive lung disease, as well. None of the extensive records concerning the Veteran's heart disease were noted or discussed. Upon receipt of that report, a January 2003 RO decision increased the rating for the Veteran's lung disorder from 30 to 100 percent, effective January 16, 2002. The RO stated that, as the degree of impairment due solely to the service-connected lung condition could not be determined, PFT findings would be used to evaluate the Veteran's service-connected condition without consideration of any impairment due to his non-service-connected heart condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (When it is not possible to distinguish or differentiate the extent of impairment that is attributable to service-connected disability from that which is not, 38 C.F.R. §§ 3.102, 4.3 require that VA resolve this doubt in the Veteran's favor and, for all intents and purposes, presume the impairment is attributable to or part and parcel of the service-connected disability). A January 2003 VA primary care note indicated the Veteran's breathing problems were aggravated by the mechanical problem of truncal obesity. A November 2003 VA primary care note reflects that his lower extremity edema was controlled with Lasix. A December 2003 VA pulmonary clinic note from the pulmonary chief physician, Dr. B., reflects that the Veteran had cardiomyopathy and pulmonary hypertension. His PFTs showed normal lung function except for severe diffusion impairment. A computed tomography (CT) scan revealed no interstitial disease. The diagnostic assessment was dyspnea associated with pulmonary hypertension, cardiomyopathy. This doctor stated, "[b]elieve pulmonary hypertension is due to heart disease." A thoracentesis was performed in January 2004, after which the Veteran said he could breathe better. In February 2004, Dr. B. diagnosed transudative effusion. An April 2004 primary care note indicated the Veteran had chronic transudative pleural effusions not responding to diuretics. He had declined pleurodesis. An August 23, 2004 note from the Coumadin clinic reflects that he complained of increased edema. An August 23, 2004 note from Dr. C. of the cardiology clinic reflects that the Veteran reported that he was using oxygen continuously and seemed fairly functional. He complained of edema and abdominal discomfort. The doctor said he could remain off his statins (Simvastatin and Lovastatin, which had caused a rash), and he would try increasing his Furosemide. These are the most recent VA treatment notes in the file, so the last concerning his condition. Dr. C., a cardiologist, was also one of the Veteran's VA and private physicians. He stated in his September 2004 letter that the Veteran's family had asked him to confirm that the Veteran was on Warfarin therapy at the time that he apparently sustained the fatal subdural hematoma. Dr. C. emphasized that the Veteran's anticoagulation therapy was closely monitored, and the degree of anticoagulation did not appear excessive based on a review of the Veteran's international normalized ratio (INR) results of August and September 2004. Dr. C.'s observation would appear to be validated by Dr. K.'s December 2001 note to the effect that the Veteran's left leg embolus "formed during a period of subtherapeutic anticoagulation around the time of [the Veteran's] pneumonia." The Board reads subtherapeutic as meaning the Veteran was on a lower than optimal dosage of his anticoagulation medication. A September 2003 VA cardiology consultation notes it as a hiatus - meaning he was not taking the anticoagulation medication at all. In a March 2006 letter, the appellant's daughter-in-law asserted that the Veteran's breathing problems caused his heart problems, and that he took several medications for both problems, which caused dizziness and resulted in his death from the head injury after a fall. In March 2006, the appellant said that letter expressed the feelings of her whole family. Dr. K.'s May 2006 letter to the appellant responded to her request for input on the Veteran's medications. It also included a qualifier that he focused on the Veteran's heart problems, and that he could not comment on his breathing and lung problems. Dr. K. then noted that the oxygen and Demadex the appellant said the Veteran was taking were typically used for breathing problems, and that Coumadin was a blood thinner, predominantly used because of the Veteran's problem with excessive blood clotting, and Verapamil was helpful for blood pressure management but also was useful for control of a rapid heartbeat. He also explained that Demadex was a diuretic pill. In a letter to the appellant dated in May 2006, the Chief of Staff of the Manchester VAMC stated that he could not give an expert opinion in this case. He said the Veteran's VA medical records showed that he was apparently on several medications for his heart for blood pressure, aortic stenosis, and atrial fibrillation (Verapamil, Lisinopril, and Coumadin). The Lovastatin was to control cholesterol levels, and Demadex was prescribed either for his CHF, chronic renal failure, or the buildup of fluid around his lungs. This doctor explained this drug is a potent diuretic. Lasix was an equivalent drug that he saw in the medical records. The Board's prior August 2010 remand was for a medical opinion concerning the appellant's contention that medications used for the Veteran's service-connected lung disability caused dizziness and the fall that resulted in his death from the subdural hematoma. In January 2011 an Advanced Registered Nurse Practitioner (ARNP) resultantly offered an opinion after reviewing the claims file. She determined the Veteran's death from the subdural hematoma was not caused by his service-connected hemothorax and right lung condition. In discussing the rationale for her opinion, she noted the Veteran was started on anticoagulation with Warfarin in July 1997 for atrial fibrillation, that he sustained a fall with resultant subdural hematoma in late August 2004, that he was seen by cardiology on August 23, 2004 with no complaints of dizziness, and that he had sustained a right lung pleural effusion in January 2004. She concluded his untimely death was not due to treatment for his lung condition, but most likely instead due to treatment of his atrial fibrillation which was diagnosed 8 years prior to his lung hemothorax/pleural effusion. Since, however, that opinion had not been provided by a physician as the Board had directed in its August 2010 remand, the RO had a VA physician (M.D.) also comment on this case in January 2011. But as the Appellant's attorney pointed out in his April 2012 argument, this physician simply recited word-for-word, so verbatim, the nurse practitioner's opinion. The only addition was the listing of this physician's credentials; she indicated she is a Board-Certified Internist with 24 years VA experience, 5 years C/P experience. In June 2012, after finding these opinions inadequate, the Board remanded the claim for another medical opinion, with review of the claims file and a clear rationale. The report of this July 2012 VA medical opinion confirms the examiner, an M.D., reviewed the Veteran's claims file for the pertinent history. This doctor concluded the claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. He stated that, after a review of the entire claims file, he concurred with the previous (January 2011) examiner's opinion that the Veteran's death was not likely caused by or the result of treatment for his service-connected lung condition. The rationale for his opinion was as follows. The Veteran had an unwitnessed fall at home with subsequent subdural hematoma and died as a result of this in September 2004. The claimant's contention is that medications used to treat the Veteran's service-connected lung disease caused dizziness that caused him to fall. There are basically two major components to this opinion and rationale, namely, the part about what medications were being used to treat his service-connected lung condition versus medications for his non-service-connected heart disease and whether the medications used to treat his service-connected lung condition could have caused dizziness leading to his fall. Given that his presumed dizziness and fall was an acute event, the medications of concern would be those taken in the time period immediately preceding his death. The VA examiner indicated that as best as he could determine from the last VA note of August 23, 2004 before the Veteran's death, medications taken at that time of pertinence to this opinion include Furosemide, spironolactone, verapamil and warfarin (Coumadin). He was also on continuous oxygen therapy. Additional medications listed included a variety of topical skin ointments, allopurinol, doxepin as needed, diphenhydramine as needed, and lovastatin. This commenting physician explained that these other medications were prescribed for unrelated conditions, though it should be noted that both doxepin and diphenhydramine can both cause dizziness and could have played a role in the Veteran's fall had he taken a dose before the fall. The examiner reiterated that these medications were not prescribed for the service-connected lung condition. The examiner then goes on to state that, after a thorough review of the medical record, it was his belief and opinion that the Veteran in fact was not taking any medical treatment for his service-connected lung condition prior to and at the time of his death with the possible exception of supplemental oxygen, and even this was most likely prescribed due to his heart disease. The medications of concern were all prescribed for the treatment of his severe non-service-connected heart disease. This examiner reiterated that Coumadin is an anticoagulant that was prescribed for this Veteran because of his chronic atrial fibrillation to aid in the prevention of embolic strokes from blood clots forming in his heart. This, the examiner explained, is a common well-established reason to prescribe this medication. There would be no medical reason to prescribe Coumadin for the Veteran's service-connected lung condition. Verapamil was prescribed to the Veteran both to control hypertension and is also used to regulate the heart rate in patients with chronic atrial fibrillation. Verapamil is not medically indicated to treat any lung disorders, therefore it was not prescribed for the Veteran's service-connected lung condition. It is possible that verapamil could cause dizziness by lowering the pulse rate or blood pressure too much, especially when combined with diuretics like furosemide and spironolactone, could have a side effect of causing dizziness and faintness sufficient to lead to a fall such as the Veteran sustained. The other medication of interest in possibly causing the Veteran to be dizzy or faint and sustain the fall that led to his death would be furosemide and also spironolactone. Demadex is mentioned in the claim as a medication that he had been taking, but not at the time of his death or immediately preceding it. Both Demadex and furosemide are potent diuretics, the purpose of which is to remove excess fluid from the body. By depleting vascular volume, diuretics can certainly lead to dizziness, sufficient to cause fainting and falling. Spironolactone is also a diuretic frequently used to treat refractory CHF. This doctor then goes on to indicate that, after reviewing all of the evidence and records, it was his opinion that these diuretic medications were used to treat the Veteran's non-service-connected CHF and not his service-connected lung condition. This commenting physician next explains that the Veteran's VA medical records clearly indicated that he had suffered from severe CHF for many years, likely on the basis of multiple cardiac conditions including CAD, aortic valve stenosis, mitral regurgitation, and chronic atrial fibrillation. He said that CHF causes patients to retain excess fluid in the body tissues, including the lung. This causes swelling of the lung tissues, causing decreased oxygen diffusion and transfer to the blood with resultant hypoxia and dyspnea. In CHF, although the lung is affected, the fluid buildup in the lung and pleural spaces with resultant decreased diffusion capacity is due to the heart disease and not due to any pulmonary disease. In the absence of cardiac disease and CHF the Veteran's service-connected lung condition would not have required diuretic treatment. This commenting doctor opined that the statement from cardiologist Dr. K. dated in May 2006 that Demadex was typically prescribed for "breathing problems" is somewhat incomplete. A more accurate statement would also have clarified that it is typically prescribed for breathing problems caused by CHF or other fluid overload conditions such as kidney nephrosis or liver cirrhosis, and not for primary lung disease itself. The Veteran was noted to have a pleural effusion that was found to be a transudate on analysis of the fluid, and this type of pleural effusion is caused by either CHF, nephrotic syndrome of the kidney, or cirrhosis of the liver. He concluded the Veteran's pleural effusion for which diuretic treatment was prescribed was due to his CHF and not due to his service-connected lung condition. He said the medical records also showed the Veteran had significant pulmonary hypertension, which is essentially high blood pressure in the lungs and can contribute to worsening CHF. Although the term "pulmonary" is used, this is a vascular condition, not a lung condition. This physician indicated the Veteran did not have pulmonary hypertension due to his service-connected lung condition or any other diagnosed pulmonary disease. He stated the Veteran had no evidence of pulmonary fibrosis on CT scan. He said the Veteran's PFTs did not show any evidence of obstructive lung disease, and even were this present, it would not be connected to his service-connected lung condition. He observed that a pulmonary specialist concluded in December 2003 that the Veteran's pulmonary hypertension was due to his heart disease. In a January 2013 letter, the appellant's attorney contended that the July 2012 VA medical opinion was inadequate as it was based on an inaccurate factual predicate. Specifically, the attorney asserted that since a December 2002 VA pulmonary medical opinion stated that the Veteran's abnormal PFT results were due to both his heart disease and his lung condition, and VA increased the Veteran's disability rating for the service-connected lung condition based on that examination report, it was an error for the July 2012 physician to "dismiss any relation of [the Veteran's] pulmonary hypertension and abnormal PFTs with his service-connected lung disorder." He asserted that this error was the basis of the July 2012 doctor's opinion that the Veteran's diuretic medication was prescribed only for the heart disorder, not for the lung disorder. The Board finds this argument unavailing. The July 2012 VA physician provided a clear and thorough rationale for his competent medical opinion, and specifically stated that diuretics are prescribed to remove excess fluid from body tissues, that the Veteran had demonstrated CHF, and that his CHF caused his fluid buildup in the lungs. Significantly, he stated, "[i]n the absence of cardiac disease and CHF the Veteran's service-connected lung condition would not have required diuretic treatment." In providing this opinion, the July 2012 VA examiner considered the Veteran's pertinent medical and other history and, more importantly, thoroughly discussed the underlying rationale for this opinion, which is where most of the probative value is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (wherein the Court discusses, in great detail, how to assess the probative weight of medical opinions and the value of reviewing the claims file. The Court holds that claims file review, as it pertains to obtaining an overview of the claimant's medical history, is not a requirement for medical opinions. The Court added, "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.") And the Veteran's VA outpatient treatment records show no evidence contrary to July 2012 examiner's findings. These records show that, by 2003, the Veteran's breathing problems had necessitated the constant use of oxygen - but due to his CHF rather than service-connected lung pathology attributable to the status post hemothorax. An April 2004 note describes the Veteran as having chronic transudative pleural effusion that was not responding to diuretics. But with the aid of his supplemental oxygen, he was mobile, could get out the house and visit friends, and was able to perform his activities of daily living. The examiner indicated the Veteran was not a good candidate for a chest tube and that he declined pleurodesis. The cardiology note for May 2004 indicates the Veteran as having essentially end-stage valvular heart disease with aortic stenosis, mitral regurgitation, and refractory pleural effusion. As is true with any piece of evidence, the credibility and weight to be attached to the medical opinions are within the province of the Board as adjudicators. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71, 73 (1993). See, too, Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). It is entirely within the Board's province to give more probative weight to certain pieces of evidence than others. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board is mindful that it cannot make its own independent medical determination and there must be plausible reasons for favoring one medical opinion over another. Evans at 31; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Here, though, there are legitimate reasons and bases for accepting the VA examiner's opinion as highly probative and, indeed, the most probative in this instance. Notwithstanding the attorney's contentions, there is no competent evidence, medical or otherwise, showing the Veteran had pulmonary hypertension due to his service-connected status post hemothorax with retained metallic foreign body, let alone competent evidence showing that he was taking medication for his service-connected lung condition and that it resulted in dizziness and the fatal fall. Moreover, both the July 2012 VA examiner and the Veteran's treating VA pulmonary specialist (in December 2003) opined that the Veteran's pulmonary hypertension was due to his heart disease. The Board finds that the weight of the competent medical evidence shows that he was taking diuretic medication for pulmonary hypertension and for edema, not for the service-connected lung condition. The medical evidence clearly demonstrates that none of his medications taken prior to his death were prescribed for the service-connected status post hemothorax. The assertions by the appellant and her attorney are, in essence, speculative. No one, including the appellant herself, was in visual contact with the Veteran when he fell in his bathroom and struck his head. The appellant readily acknowledged during her hearing that she did not actually witness the fall, only instead came on the scene afterwards, albeit rather immediately once she heard a noise and realized the Veteran needed her assistance. And while she also testified that he had, on several prior occasions, experienced dizziness and fallen, though not fatally, there is absolutely no evidence that he complained of dizziness around the time period of his fatal accident. Further, Dr. K.'s 2002 treatment notes clearly indicate the Veteran had not reported any dizziness and also indicated that his reported light-headedness was probably related to his blood pressure medication, so, again, not for his service-connected lung disability. Service connection was not established for his hypertension or even for his CAD, status post CABG, or CHF. Having said that, the Board also has considered the appellant's lay statements in support of her claims. This particular case at hand, however, is not the type of situation discussed in Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) and a number of other related cases or progeny holding that lay evidence may be sufficient to establish this required nexus (i.e., link) between the Veteran's military service and his disability and/or death. There is no evidence that either the appellant, her daughter-in-law, or their attorney have any medical training or expertise. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether the Veteran was dizzy due to prescribed medication and the reason that such medication was prescribed falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue requiring expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). As this cause-of-death claim concerns the Veteran's many medical conditions and the medications used to treat them, and the purpose and effect of these medications, issues that are not readily amenable to lay diagnosis or probative comment, the appellant has to have supporting medical evidence - which, for the reasons and bases discussed, she simply does not or, at least, sufficient to refute the medical findings noted above. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom, i.e., need for supporting medical nexus evidence, in a claim for rheumatic fever). For these reasons and bases, the Board finds that the preponderance of the competent and credible evidence establishes that the medications alleged by the attorney and the appellant to have impacted the Veteran were, in fact, prescribed for his non-service-connected CAD, CHF, hypertension, etc. The preponderance of the evidence shows that neither the Veteran's service-connected disabilities (but particularly his status post hemothorax) nor any medication prescribed for them, caused or contributed substantially or materially to his death, see 38 C.F.R. § 3.312, but instead that it was due to an unfortunate accident of unrelated circumstance. In light of this finding, there is no reasonable doubt to resolve in the appellant's favor, and the claim must be denied. 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). ORDER The claim for service connection for the cause of the Veteran's death is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs