Citation Nr: 0526418 Decision Date: 09/27/05 Archive Date: 10/05/05 DOCKET NO. 94-07 067 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Lewis C. Fichera, Attorney WITNESSES AT HEARING ON APPEAL Appellant and her daughter ATTORNEY FOR THE BOARD Dennis F. Chiappetta, Counsel INTRODUCTION The appellant is the surviving spouse of the veteran who served on active duty from January 1942 to September 1945. This matter is before the Board of Veterans' Appeals (Board) by Order of the United States Court of Appeals for Veterans Claims (Court) dated June 29, 2001, which vacated a March 2000 Board decision and remanded the case for additional development involving compliance with the Veterans Claims Assistance Act of 2000 (VCAA). [The Court Order specifically refrained from addressing whether there was any error in the Board decision.] This matter initially arose from an April 1993 rating decision by the Philadelphia, Pennsylvania Regional Office (RO) of the Department of Veterans Affairs (VA). In August 1998 the appellant testified at a personal hearing before the undersigned. A transcript of that hearing is of record. In February 2002 the Board undertook development under authority then in effect. In June 2003 the matter was remanded for notice, development, and initial RO consideration of additional evidence. Additional evidence was then again received, and in May 2004, the matter was again remanded to afford the RO initial consideration of the additional evidence. In August 2004, the matter was remanded for the purpose of providing the appellant notice under 38 C.F.R. § 3.159(e) of VA's inability to obtain a June 1978 VA treatment record. In December 2004, VA sought and obtained a VHA advisory opinion in this issue. The appellant was notified of the opinion and submitted a response with supporting opinions. FINDINGS OF FACT 1. The veteran died in June 1978; he was pronounced deceased on arrival at the hospital where he was brought after being found not breathing on the floor of his car; toxicology showed blood alcohol .34 %; there was no autopsy; and his original death certificate identified the cause of his death as acute alcoholism. 2. Upon request of the appellant (who advised that at the time of his last, May 17, 1978, visit to the VA hospital the veteran had "thrombosis phlebitis in the right leg", "that doctors at the hospital [felt] that [the veteran] died from a blood clot in the right leg", that the veteran's medical records never showed alcohol in his blood; and that she could not get a VA pension unless the death certificate was revised to delete acute alcoholism as the cause of death), the physician who issued the original death certificate issued in November 1981 a revised death certificate listing the immediate cause of the veteran's death as chronic thrombophlebitis, and obesity bypass surgery as other significant condition contributing to death, but not related to the terminal disease or condition. 3. The veteran had established service connection for varicose veins of the right leg, rated 40 percent when he died; nonservice connected disabilities treated in the months preceding his death included massive obesity, hypertension, chronic alcohol abuse, and anxiety; thrombophlebitis was not noted in any treatment record in the months preceding the veteran's death. 4. Based on the competent evidence of record, it cannot be found, without resort to speculation, that the cause of the veteran's death was a pulmonary embolus as a complication of a thrombophlebitis that was caused or aggravated by the veteran's service connected varicose veins of the right leg. 5. The preponderance of the evidence is against a finding that service- connected varicose veins of the right leg caused, or contributed substantially or materially to cause, the veteran's death. CONCLUSION OF LAW Service connection for the cause of the veteran's death is not warranted. 38 U.S.C.A. § 1310, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.312 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Preliminary Matters The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2004). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2005); 38 C.F.R. § 3.159(b) (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The June 2001 Court Order and the June 2003 Board remand both directed compliance with the VCAA, and VA has complied with the notice and assistance requirements of the VCAA. A June 2003 notice letter outlined what is needed to establish entitlement to service connection for the cause of the veteran's death, and informed the appellant of her and VA's responsibilities in developing this claim. The RO's decision (and a previous Board decision), numerous supplemental statements of the case (SSOCs), and the Board remands have explained what the record shows and why the claim was not granted. The June 2003 notice letter specifically advised the appellant to tell VA of any additional information or evidence that she would like VA to obtain and to send any information describing additional evidence or the evidence itself to VA. While full notice did not precede the initial rating decision (as the initial rating preceded the VCAA), the claims were readjudicated after content complying notice was given. See the numerous SSOCs (most recently in September 2004). The appellant has had ample opportunity to respond, and thus is not prejudiced by any notice timing defect. The Court acknowledged in Pelegrini that where, as here, the § 5103(a) notice was not mandated at the time of the initial AOJ decision, the AOJ did not err in not providing such notice. Rather, the appellant has the right to content complying notice and proper subsequent VA process. Pelegrini, 18 Vet. App. at 120. The content of the notice provided to the appellant fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The VA correspondence in June 2003 and the SSOCs specifically advised her of the type of evidence that was necessary to establish her claim, asked her to assist in obtaining any outstanding medical records, and asked her to identify any other evidence or information supporting her claim. The purpose behind the notice requirement is satisfied, as the appellant has been afforded a meaningful and full opportunity to participate in the processing of her claim. Regarding the duty to assist, the RO obtained service medical records and records of postservice treatment the veteran received for his varicose veins (and for non-service- connected problems). Additional development has been undertaken to ensure that all pertinent medical records were secured and associated with the claims file. The appellant, including via her attorney, alleged that June 6, 1978 treatment records (when the veteran was allegedly seen for a right leg blood clot) were outstanding. And in written argument dated in January 2002 the attorney points to notations on the veteran's appointment card showing a date of July 6, 1978 as reflecting "error in the facts that have been accepted as true in this case" (because the date shown was after the veteran died). Despite the fact that the appellant had previously reported that the veteran's last VA visit was May 17, 1978, VA arranged for an exhaustive search for June 1978 records, which proved fruitless, and the appellant was so advised. On close review of the record, the undersigned found that rather than reflecting any error in the record, the cited documents reflect consistency in VA record-keeping and, along with more contemporaneous statements by the appellant that the veteran's last VA clinic visit was on May 17, 1978, contra-indicate that there was additional VA treatment in June 1978. The record of the veteran's May 17, 1978 VA clinic visit shows that he was to be scheduled for follow-up on July 3, 1978. The document cited by the appellant and her attorney as reflecting first that he was seen in June 1978, then that there were errors in the record, is in fact an appointment card which shows that the veteran was scheduled to be seen on May 17, 1978 (of which visit there is a record), then was first scheduled for follow-up on July 3, 1978, with that date crossed out and revised to July 6, 1978 (perhaps because of the Independence day holiday). It has also been alleged on behalf of the appellant that records of the veteran's treatment by VA in 1978 were destroyed by fire. That allegation is inconsistent with the fact that such records are associated with the claims file. In December 2004, VA sought and obtained a VHA advisory opinion in this matter. The appellant, through her attorney, submitted additional evidence and argument (with a waiver of RO review). She has not identified any further pertinent evidence outstanding. VA's assistance obligations are satisfied. The appellant is not prejudiced by the Board's proceeding with appellate review. Mayfield v. Nicholson, 19 Vet. App. 103 (2005). II. Factual Background The veteran's service medical records reflect that varicose veins of the right lower leg were noted in April 1943, and also on service separation examination in September 1945. Postservice evidence includes VA medical records, which show that the veteran underwent multiple abdominal surgeries, including colostomy, ileostomy and cholecystectomy from 1967 to 1969. He was found to have Pickwickian syndrome. Upon hospitalization in 1970, he was referred to the psychiatric clinic due to heavy drinking. During hospitalizations in 1971 and 1972 and on VA examination in 1973, varicose veins were noted bilaterally, as well as chronic alcoholism/ethanol excess. In October 1973, the veteran was hospitalized at the Philadelphia VA Medical Center (VAMC) for drainage of a left leg hematoma, after dropping a garage door on his left leg. Examination of the extremities at that time revealed varices of the right leg saphenous system which were thrombosed. There were also varicosities of the left leg short saphenous system. VA outpatient treatment records of the veteran from 1974 to 1975 show that he sought treatment for swelling of both legs in December 1974. An undated record from the orthopedic clinic notes varicose veins. On VA examination in January 1975, the veteran gave a history of right leg thrombophlebitis a few years prior which lasted five days. The diagnosis was tortuous, gross, palpable varicosities with saccular varicosities in both saphenous systems of the right leg. On the left, the diagnosis was milder tortuous varicosities. There was venous incompetency of the superficial systems. VA treatment records of the veteran from 1977 to 1978 primarily show treatment for obesity and hypertension. Elevated blood pressure with venous insufficiency was noted in April 1977. Venous varices of the right leg with 1+ edema of the right ankle were noted in May 1977. In February 1978, the veteran noted that he was a compulsive drinker. Bilateral lower extremity varicosities were noted in January and March 1978. The veteran reported in April 1978 that he drank 1/4 to 1/3 gallon of wine each night. He was seen for a check up for high blood pressure and weight control on May 17, 1978. The examiner indicated that he was doing poorly with weight reduction, but his blood pressure was under good control. There were no complaints or findings pertaining to the lower extremities. The veteran died on June [redacted], 1978. A report from the Peninsula General Hospital Medical Center shows that he was dead on arrival at the hospital. A June 16, 1978, investigation report from Earl L. Royer, M.D., a deputy medical examiner of the Office of the Chief Medical Examiner, notes that according to the veteran's wife he had been in failing health for years. He was followed by the VA hospital once a month for various problems and was an alcoholic. On the day of his death the veteran stated that he did not feel well and went to sit in the back of his car. When checked on by friends, he was lying on the floor; when propped up, the veteran said he would be O.K. When checked on again two hours later, it was discovered that he had apparently ceased to breathe, and an ambulance was called. He was dead on arrival at the Pensacola General Hospital Medical Center. His blood alcohol level was .34%. The cause of death was determined to be acute alcoholism. The veteran's original death certificate, prepared by Dr. Royer in June 1978, listed the cause of his death as acute alcoholism. A June 1978 toxicology laboratory report shows that the veteran's blood alcohol content was 0.34 %. No autopsy was performed. At the time of the veteran's death, service connection was in effect for varicose veins of the right leg, rated 40 percent. The appellant originally claimed entitlement to service connection for the cause of the veteran's death in 1978. She stated that the veteran was not a heavy drinker and that he died from poor circulation caused by his service-connected varicose veins. The appellant wrote to Dr. Royer in October 1981 and requested that the veteran's death certificate be revised, as acute alcoholism could not have been the cause of his death. She stated that VA obtained the veteran's blood test report and found that it was under the lethal percentage range. She further stated that the veteran had a severe problem with his right leg and was treated at the VAMC in Philadelphia, Pennsylvania, for thrombophlebitis on May 17, 1978. She indicated that VA doctors felt that the veteran's death was caused by a blood clot in the right leg, and that all of his medical records from the 10-year period prior to his death were thoroughly examined and showed no alcohol in his blood. She stated that VA would provide her benefits only if the death certificate was rectified. Dr. Royer thereafter referred the veteran's case to Russell S. Fisher, M.D., the Chief Medical Examiner, for review. In a November 1981 letter to Dr. Royer, Dr. Fisher indicated he would have handled the veteran's case similarly since while a blood alcohol level of .34% was not a fatal level, the veteran had been sitting in the back seat of his car for quite some time and it was no doubt much higher. However, as pulmonary embolus or some other cause of death could not be ruled out, Dr. Fisher had no serious objection to changing the death certificate to read "chronic thrombophlebitis complicating bypass surgery for obesity - natural causes." Dr. Royer wrote to the appellant in November 1981 and stated that although Dr. Fisher agreed with his assessment in the case, he felt that there was no real problem in changing the death certificate to eliminate alcohol. The veteran's death certificate was revised by Dr. Royer in November 1981 to reflect that the immediate cause of death was chronic thrombophlebitis, with "[o]besity bypass surgery" being a significant condition contributing to death but not related to the terminal disease or condition. In February and June 1992 statements, the appellant disagreed with the denial of service connection for the cause of the veteran's death, stating that on June 6, 1978, the veteran was seen at the VA hospital for blood clots in the right leg, and was given medication for the condition. She submitted a copy of the reverse of a VA Patient Data card which listed dates from June 1977 through July 1978 at which time medication was dispensed. In a September 1997 letter, Nicholas C. Cavarocchi, M.D. indicated that he reviewed the veteran's death certificate, letters from his wife to VA, a letter from Dr. Royer, and a summary of evidence and judicial actions. He also interviewed the appellant and her daughter about events leading up to the veteran's death. In his letter, Dr. Cavarocchi suggested that the veteran died from a pulmonary embolus, a complication of thrombophlebitis, and cited statistics concerning the frequency of occurrence of pulmonary embolus at death. He noted that prior to his death, on May 17, 1978, the veteran was treated for an episode of thrombophlebitis of the right leg. He was uncertain as to why the veteran's treatment included outpatient management and no anticoagulants. Significant risk factors for pulmonary embolus were noted to include a history of severe ilio-femoral thrombophlebitis, which Dr. Cavarocchi appeared to relate to the veteran's service- connected varicose vein disability. Additional risk factors for the veteran included obesity, age, and extensive postoperative procedures for gastric stapling procedure. Dr. Cavarocchi stated "If one was to even consider that the death certificate is factual, then the true cause of death was most likely pulmonary embolus." He stated that the veteran had numerous significant risk factors for pulmonary embolus, including a history of severe ilio- femoral thrombophlebitis, and opined that the cause of the veteran's death "is directly related to his previous disability which was varicose vein/phlebitis for which he was originally disabled." A copy of Dr. Cavarocchi's extensive curriculum vitae, showing that he has expertise in cardiothoracic surgery, was attached to the letter. The appellant and her daughter offered several lay statements in support of her appeal, including in written documents, at a hearing at the RO in December 1983, and at a hearing before the undersigned in August 1998. The appellant indicated that she had been a nurse. She and her daughter asserted that the veteran's service-connected varicose vein condition caused or substantially contributed to his death. She testified that he was reportedly treated for thrombophlebitis at the VAMC on May 17, 1978. Treatment included elastic stockings, but no blood thinner. She stated that the veteran was not an alcoholic and that there had been a mix-up with his death certificate. She indicated that the funeral director told her that the veteran's death was caused by a blood clot. A friend of the veteran's testified in 1983 that the veteran did not have a problem with alcohol. In an August 1998 letter to the appellant, A. Y., D.O., cited several textbooks to facilitate the descriptions of certain venous disorders and generally linked the presence of pulmonary embolism to deep vein thrombosis; it was stated that more than 95% of pulmonary emboli arise from thrombosis in the deep venous system of the lower legs. In March 1999 the case was remanded by the Board for review by a specialist in cardiology. The Chief of Cardiology at the Philadelphia VAMC (L.F., M.D.), who was a professor of Medicine at the University of Pennsylvania and President of the American Heart Association in Pennsylvania, reviewed the entire claims file and multiple medical texts and provided a medical opinion in May 1999 with an addendum in August 1999. He recounted the veteran's history in detail, indicating that Dr. Cavarocchi's opinion that the veteran probably died of pulmonary embolus was based upon acceptance of information in the death certificate that the veteran suffered from chronic thrombophlebitis and had an episode of thrombophlebitis one month prior to his death. He noted that the medical examiner changed the veteran's death certificate three years after his death to attribute death to thrombophlebitis based upon information provided by the appellant. He further noted that there was no mention of leg tenderness, venous cords, or other evidence of venous thrombosis or thrombophlebitis in VA clinical notes dated on May 17, 1978. The only evidence of superficial thrombophlebitis was in 1973, five years prior to the veteran's death. He stated that there was no evidence that the veteran suffered from deep vein thrombophlebitis at any time, much less during several months prior to his death. He provided clarifying statistics concerning the occurrence of pulmonary embolism upon death. In conclusion, he opined: Since varicose veins can be a risk factor for deep vein thrombosis and deep vein thrombosis can cause pulmonary emboli, it remains a possibility that the varicose veins are related to [the veteran's] cause of death. However, in the absence of documentation of deep vein thrombosis despite ample evidence of regular medical care and in the absence of autopsy evidence or other clinical evidence supporting pulmonary emboli, the possibility that varicose veins contributed to [the veteran's] cause of death is a speculative possibility that is no more likely than other possible causes of death. Specifically, it is my opinion that it is not at least as likely as not that the veteran's service connected varicose vein disability caused his death or contributed substantially or materially to cause his death. Furthermore, I conclude that it is not at least as likely as not that the veteran's service connected varicose vein disability aided or lent assistance to the production of his death. The appellant's attorney then secured a January 2004 medical opinion by Craig N. Bash, MD, specialist in neuro-radiology. Dr. Bash stated that it was his opinion that the veteran's service-connected varicose veins caused his demise by way of pulmonary embolus. Dr. Bash based his opinion, in part, on the following: the death certificate (revised) listing chronic thrombophlebitis as the cause of death; the appellant's October 1981 statement that doctors felt the veteran died of a blood clot; the fact that the veteran had service-connected varicose veins; the fact that varicose veins are positively associated with deep vein thrombosis (citing Table 84-1 of Cecil's Textbook of Medicine, 2001[sic], p. 443 [sic] as support) which is positively associated with pulmonary embolus; and a history that the veteran made multiple medical visits for thrombophlebitis and varicose vein problems prior to his demise. Dr. Bash noted supporting medical opinions on file, and stated his reasons for disagreeing with the VA cardiologist's August 1999 opposing view. In March 2004, Dr. Bash submitted a letter buttressing his January 2004 opinion. In August 2004, the appellant's attorney submitted copies of previously submitted medical records, including an April 1977 VA outpatient treatment record that noted increased (by way of an upward-pointing arrow) "BP" (blood pressure) and venous insufficiency. Having characterized the upward pointing arrow (?) as a T, the appellant's attorney asserted that "TBP" evidenced the presence of thrombophlebitis. In December 2004, VA sought and obtained a medical opinion from JAC, MD, Assistant Professor of Surgery (Vascular Surgery) at the School of Medicine at Washington University in St. Louis. Dr. JAC noted that the veteran's medical history was significant for the following: morbid obesity; hypertension; jejunoileal bypass with complications resulting in hospitalization (1967-68); persistent ventral hernia; bilateral lower extremity saphenous varicosities and venous insufficiency (right saphenous vein described as thrombosed in one evaluation in October 1973); and alcohol use requiring treatment for withdrawal. Dr. JAC stated that with the veteran's history and the clinical scenario at the time of his death, the veteran's death could have been caused by pulmonary embolus, ventricular arrhythmia, acute stroke, or obstructive apnea. He stated that if pulmonary embolus is the cause of the veteran's death, it could only be related to the veteran's venous circulation through the development of deep venous thrombosis. Dr. JAC found that this diagnosis was never established in the veteran. He noted that while the veteran had venous disease in the form of superficial varicosities in the right leg, he had no documented history of diagnostic testing to delineate the etiology and extent of his venous insufficiency. Also, the veteran never had any testing performed to document the presence or absence of deep vein thrombus. Dr. JAC noted that while the veteran had one report of a history of superficial thrombophlebitis in 1973, he thought such a finding was a mistake, as the veteran's varicosities were isolated varicose veins and because the veteran was never treated with anti-coagulation medication (blood thinners), as would be the case if he had deep vein thrombosis. Also, he noted that none of the other records of medical treatment within the five years prior to the veteran's death noted evidence of superficial thrombophlebitis, while records from the year prior to his death noted varicosities and pedal edema. Dr. JAC went on to state that even if it is assumed that the veteran had superficial thrombophlebitis, there would only be a 10 to 20 percent chance that this would progress to deep vein thrombosis. He extrapolated further to assert that the presence of deep vein thrombosis does not necessarily result in pulmonary embolism. Based on this reasoning, Dr. JAC found that the evidence did not support a finding that the veteran's service-connected varicose vein disability was as likely as not causally related to his death. Dr. JAC went on to respond to each of the prior medical opinions of record. With regard to Dr. Cavarocchi's opinion, he noted that that opinion was based on the belief that the veteran had thrombophlebitis or severe ilio-femoral thrombophlebitis - findings for which there is no documentation. With respect to Dr. Bash's opinion, Dr. JAC noted out that Dr. Bash's recitation of "associations" between various conditions says little about causal connections and likelihoods. He found it remarkable that Dr. Bash interpreted the amended death certificate listing thrombophlebitis as the cause of death to presume it a medical fact that the veteran died from a pulmonary embolism. He noted that this interpretation ignores other possible causes of death and ignores the significant political pressure placed on the medical examiner to revise the death certificate many years after the death of the veteran. In February 2005, Dr. Bash submitted a response in which he presented arguments to the points raised by Dr. JAC. Dr. Bash re-asserted his belief that the veteran's service- connected varicose vein disability contributed to the veteran's death based on the following: the veteran had a 1973 superficial thrombophlebitis in the right leg; superficial thrombophlebitis significantly increases the development of deep venous thrombosis; and that the veteran died of an unknown cause that may have been pulmonary embolus. In a March 2005 opinion, Dr. Butler concurred with Dr. Bash's opinion that the veteran, at least as likely as not, died suddenly of an acute pulmonary embolus that came from his documented diseased, venous system of his lower extremities. In support, Dr. Butler stated that it was documented that the veteran had acute thrombophlebitis in the past and had varicosities in the groin bilaterally. He noted how there was documentation in medical treatise of instances where thrombus extended into the deep system at the perforating veins and more commonly at the point the superficial system empties into the deep system in the groin, and instances where pulmonary embolus can occur in these circumstances. III. Legal analysis Service connection may be established for the cause of a veteran's death when a service-connected disability "was either the principal or a contributory cause of death." 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312(a). The issue involved will be determined by exercise of sound judgment, without recourse to speculation. 38 C.F.R. § 3.312(a) (emphasis added). A service-connected disability is the principal cause of death when that disability, "singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto." 38 C.F.R. § 3.312(b). "In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. 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)(1) (emphasis added). Therefore, service connection for the cause of a veteran's death may be demonstrated by showing that the veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. Neither the initial (1978) nor the revised (1981) death certificate lists the veteran's sole service connected disability, right leg varicose veins, as the immediate cause of his death, and it is not alleged otherwise. The appellant's claim is premised instead on a theory that the veteran died of a pulmonary embolus due to deep vein thrombosis which was a complication of thrombophlebitis which, in turn, was caused or aggravated by the service connected right leg varicose veins. The Board must base its decision not on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record or adequate quotation from recognized medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The record includes both medical evidence that supports the appellant's claim and medical evidence that is against the claim. Evidence in support of (or tending to support) the appellant's claim includes the revised death certificate issued in 1981, a September 1997 opinion from Dr. Cavarocchi, an August 1998 letter from Dr. Young, opinions from Dr. Bash (January 2004, March 2004 and February 2005), and a March 2005 opinion from Dr. Butler. Evidence against the appellant's claim includes the May/August 1999 VA doctor's opinion and the December 2004 VHA opinion. The Board must weigh this evidence and determine whether the preponderance of the evidence supports the claim or the evidence is in equipoise (in which case the claim would be allowed) or whether the preponderance of the evidence is against the claim (in which case the claim must be denied). In making its determination the Board must analyze the credibility and probative value of the evidence, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). First, we have the revised death certificate which lists thrombophlebitis as the immediate cause of the veteran's death and post-bypass surgery obesity as a contributory cause. This item of evidence is significant, as the listed immediate cause of death is the basis for later medical opinions supporting the appellant's claim that the veteran's service connected varicose veins contributed to cause his death. The Board finds that the probative value of this document as establishing the cause of the veteran's death must be viewed in light of the revising official's explanation for the revision, i.e., that he was requested to do so by the appellant, that she advised him that the blood alcohol level found was under the lethal range, that the veteran was treated for a severe right leg problem when he was last seen by VA on May 17, 1978 (a fact not supported by the record), that doctors at the hospital felt the veteran's death was caused by a blood clot (also not otherwise noted in the record), and that she could not get VA benefits unless the death certificate was amended to delete alcoholism as the cause of death. The certifying official informed that he consulted with his supervisor who indicated that he agreed with the official's initial assessment, but noted that a pulmonary embolism or some other cause could not be ruled out. The supervisor indicated that "cardiorespiratory arrest" was useless as a cause of death for statistical purposes, and that he would have no serious objection to revising the cause of death from alcoholism to thrombophlebitis complicating bypass surgery for obesity, natural causes. The Board finds that "chronic thrombophlebitis" was recorded as the veteran's cause of death (revised) based solely, it is readily apparent, on the inaccurate history provided by the appellant. The opinion from Dr. Young is general in nature, and does not appear to be based upon the particular facts of this case or on a review of this veteran's medical records. There is no indication that Dr. Young reviewed the claims file, and she made no mention of the facts of this veteran's case and rendered no medical opinion concerning this case. Dr. Cavarocchi's opinion that the veteran died of pulmonary embolus has limited probative value because it is premised on incorrect factual assumptions, i.e., that the veteran was being followed for chronic thrombophlebitis, and that he had an episode of right leg thrombophlebitis on May 17, 1978. In fact, no treatment record after 1973 reports any findings of thrombophlebitis, and when the veteran was seen on May 17, 1978, it was in follow-up for obesity and hypertension, and there was no mention of lower extremity complaints, and specifically no mention of complaints or findings pertaining to thrombophlebitis. The history of thrombophlebitis cited by Dr. Cavarocchi was provided by the appellant, and is unsupported by clinical data. The Board is not required to accept doctors' opinions that are based upon the appellant's recitation of medical history. See e.g. Owens v. Brown, 7 Vet. App. 429 (1995). The opinions of Dr. Bash are also premised on acceptance, as fact, of statements by the appellant that are not supported by the medical evidence of record. Dr. Bash indicated that he based his opinion, in part, on the (revised) death certificate identifying chronic thrombophlebitis as the cause of death, the appellant's October 1981 statement that doctors felt the veteran died of a blood clot, and the veteran's history of multiple medical visits for thrombophlebitis prior to his demise. None of these assumptions is supported by the medical evidence of record, and a medical opinion resting on such assumptions can be afforded limited probative weight. While Dr. Bash points to a positive association in medical history between varicose veins and deep vein thrombosis, careful review of Table 84-1 (Cecil's) which is cited in support of that proposition does not identify such association. Furthermore, no evidence has been provided supporting a chain of events from varicose veins to deep vein thrombosis to pulmonary embolism in this case. Finally, it is noteworthy that the opinion by Dr. Butler also begins with acceptance, as fact, of the unsupported statement that the veteran suffered from chronic thrombophlebitis. From there Dr. Butler points to instances in medicine where thrombophlebitis can extend to the deep venous system at the groin, and where it is possible for an embolus to occur in these circumstances. [It is also significant, regarding the scenario proposed by Dr. Butler, i.e., that the veteran "curled up on the floor" on the back seat of his car for several hours "passed out" due to an inebriated state, resulting in "Travelers' thrombosis", that in such a scenario, the veteran's alcohol abuse becomes the underlying cause of the condition that caused his death. If that is the case, compensation for the cause of death would be prohibited by law. See 38 U.S.C.A. § 1110.] Each of the medical opinions favoring the appellant's claim begins with the acceptance, as fact, of statements regarding the veteran's medical history that are not supported in the record, and, upon that tenuous basis these opinions proceed to speculate as to the possible chain of developments that may have led from varicose veins to thrombophlebitis to deep vein thrombosis to death by pulmonary embulus. The opinions, individually or cumulatively, do not establish without resort to speculation, as the law requires (see 38 C.F.R. § 3.312(a) that the proposed chain of events occurred in the instant case. The Board finds that substantial probative weight must be given to the opinion of the May/August 1999 VA opining physician (Dr. L.F.) because he reviewed and provided a detailed account of the veteran's medical history which is consistent with the treatment records, and based his opinion upon that history, without resorting to speculation or facts not in evidence. He also provided a detailed rationale for his opinion that it was not at least as likely as not that the veteran's service-connected varicose veins caused his death or contributed substantially or materially to cause his death or aided or lent assistance to the production of his death. Likewise, greater probative weight must also be given to the VHA opinion by Dr. JAC in December 2004. Dr. JAC reviewed the entire claims file, complete with all prior medical opinions and carefully laid out the medical facts shown by the evidence and identified the statements accepted in some opinions as fact - though not shown by evidence. He thoroughly detailed the many possible causes of the veteran's death, without resorting to speculation, and based his conclusion on medical facts shown in the record. Dr. JAC showed nuanced consideration of conflicting findings when he reported that the veteran's history was complicated by the single reference from 1973 of superficial saphenous thrombophlebitis, but stated his belief that this likely was in error based on the fact that no subsequent records identified thrombophlebitis and noted that the veteran was not treated with anti-coagulation drugs (as would have been indicated once thrombophlebitis was established). Dr. JAC provided a sound medical basis for his conclusion that it was not likely that the veteran's varicose veins were related to the cause of his death. He noted that even if the veteran's varicose veins had progressed into thrombophlebitis, there was no evidence of record showing that the veteran had developed deep vein thrombosis or that this condition caused a pulmonary embolus and death. Dr. JAC found the contrary medical opinions of record to be logically flawed in that they relied on presumptions and associations without consideration of the actual medical record or the probabilities of such associations. The Board has also considered the appellant's statement that a funeral director told her that the veteran died from a blood clot. However, "hearsay medical evidence" is not competent medical evidence. See Robinette v. Brown, 8 Vet. App. 69 (1995). In addition, there is no evidence suggesting the funeral director had the medical expertise to ascribe the veteran's death to a blood clot. Similarly, the appellant's daughter's contentions concerning the cause of the veteran's death are not competent evidence. There is no indication that she possesses the requisite medical knowledge or education to render a probative opinion involving medical diagnosis or medical causation. See Edenfield v. Brown, 8 Vet. App. 384, 388 (1995); Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Further, regarding the appellant's statements that the veteran's service-connected varicose veins caused or contributed to his death, at her personal hearing in December 1983, she stated that she had been a nurse; however, there is no evidence in the record documenting her medical credentials. She also has an obvious self-interest in this claim. Regardless, given their respective medical expertise, the Board finds far less probative value in her statements than in the opinions of the VA physician (Dr. L. F.) in May and August 1999 and the VA physician (Dr. J.A.C.) who provided the December 2004 VHA opinion. The VA doctor who performed the 1999 examinations is a specialist in cardiology, and the physician who provided the December 2004 opinion is an Assistant Professor of Vascular Surgery. Both are eminently qualified to opine regarding the cause of the veteran's death. These two opinions are based on review of the entire claims file with detailed rationale, and are found persuasive when considered with the rest of the evidence of record. They rest on documented medical findings, and are not the result of speculation. The preponderance of the evidence is against the claim and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. ORDER Service connection for the cause of the veteran's death is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs