Citation Nr: 1237347 Decision Date: 10/31/12 Archive Date: 11/09/12 DOCKET NO. 05-11 390 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to dependency and indemnity compensation (DIC) under 38 U.S.C.A. § 1151. 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Jeany Mark, Esq. WITNESSES AT HEARING ON APPEAL Appellant and Son ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is the surviving spouse of a Veteran who served on active duty from November 1948 to June 1952, and died in October 2002. This matter is before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). The case was originally before the Board on appeal from a March 2003 rating decision of the Roanoke, Virginia Department of Veterans Affairs (VA) Regional Office (RO). In May 2004, a hearing was held before a Decision Review Officer at the RO. In June 2006, a Travel Board hearing was held before the undersigned. Transcripts of these hearings are associated with the Veteran's claims file. In July 2007, the Board denied service connection for the cause of the Veteran's death and remanded the matter of entitlement to DIC benefits under 38 U.S.C.A. § 1151 to satisfy notice requirements. In March 2009, the Board denied entitlement to DIC under 38 U.S.C.A. § 1151. The appellant appealed that decision to the Court. In August 2010, the Court vacated the Board's March 2009 decision and remanded the matter on appeal for readjudication consistent with instructions outlined in an August 2010 Joint Motion for Remand (Joint Motion) by the parties. In February 2011, additional argument was received from the appellant's attorney. Thereafter, the attorney submitted additional evidence with a waiver of RO initial consideration. See 38 C.F.R. § 20.1304(c). In the interim, the appellant perfected the appeal of an August 2010 decisional letter which declined to reopen the claim of service connection for the cause of the Veteran's death. In her VA Form 9, received in February 2012, the appellant did not request a hearing before the Board in this matter. In February 2012 the Board sought an advisory medical opinion from the Veterans Health Administration (VHA) regarding the matter of entitlement to DIC benefits under 38 U.S.C.A. § 1151. The Board found that clarification of the March 2012 opinion received was necessary. Such clarification was provided in June 2012. In March 2007 and September 2012, the Board sought a VHA advisory medical opinion regarding the matter of the cause of the Veteran's death. Such opinions were received in May 2007 and October 2012, respectively. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran died in October 2002; the immediate cause of his death was coronary artery disease (CAD); no contributory cause was listed. 2. At the time of his death, the Veteran had established service connection (and was receiving compensation at the 100 percent rate) for posttraumatic stress disorder (PTSD) and cold injury residuals of both feet; bruxism was service connected as a symptom of PTSD for dental treatment purposes. 3. It is not shown that the Veteran's death resulted from carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment, or was an event not reasonably foreseeable. 4. An unappealed July 2007 Board decision denied service connection for the cause of the Veteran's death essentially based on a finding that his death-causing CAD was unrelated to his service or to a service-connected disability. 5. Evidence received since the July 2007 Board decision relates the Veteran's death causing CAD to his service-connected disabilities; relates to previously unestablished elements necessary to substantiate the claim of service connection for the cause of the Veteran's death; and raises a reasonable possibility of substantiating such claim. 6. It is reasonably shown that the Veteran's death-causing CAD was aggravated by his service-connected PTSD and cold injury residuals, and that such disabilies contributed to cause his death. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to DIC under 38 U.S.C.A. § 1151 are not met. 38 U.S.C.A. §§ 1151, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.361 (2012). 2. New and material evidence has been received, and the claim of service connection for the cause of the Veteran's death may be reopened. 38 U.S.C.A. §§ 5108, 7104, 7105 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. Service connection for the cause of the Veteran's death is warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1310, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Regarding the matter of service connection for the cause of the Veteran's death, inasmuch as this decision grants the appellant's claim, there is no reason to belabor the impact of the VCAA on this matter, since any notice defect or duty to assist failure is harmless. Regarding entitlement to DIC under 38 U.S.C.A. § 1151, the appellant was advised of VA's duties to notify and assist in the development of the claim. An August 2007 letter explained the evidence necessary to substantiate her claim for DIC under 38 U.S.C.A. § 1151, the evidence VA was responsible for providing, and the evidence she was responsible for providing. The Board acknowledges that the appellant did not receive the August 2007 VCAA notice letter until well after the initial rating decision on appeal was issued; however, various supplemental statements of the case (SSOCs), most recently in August 2011, have readjudicated the matter after the appellant and her attorney responded and further development was completed. Consequently, she is not prejudiced by any technical notice deficiency, including in timing, that may have occurred earlier in the process, nor is it so alleged. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (VCAA timing defect may be cured by the issuance of fully compliant notification followed by readjudication of the claim); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). The Veteran's service treatment records (STRs) are associated with his claims file, and pertinent postservice treatment records have been secured. The Board notes in particular that the August 2010 Joint Motion found that "the veteran's claims file does not appear to contain, nor does the Board [in its March 2009 decision] cite to, any VA treatment records dated after September 20, 2002;" i.e., the period immediately preceding the Veteran's death. The Joint Motion further found that "[r]ecords generated in the weeks prior to the veteran's death at the VAMC may be relevant to the claim on appeal because they may relate to the issue of whether the veteran received this medical treatment without being informed of the reasonably forseeable associated risks or complications." The Board subsequently noted that the Veteran had been hospitalized at the Hunter Holmes McGuire VAMC from June 24, 2002 to July 16, 2002, and from July 16, 2002 to October 20, 2002 and remanded the case for such records, and on remand, the RO was able to secure for the record the Veteran's complete VA treatment records from May 2002 to November 2002 and his January 13, 2003 autopsy report. The RO also secured a January 2005 medical advisory opinion from a physician who reviewed the Veteran's claims file. Following the receipt of additional VA medical records (noted above), the Board also sought a medical advisory opinion from the VHA in February 2012 (with clarification opinion in March 2012); as will be discussed in greater detail below, these opinions (combined) are adequate. The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claims. Legal Criteria, Factual Background, and Analysis Initially, Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and in Virtual VA, with an emphasis on the evidence relevant to this appeal. (The Virtual VA file does not contain any evidence pertinent to the matter at hand.) Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Factual Background The appellant contends that the Veteran's death was caused by VA medical treatment he received for his gout or, alternatively, due to his service connected disabilities. Specifically, the appellant feels, "the medications prescribed to my husband in order for him to live without so much body pain and PTSD had a direct impact on his death. . . . I also feel that the death of my husband was directly related to his disabilities from service in the Korean War Conflict." See November 2002 claim for service connection for the cause of the Veteran's death. The appellant's written statements and her hearing testimony include her allegations that the Veteran's nonservice-connected gout was treated with Prednisone, which caused him to gain over 80 pounds in 7 weeks and contributed to his death, and his cold injury to the feet caused and/or aggravated his cardiovascular disorders. At the time of his death, the Veteran's service connected disabilities included PTSD (rated 100 percent since May 13, 1996) and cold injury residuals of both feet, rated 10 percent each. Bruxism as a symptom of PTSD had also been found service connected (for dental treatment purposes). VA outpatient treatment records show that the Veteran had a history of severe gouty arthritis that made him wheelchair bound in November 1998. VA hospitalization reports dated in September 1999 note that he was admitted with gastrointestinal complaints. His history of gout was noted and he was stable on his current doses of Colchicine and probenecid. VA treatment records note that the Veteran was hospitalized in July 2002 with complaints of a long history of nausea, vomiting, diarrhea and a 20-pound weight loss over the past two months. It was noted that his weight was 146.5 pounds in April 2002 and 135.8 pounds in June 2002. This was within his ideal body weight but at the lower end of it. The Veteran was taking Colchicine for his gout, which had to be decreased because of the diarrhea. An extensive workup for diarrhea was inconclusive, but there was a working diagnosis of irritable bowel syndrome. Then the Veteran developed foot pain which he indicated prevented him from moving from his bed to a chair. He was evaluated by Rheumatology and Podiatry. In August 2002, the Veteran was transferred to the VA Nursing Home Care Unit for long term care. His weight on August 5, 2002, was 132 pounds, uric acid was in normal range, and foot pain was improved on a tapering dose of Prednisone. A Rheumatology consult that same day noted a diagnosis of chronic tophaeous gout with a recent episode of swelling over the lateral left fifth metatarsalphlangeal joint. The Veteran's symptoms were noted to be better on 20 mg Prednisone per day. The VA physician recommended reducing the dose by 5 mg decrements until on none. An August 7, 2002 treatment record notes that the Veteran was to finish Prednisone on August 9, 2002. The Veteran was seen for a gouty flare on August 15, 2002. He was started on Colchicine. An August 20, 2002 Nutrition Progress Note indicated that the Veteran's weight was 134.4 pounds. The Veteran reported that his appetite was "pretty good"; the goal was to prevent additional weight loss. An August 30, 2002 Podiatry Consult report notes that the Veteran was seen with complaints of painful heels. The examiner recommended nail debridement, gel inserts, multi-podas boots, ice massage and stretching. The Veteran's weight on September 16, 2002, was 131.2 pounds. Oxycodone resolved his pain initially, but wore off quickly. Podiatry was considering steroid injection versus Medrol pack. A Medrol pack was started on September 18, 2002. Pain did not improve, and Rheumatology recommended changing to Prednisone on September 20, 2002. The pain did not resolve until high dose steroids were initiated. After several days, the steroids were tapered down to 20 mg. Gout was controlled at that point and further tapering down of Prednisone was planned. The Veteran died in October 2002. He was found unresponsive and never regained consciousness despite cardiopulmonary resuscitation. His death certificate identifies the cause of death as CAD. An autopsy performed by VA found that the Veteran's weight was 100 kilograms (220 pounds). The Final Anatomic Diagnosis Autopsy Report in January 2003 showed: I. Cardiovascular disease, atherosclerotic and hypertensive A. Atherosclerosis, severe, of left anterior descending coronary artery. B. Myocardial infarction, old, of apex of interventricular septum. C. Atherosclerosis, severe, of aorta, descending to bifurcation. 1. Aneurysm, saccular, 4 cm diameter, of descending thoracic aorta immediately distal to left subclavian artery. 2. Aneurysm, fusiform, of right iliac artery. 3. Arterioarteriolonephrosclerosis, severe bilateral. D. History of (2) cerebral insults. 1. Infarcts, old, of superficial occipital lobes, bilateral. 2. Infarcts of right inferoposterior cerebellum, 3.0 cm diameter. E. Status post right carotid artery endarterectomy. F. Recurrent diarrhea presumed secondary to ischemic colitis. II. Subpleural pulmonary scarring and bronchiectasis. III. Adrenals. A. Cortical atrophy, bilateral. B. Extramedullary myeloid (marrow) metaplasia. IV. Osteoporosis. V. Arthritis. A. Rheumatoid arthritis. B. Osteoarthritis. C. Gout with olecranon bursitis. D. Status post left total knee replacement. VI. Status post: A. Cholecystectomy. B. Appendectomy. C. Amputation right third and fifth toes. [Notably, an October 2002 Provisional Anatomic Diagnosis Autopsy Note includes a finding of "I. Probable pneumonia right upper and lower lobes" and does not include "II. Subpleural pulmonary scarring and bronchiectasis."] As to entitlement to DIC under 38 U.S.C.A. § 1151, in a January 2005 medical opinion, a VA physician stated: 1. C-file [claims file] reviewed and it is at least as likely as not that the weight gain veteran experienced in the last month of life contributed to causing death. 2. It is at least as likely as not that the weight gain was due to the steroids he was taking for his gout. 3. Medical literature was reviewed and it is less likely than not that the gout condition was due to or the result of cold injuries he incurred during combat service in Korea. 4. It is at least as likely as not that weight gain was the result of nutrition provided during hospitalization and medical treatment ([P]rednisone). 5. It is less likely than not that the weight gain was the result of carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on VA's part in furnishing hospital care. Hospital care and treatment was furnished with the veteran's consent. Weight gain is an event that may occur in patient's taking [P]rednisone in the dose provided to [the Veteran]. The appellant has submitted medical treatise materials in support of her allegation that the veteran's PTSD caused and/or aggravated his cardiovascular disease. These articles suggest that PTSD adversely affects a number of distinct biological systems, including the central and peripheral sympathetic nervous system, the hypothalamic-pituitary-adenocortical axis, the endogenous opioid system, and the diurnal sleep cycle. One theory posits that PTSD may cause excessive sympathetic reactivity and adrenergic dysregulation increasing the vulnerability to cardiovascular disorders such as hypertension and atherosclerotic heart disease. Some studies document that PTSD patients manifest increased rates of nonspecific ECG abnormalities, atrioventricular conduction defects and infarctions suggesting that long-term, severe psychological stress may be a clear marker for CAD. One article suggests that depression itself may be an independent risk-factor for subsequent cardiovascular death. A September 2005 statement from K.D.S., M.D., (Dr. S) of Sutherland Family Practice, Inc., indicates that he had treated the veteran from 1986 to 1989 for CAD and chest pain. The Veteran was observed to have an affective disorder with suspiciousness and irritability. Upon review of the medical record, Dr. S indicated that it was clear the Veteran's death resulted from a myocardial infarction due to coronary disease. It was noted that medical literature reported a correlation of an increased risk of a fatal myocardial infarction in patients who suffered from PTSD. In the Veteran's particular case, it appeared his aspects of major depression placed him at a much higher risk of CAD and early death. Dr. S stated that a strong case could be made that the Veteran's depression resulted from his PTSD and Korean experience. Dr. S opined that, after review of the records, it was likely that the Veteran's advanced coronary disease and resultant myocardial infarction were a result of his war experience and resultant PTSD, major depression and hypertension. In March 2007, the Board sought a VHA medical advisory opinion from a VA cardiologist as to whether the Veteran's PTSD caused and/or aggravated an underlying cardiovascular disorder and, if so, whether such cardiovascular disorder materially contributed to the cause(s) of the Veteran's death. In a May 2007 response, a VHA medical expert reviewed the claims file and opined: My review of the association between CAD/MI using standard medical textbook, and UpToDate [a clinical knowledge database] did not yield known strong causative association between PTSD and subsequent CAD/MI. On Medline search, one recent study on WWII and Korea War veterans by Kubzansky and colleagues found increased risk for all of the CHD outcomes combines (nonfatal myocardial infarction, fatal CHD, and angina) at 1.21 (95% confidence interval, 1.05-1.41). This study, however, has been criticized for confounder bias that limits its generalizability (see attached critique). It also remains to be replicated in other settings. ... On the other hand, there are several reported cases that suggest mechanisms of interactions between PTSD and underlying CAD. ... Some of the purported mechanisms include medical and therapeutic management non-compliance, EKG abnormalities, lipid disorder, and arrhythmia. These purported mechanisms of actions have not been replicated in well-designed trials and therefore are subject to speculations. In clinical setting, non-compliance (in this case from PTSD) can be a major problem leading to worsening of underlying co-morbid conditions (which, in this cases, is CAD/MI). However, my review of the veteran's in-patient records ... did not indicate that he was refusing treatment. He did not depression (sic) and PTSD but he continued to be on medications. Likewise the discharge summary in 2002 does not indicate non-adherence or issue of capacity to decide treatment (also called competence) among the medical issues. Thus, I find not (sic) specific evidence that the veteran's PTSD had led to non-adherence to therapeutic regimen. In sum, while there are published articles linking PTSD with subsequent CAD/MI, there is no well-designed study that suggests strong consistent association between the two variables. PTSD remains not among the traditional risk factors for CAD. Therefore, from a causative association perspective, it is less likely that the veteran's service-connected condition led to CAD/MI directly. And barring documentation or argument for non-compliance to therapeutic regimen as a result of the veteran's PTSD, it is less likely that the veteran's PTSD has aggravated the underlying CAD/MI. In February 2012, the Board sought a VHA medical advisory opinion from a VA internist in the matter of entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability claimed to have resulted from the Veteran's final VA hospitalization from July 16, 2002 to October [redacted], 2002. In a March 2012 response, a VA Chief of Primary Care reviewed the Veteran's claims file and opined that the "factual evidence indicates that it is less likely than not that the weight gain was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA." The expert explained: Review of supplied VA records in fact shows substantial contradiction in terms of the patients degree of weight gain. Autopsy report from 10/02 indicates weight of "100 kilograms", but progress notes dated up to and including 10/8/02 show weight of 152 lbs or 69 kilograms. Autopsy report from January 2003 does not include a weight but would likely not if in fact it was a re-examination of the patient's tissues only. Thus, while patient does appear to have gained weight (approximately 22 lbs.) over the course of his prolonged hospitalization from June of 2002 to October 2002, the total weight gain may be overestimated if the autopsy weight was incorrect as was more likely to be the case given repeated weight measures in progress notes from September to October indicating a gradual increase. Examples to support the assertion that the weight gain was more on the order of 22 lbs include: a. p 28, 9/3/02, weight 131 lbs b. p 35, Dr. Harper notes "no edema" c. p 9, Kathy Little RD, 10/8/02, weight 152 lbs., 101%IBW Assuming some degree of weight gain, the question as stated above remains as to whether the treating VA providers should have stopped the prednisone. It is highly important to note that the patient was originally admitted for substantial weight loss and as of 10/8/02, shortly before his death, had finally achieved 101% of his Ideal Body Weight. In that note, p 9 of supplied records, K. Little notes that a new nutritional goal has been set and that further weights would be monitored. This demonstrates a recognition of the weight gain and an alteration in the plan due to this recognition. Further, in examining the question of negligence, carelessness or lack of judgment/skill one must consider the utility/necessity of prednisone in this case. The record demonstrates repeated evidence of significant foot pain despite narcotic pain medications, repeated examinations for said complaint by the primary treating team, podiatry and rheumatology, including xray imaging and serologic testing. The leading diagnosis was gout, and due to age/comorbidities and history of diarrhea, prednisone was likely the ideal treatment choice. Colchicine is associated with diarrhea and it is documented in the veteran's record that diarrhea was a recurrent problem. Other treatments such as intra-articular steroid injections are not ideal for large and complex areas like the foot (meta-tarsal inflammation for example), and uric acid lowering agents are useful for long term prevention but not acute gouty attacks. ... The patients degree of weight gain stands in question due to contradictory information in the medical record. That being said, factual documentation indicates that weights were closely monitored, nutrition assessments were performed appropriately and adjustments to plans were made accordingly. Factual evidence also strongly supports the choice to prescribe prednisone given patients continued gouty pain and lack of safer alternatives. The expert also opined that the Veteran's death was "not reasonably forseeable as a consequence of VA treatment/care provided" and explained: In answering this question there are several important facts to consider. First off, the autopsy report from Dr. [L] date 10/22/02 lists multiple final anatomical diagnoses. It does not include a conclusion as to the cause of death. In fact, it lists "probable pneumonia right upper and lower lobes" as diagnosis "I". It is not possible based on the structure of the report to surmise whether this is standard format or a prioritized list. The death certificate indicates "CAD" but it was signed by a Dr. [N] and not Dr. [L] so the two must be considered in isolation. Furthermore, while it is true that the patient had extensive and severe coronary artery disease, Dr. [L]'s report does not show evidence of an acute arterial thrombosis or myocardial infarction. It makes note of multi vessel arteriosclerosis but not an acute coronary artery occlusion. This is significant in determining the cause of death. Finally, in addition to pneumonia and severe coronary artery disease, the autopsy in this case shows severe atherosclerotic disease of multiple vascular beds throughout the body, prior strokes, ischemic colitis, etc...etc... The autopsy showing severe vascular disease of multiple organs indicates an insidious build up of atheromatous burden over years to decades. Often the burden of disease in multiple vessels goes unrecognized and/or without symptoms. Given the known natural progression of coronary artery disease and other arteriosclerotic forms of illness, it is highly unlikely that this burden developed in a period of months or even a single year. To summarize, factual evidence does not support even the primary premise that the cause of death was in fact coronary artery disease leading to an acute myocardial infarction (no evidence of this on autopsy). It is just as likely that the death was due to an unfortunate combination of multiple factors in this veteran including underlying pneumonia, or ischemic events in other organs and possibly an arrythmogenic milieu. More than likely, the event was unforeseeable and contributed to by multiple factors including decades of chronic illness (whether symptomatic or asymptomatic). In May 2012, the Board found that the March 2012 opinion required clarification as to whether VA treatment/care in any way contributed to the Veteran's death. In a June 2012 addendum (clarification), the expert opined that VA treatment/care did not in any way contribute to the Veteran's unfortunate death and explained: As previously noted, close inspection of the medical record indicates a high likelihood that this patient's death was the result of a sum-total of chronic illness. Though the autopsy indicates the presence of coronary atherosclerosis, it does not indicate acute myocardial infarction. Furthermore, the autopsy found extensive atherosclerotic disease throughout multiple vascular beds, and pneumonia for example, other significant pathologies that could have contributed to his death in various ways. Lastly, even if we were to speculate that this Veteran's death was caused by coronary atherosclerosis, it is unreasonable to assume that this atherosclerotic disease accumulated in a short time and was in any way caused by acute weight gain. Stated in a different way, the VA's treatment/care did not in any way contribute to the observed pathologies on autopsy and thus this patient's death. In September 2012, the Board sought another (updated) VHA medical advisory opinion from a VA cardiologist in the matter of service connection for the cause of the Veteran's death. The Board noted the additional medical treatise evidence submitted by the appellant, the September 2005 medical opinion from Dr. S, the June 2007 VHA medical advisory opinion against her claim, that a Federal Register statement of June 28, 2005, 70 F.R. 37040, established that presumption of service connection was warranted for atherosclerotic heart disease and hypertensive vascular disease for prisoners of war (it was reasoned that presumption of service connection was warranted on the basis that several medical studies had found that veterans who have a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction, and since POWs have a relatively high rate of PTSD incurrence, they would presumably be at risk of cardiovascular disease to include hypertension), and that her attorney had asserted that the Veteran's service-connected cold injury residuals of both feet contributed to cause his death. In an October 2012 response, the VHA medical expert opined that the "veteran's death causing coronary artery disease was definitely aggravated by his service-connected disability, specifically including his PTSD and cold injury residuals of both feet" and the "veteran's death-causing coronary artery disease was related to his service." The medical expert noted that this opinion was based on a review of the Veteran's claims file, updated medical literature and his "personal experience of practicing cardiology for the last 27 years." The expert included "two UpToDate articles" and explained: 1-There is no doubt that chronic stress, heightened sympathetic system activity, acute and or especially chronic is detrimental to many systems of the body including the cardiovascular one. 2-The veteran had more than one established service connected condition; each of them is a reason for chronic stress and chronic sympathetic system activation. Those were the: PTSD, the cold injury residual to lower feet and significant depression. DIC under 38 U.S.C.A. § 1151 When a veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, DIC shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. For claims filed on or after October 1, 1997, as in this case, the appellant must show that the VA treatment in question resulted in additional disability or death, and that the proximate cause of the disability or death was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability was an event which was not reasonably foreseeable. See VAOPGCPREC 40-97; 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. To establish actual causation, the evidence must show that the hospital care, medical or surgical treatment, resulted in the veteran's additional disability or death. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability/died does not establish cause. 38 C.F.R. § 3.361(c). To establish that fault on the part of VA caused the additional disability or death, it must be shown that VA hospital care, medical or surgical treatment, or examination caused the veteran's additional disability and that VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. 38 C.F.R. § 3.361(d). Whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). Informed consent is the freely given consent that follows a careful explanation by the practitioner to the patient of the proposed diagnostic or therapeutic procedure or course of treatment. The practitioner must explain in a language understandable to the patient the nature of a proposed procedure of treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and anticipated results if nothing is done. 38 C.F.R. § 17.32. As outlined above, the record includes medical evidence that tends to both support and refute the appellant's claim that VA treatment caused, or contributed to cause the Veteran's death or the disability or additional disability that was a primary or contributory cause of his death. When evaluating this evidence, the Board must analyze its credibility and probative value, 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). The evidence that tends to support the appellant's claim is the January 2005 VA medical opinion that it is at least as likely as not that "the weight gain veteran experienced in the last month of life contributed to causing death," "the weight gain was due to the steroids he was taking for his gout," and "weight gain was the result of nutrition provided during hospitalization and medical treatment ([P]rednisone)." Recognizing the qualifications of the opinion provider, the Board has given careful consideration to the January 2005 medical opinion and finds it insufficient because it provides conclusory statements without an explanation of rationale. Furthermore, although the VA examiner indicated that the claims file had been reviewed, it is not readily apparent from his opinion what records/information he reviewed in rendering his opinion because he did not discuss the specific weight measurements noted in the Veteran's final treatment records or his other comorbid medical conditions. While claims file review is not required for a medical opinion to have probative value, it must be clear from the record that the opinion provider was aware of any pertinent facts relevant to determining the etiology of a disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008) (finding that the relevant focus is not on whether the clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" in rendering a medical opinion). In contrast, in the March 2012 VHA medical advisory opinion and June 2012 clarification, the consulting physician reviewed the Veteran's claims file, gave consideration to the arguments presented by the appellant, and provided a detailed explanation of the rationale for the opinion. Specifically, the expert noted that, while the Veteran "does appear to have gained weight (approximately 22 lbs.) over the course of his prolonged hospitalization from June of 2002 to October 2002, the total weight gain may be overestimated." Further, the medical expert opined that the record showed "repeated evidence of significant foot pain despite narcotic pain medications" and "due to age/comorbidities and history of diarrhea, prednisone was likely the ideal treatment choice." The medical expert also explained that "[o]ther treatments such as intra-articular steroid injections are not ideal for large and complex areas like the foot (meta-tarsal inflammation for example), and uric acid lowering agents are useful for long term prevention but not acute gouty attacks." Finally, in the June 2012 clarification, the medical expert opined that VA treatment/care did not in any way contribute to the Veteran's unfortunate death and explained that the Veteran's "death was the result of a sum-total of chronic illness" and "it is unreasonable to assume that this atherosclerotic disease accumulated in a short time and was in any way caused by acute weight gain." The medical expert concluded that "VA's treatment/care did not in any way contribute to the observed pathologies on autopsy and thus this patient's death." In evaluating medical opinions, the Board may place greater weight on one medical professional's opinion over another's depending on factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Here, the Board places greater weight on the opinion of the VHA consulting physician that, even assuming the accuracy of the reports of the Veteran's weight gain during his final hospitalization, his death was not the result of acute weight gain and VA treatment/care did not contribute to his death. The opinion of the VHA medical expert is accorded greater probative weight because, by virtue of specialized training and experience, he is eminently qualified to offer the opinion; because the opinion is based on a complete knowledge of the clinical data; and because the medical expert included a rationale for the opinion provided, and considered possible alternative risk factors for the Veteran's death-causing condition. Even assuming that the Veteran's death is the result of acute weight gain due to the steroids he was taking for gout during his final VA hospitalization and medical treatment, to substantiate the appellant's claim for DIC under 38 U.S.C.A. § 1151, the evidence must also show that some element of fault on the part of VA was the proximate cause of the Veteran's death, or that his death was due to an event not reasonably foreseeable. There is no indication in the competent (medical) evidence of record that VA fault (carelessness, negligence, lack of proper skill, error in judgment, et. al.) was in any way a factor in causing the Veteran's death. The January 2005 VA medical opinion, while conceding that VA's treatment of the Veteran with Prednisone, contributed to his weight gain, which contributed to cause his death found it less likely than not that the prednisone treatment related weight gain was the result of carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on VA's part. Similarly, the 2012 VHA medical expert opined that "nutrition assessments were performed appropriately and adjustments to plans were made accordingly" and "due to age/comorbidities and history of diarrhea, prednisone was likely the ideal treatment choice." Thus, not only was there no fault in the Veteran's death due to VA medical treatment, the VHA medical expert opined that it was "the ideal treatment choice." These opinions were based on review of the complete record and the appellant has presented no evidence to the contrary. The standard of medical care provided is essentially a medical question, and, because she is a layperson, the appellant's own opinion that there may have been some fault on the part of VA is not competent evidence in the matter. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As to whether the Veteran's death resulted from an event not reasonably foreseeable, it is noteworthy initially that there is no evidence in the record that the VA treatment alleged to have contributed to cause the Veteran's death was without his informed consent. The January 2005 consulting VA physician noted that hospital care and treatment were furnished with the Veteran's consent and the VHA medical expert noted that the Veteran's death was "not reasonably forseeable as a consequence of VA treatment/care provided." The VHA medical expert referred to the Veteran's autopsy report and explained that "[m]ore than likely, the [Veteran's death] was unforeseeable and contributed to by multiple factors including decades of chronic illness (whether symptomatic or asymptomatic)." In summary, the preponderance of the evidence is against a finding that the Veteran's death following VA treatment for gout was the result of fault on the part of VA, or was the result of an unforeseen event due to VA treatment. The criteria for establishing entitlement to DIC under 38 U.S.C.A. § 1151 are not met, and such claim must be denied. Service Connection for the Cause of the Veteran's Death - New and Material Evidence to Reopen A July 2007 Board decision denied the appellant's claim of service connection for the cause of the Veteran's death based essentially on a finding that it was not shown that the CAD that caused his death was related to his service or a service-connected disability. That decision is final. 38 U.S.C.A. § 7104. Generally, when there is a final decision denying a claim for VA benefits such claim may not be reopened or allowed based solely on the evidence of record at the time of such decision. 38 U.S.C.A. §§ 7104, 7105. However, if new and material evidence is presented or secured with respect to the claim that has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C.A. § 5108. 38 C.F.R. § 3.156(a), which defines "new and material evidence," was revised, effective for all claims to reopen filed on or after August 29, 2001. The instant claim to reopen was filed after that date and the new definition applies. "New" evidence means existing evidence not previously submitted to agency decisionmakers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). The Board finds that the evidence received since the July 2007 Board decision is new and material because it was not before agency decision-makers in July 2007, and directly addresses the unestablished fact necessary to substantiate the claim. Specifically, the July 2007 Board decision denied the claim essentially based on a finding that the Veteran's death-causing CAD was unrelated to his service or a service-connected disability. As described above, after the July 2007 Board decision, the appellant submitted additional (updated) newspaper articles and medical treatise evidence to assert that there is a causal relationship between PTSD and cardiovascular symptomatology, a Federal Register statement of June 28, 2005, 70 F.R. 37040, established that presumption of service connection was warranted for atherosclerotic heart disease and hypertensive vascular disease for prisoners of war because several medical studies had found that veterans who have a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction, and her attorney had asserted that the Veteran's service-connected cold injury residuals of both feet contributed to cause his death. When taken at face value, as is required when determining solely whether to reopen a previously denied claim, the additional evidence received is competent evidence that relates to the matter of a nexus between the cause of the Veteran's death and his service-connected disabilities, and raises a reasonable possibility of substantiating the claim. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010) (Section 3.156(a) "must be read as creating a low threshold" which "suggests a standard that would require reopening if newly submitted evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim."). Thus, the additional evidence received is new and material and is sufficient to reopen the claim of service connection for the Veteran's death. De Novo Review At issue is whether the Veteran's service-connected disabilities (PTSD, cold injury residuals of both feet, and bruxism (service connected as a symptom of PTSD for dental treatment purposes)) played a causal role in his death-causing CAD. To establish service connection for the cause of the Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312(a). In order to constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). It is not sufficient to show that a service-connected disability casually shared in producing death; rather, it must be shown that there is a causal connection. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases (including cardiovascular disease), service connection may be established on a presumptive basis if they are manifested to a compensable degree in a specified period of time postservice (one year for cardiovascular disease). 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The record includes both medical evidence that tends to support the appellant's claim of service connection for cause of the Veteran's death and medical evidence that is against her claim. When evaluating this evidence, the Board must analyze its credibility and probative value, 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). The evidence against the appellant's claim consists of the May 2007 VHA medical advisory opinion that it was less likely than not that the Veteran's service-connected PTSD had caused or aggravated his coronary artery disease/ myocardial infarction. The consulting physician explained that his review of the association between PTSD and coronary artery disease/myocardial infarctions using standard medical textbook and UpToDate did not yield any known, strong causative associations between PTSD and subsequent coronary artery disease/myocardial infarctions. The evidence that tends to support the appellant's claim are the September 2005 statement from Dr. S and the October 2012 VHA medical advisory opinion that the Veteran's death causing coronary artery disease was definitely aggravated by his service-connected PTSD and cold injury residuals of both feet. See October 2012 VHA medical advisory opinion. Although Dr. S. did not refer to specific medical literature in support of his opinion, he had been the Veteran's treating physician from 1986 to 1989 for CAD. The October 2012 VHA medical advisory opinion was based on a review of the Veteran's claims file, updated medical literature and the medical experts 27 years of experience of practicing cardiology. Furthermore, the medical expert included 2 UpToDate articles in support of his opinion. As discussed above, in evaluating medical opinions, the Board may place greater weight on one medical professional's opinion over another's depending on factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Here, the Board places greater weight on the private opinion from Dr. S. and the October 2012 VHA medical advisory opinion as they explained the rationale and the VHA medical expert cited to current medical literature in support of the opinion provided. Notably, the Board finds no reason to question the opinion of the VHA medical advisor given his 27 years of expertise as a cardiologist, and the fact that his opinion was based on an extensive review of the claims file and was accompanied by a detailed explanation of rationale, with citation to the factual data. Resolving reasonable doubt in the appellant's favor, the Board concludes that the competent evidence of record supports her claim. Consequently, service connection for the cause of the Veteran's death is warranted. ORDER Entitlement to DIC under 38 U.S.C.A. § 1151 is denied. New and material evidence has been received, and the claim of service connection for the cause of the Veteran's death, is reopened; service connection for the cause of the Veteran's death is granted on de novo review. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs