Citation Nr: 1302709 Decision Date: 01/24/13 Archive Date: 01/31/13 DOCKET NO. 07-28 794 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from June 1950 to December 1953 and from September 1954 to July 1971, and died in October 2006. The appellant, who is the Veteran's widow, appealed a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that denied service connection for the cause of the Veteran's death. In a January 3, 2007 letter, the RO advised the appellant's of its determination that denied entitlement to service connection for the cause of the Veteran's death and entitlement to service-connected burial benefits; the cause of death determination was required to determine the amount of burial benefits to be paid. In January 2007, she filed timely notices of disagreement with the RO's denial of her claims for dependency and indemnity compensation (DIC) and burial benefits based on denial of her claim for service connection for the cause of the Veteran's death. In June 2011, the Board of Veterans' Appeals (Board) remanded the appellant's case to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further development. In a September 2012 written statement, the appellant's representative raised an "inferred claim" for accrued benefits to include service connection for hypertension based on clear and unmistakable error (CUE) in an unappealed September 16, 1974 rating decision that denied the Veteran's claim for service connection for hypertension. An article from the Internet regarding heart failure was submitted in support of the claim. While there was no claim of CUE pending at the time of the Veteran's death, the Board refers the matter to the RO for any action deemed appropriate. FINDINGS OF FACT 1. According to the death certificate, the Veteran died in October 2006 at the age of 73, due to congestive heart failure. Other significant conditions that were underlying causes were renal carcinoma and prostate cancer. 2. At the time of his death, the Veteran was service-connected for sinusitis and hemorrhoids with anal fistula, postoperative, each assigned noncompensable disability ratings. 3. Congestive heart failure, renal carcinoma, and prostate cancer, were not present in service, manifested within one year after discharge, or etiologically related to service; and the preponderance of the evidence is against a finding that the Veteran's service-connected disabilities caused or contributed substantially or materially to his death. CONCLUSION OF LAW A disability incurred or aggravated in service, a disability that may be presumed to have been incurred in service, or a disability that is otherwise related to service did not cause or contribute substantially or materially to the cause of the Veteran's death. 38 U.S.C.A. §§ 1110, 1131, 1310, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist In November 2006, October 2007, and September 2011 letters, the AOJ satisfied its duty to notify the appellant under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012) and 38 C.F.R. § 3.159(b) (2012). The AOJ notified the appellant of information and evidence necessary to substantiate her claim. She was notified of the information and evidence that VA would seek to provide and the information and evidence that she was expected to provide. In a September 2007 letter, the appellant was informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the context of a claim for DIC benefits, which includes a claim of service connection for the cause of the Veteran's death, section 5103(a) notice must be tailored to the claim. The notice should include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service-connected. Hupp v. Nicholson, 21 Vet. App. 342 (2007). Unlike a claim to reopen, an original DIC claim imposes upon VA no obligation to inform a DIC claimant who submits a non-detailed application of the specific reasons why any claim made during the deceased veteran's lifetime was not granted. Id. Where a claimant submits a detailed application for benefits, VA must provide a detailed response. Id. The September 2011 letter provided notice consistent with the holding of the United States Court of Appeals for Veterans Claims (Court) in Hupp. VA has done everything reasonably possible to assist the appellant with respect to her claim for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). The Veteran's service treatment and personnel records and VA and private medical records have been associated with the claims file, to the extent available. All reasonably identified and available medical records have been secured. A review of the Veteran's Virtual VA electronic record does not reveal any additional evidence relevant to the claim on appeal. In August 2012, a VA medical opinion was obtained. This examination report is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, and offered an etiological opinion with rationale from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326 (2012). As noted above, in June 2011, the Board remanded the appellant's case to the RO for further development, that included sending the appellant an appropriate notice letter, obtaining the Veteran's Airman Performance reports from the National Personnel Records Center (NPRC), to particularly include his performance reports from June 1970 to July 1971, and obtaining records of his treatment at the Sacred Heart Hospital from October 2004 to October 2006. There has been substantial compliance with this remand, as the appellant was sent an appropriate letter in September 2011 and, in September 2011, the NPRC advised the AMC that all available performance reports were mailed and a report from June 1970 to July 1971 was not a matter of record. Private treatment records from Sacred heart Health Hospital, dated in October 2004 and October 2006, were obtained. The Board finds the duties to notify and assist have been met. II. Legal Analysis The Board has reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). The appellant seeks service connection for the cause of the Veteran's death. In written statements in support of her claim, including in January and December 2007 and August 2012, the appellant asserts that the Veteran was in Vietnam for three months prior to being stationed in Korea in 1969 or 1970 and that exposure to Agent Orange was a known cause of prostate cancer that was one of the causes of his death. In an August 2012 statement, she contends that exposure to Agent Orange may also have been a contributing factor to the Veteran's congestive heart failure. Thus, she asserts that the Veteran's death was caused by his exposure to Agent Orange that was a cause of his prostate cancer and congestive heart failure and caused or contributed to the his death. The appellant further argues that the Veteran suffered from hypertension in service, although it was not diagnosed until after he left service, and it was also a major contributing factor to the congestive heart failure that was the main cause of his death. According to the evidence of record, the Veteran died in October 2006 at the age of 73. An October 2006 death certificate indicates that the immediate cause of the Veteran's death was congestive heart failure. Other significant conditions that were underlying causes were renal carcinoma and prostate cancer. During the Veteran's lifetime, he was service-connected for sinusitis and hemorrhoids with anal fistula, postoperative, assigned noncompensable disability ratings. Service records show that, when examined for enlistment into the United States Air Force in September 1954, the Veteran's cardiovascular and genitourinary systems were normal, his blood pressure was 134/90, and he was found qualified for active service. Clinical records are not referable to complaints or diagnosis of, or treatment for, a cardiac, renal, or prostate disorder, or hypertension. Medical records, dated in March 1969, indicate that the Veteran was evaluated in the clinic because blood pressure readings taken for his employment were 170/100 on two readings. He felt fine and his current blood pressure readings were 135/85 (twice) and 135/80 (once). When evaluated the following week, in April 1969, it was noted that his blood pressure readings for the past week ranged from 140/94 to 124/86 and, currently, it was 130/85. The Veteran was examined for retirement in January 1971, when his blood pressure reading was 136/88, results of an electrocardiogram (EKG) were considered "probably" within normal limits, and a renal, genitourinary, or heart disorder was not noted. Service personnel records show that the Veteran was stationed at Osan Air Force Base in Korea from August 1970 to June 1971; there is no record of his ever being in the Republic of Vietnam (see November 2006 record from the NPRC). The Veteran's available Airman Performance Reports are not reflective of his travel through Vietnam en route to or from Osan, Korea. Thus, he cannot be presumed to have been exposed to herbicides. 38 U.S.C.A. § 1116 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 307, 3.309 (2012). Post service, VA medical records, dated in July 1974, describe the Veteran's treatment for essential hypertension that he had for one year. As noted above, in an unappealed September 1974 rating decision, the RO denied the Veteran's claim for service connection for hypertension. The record shows that the Veteran's history was significant for known coronary artery disease and that he underwent coronary bypass graft surgery in 1992, and coronary angioplasty in approximately 1998, with cardiac catherizations in approximately 1998 and 2000 (see July 5, 2001 Sacred Heart Hospital Admission History and Physical). In 1998, the Veteran was treated for congestive heart failure according to private medical records. He was also treated for adenocarcinoma of the prostate. Private treatment records show that it recurred in 2003. According to December 1998 and January 2003 private treatment records, the Veteran was initially diagnosed with Gleason 6 prostate cancer on the left in September 1997. He did not immediately follow through with any therapy at the Navy (apparently a reference to the Navy Hospital) where he was initially diagnosed. The Veteran underwent pre-hormormal therapy and isolated brachytherapy in June 1999. His prostate-specific antigen (PSA) levels dropped to undetectable levels and the record reflects that he was lost to follow up. The Veteran had an elevated PSA in November 2002 and subsequent tests revealed a Gleason 7 adenocarcinoma on the left. His cardiac condition precluded extensive surgery. A June 2004 private hospital discharge summary shows that the Veteran's admitting diagnoses were acute myocardial infarction, congestive heart failure, and hypertension. His discharge diagnoses were acute myocardial infarction, congestive heart failure, hypertension, renal masses, hematuria, rectal bleeding, and diverticulitis. The Veteran was known to have coronary artery disease and other medical problems and experienced chest pain that he initially believed was indigestion. The pain eased, and then returned, and the Veteran went to the hospital emergency room. His pain was relieved with nitroglycerin and he was admitted for observation. Results of a cardiac catherization revealed significant vascular disease and two stents were placed. A renal ultrasound showed a mass on his left kidney and a computed tomography showed masses on both kidneys thought to be consistent with renal cell carcinoma. Additional diagnostic tests revealed that the Veteran had distal esophagitis, erosive gastritis, and diverticulitis. In August 2004, the Veteran was hospitalized with a history of progressive prostate cancer and underwent a left radical nephrectomy. The private hospital records further reveal that, in October 2004, the Veteran underwent thermal ablation of a right kidney mass. In December 2004, the Veteran submitted a request to reopen his previously denied claim for service connection for hypertension status post heart attacks. His claim was denied by the RO in an unappealed May 2005 rating decision. In reaching its determination, the RO considered the findings of an April 2005 VA examination report that noted his history of hypertension, coronary artery disease, and myocardial infarction in 1992 and 2004. Triple bypass surgery with stent placement was noted in 2003 and 2004. The VA examiner reported two occasions of elevated diastolic blood pressure (88 and 90) while the Veteran was on active duty. The examiner said that all other blood pressure readings were excellent and opined that the Veteran's coronary artery disease was as likely as not caused by hypertension but "hypertension [was] not caused by or a result of active duty". In July 2006, the Veteran was privately hospitalized and underwent a left simple mastectomy for metastatic renal cell carcinoma and a laparoscopic cholecystectomy. On October [redacted], 2006, the Veteran was privately hospitalized for treatment of acute renal failure. His history of bilateral renal cell carcinoma, status post left nephrectomy in 2004 and a history of prostate cancer were noted. The Veteran complained of chest tightness and progressive shortness of breath, and was in atrial fibrillation with rapid ventricular response. The impression was acute renal insufficiency likely exacerbated by volume overload. The Veteran died the next day and the discharge summary includes a history of coronary artery disease, status post bypass surgery in 1992, stent placement in June 2004, chronic atrial fibrillation and congestive heart failure, underlying ischemic cardiomyopathy with ejection fraction during cardiac catherization in June 2004 of 35 percent. Also noted was metastatic renal cell carcinoma with metastases to the breasts requiring left nephrectomy and left simple mastectomy and a history of prostate cancer. An August 2012 medical report indicates that a VA physician noted the Veteran's service-connected disabilities and reviewed private hospital records, dated from June 2004 to October 2006, discussed supra. The VA physician opined that it was less likely than not (less than a 50 percent probability) that the Veteran's service-connected sinusitis and hemorrhoids with anal fistula contributed materially to his cause of death from congestive heart failure, with conditions of renal cell carcinoma and prostate cancer, as underlying causes of death. The VA physician explained that there was no evidence of infection of the Veteran's sinuses in his final admission and essentially normal hemoglobin and hematocrit would preclude bleeding from hemorrhoids with anal fistula contributing to congestive heart failure. Pursuant to 38 U.S.C.A. §§ 1110 and 1131; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). This is a direct service connection theory of entitlement. See Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). Certain chronic diseases, such as cardio-vascular renal disease, including hypertension, arteriosclerosis, and malignant tumors, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). This is also a direct service connection theory of entitlement. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, although the appellant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the appellant is not competent to provide evidence as to more complex medical questions such as the origin of cardiovascular or cancerous pathology. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In order for service connection for the cause of the Veteran's death to be granted, it must be shown that a service-connected disability caused the death, or substantially or materially contributed to cause death. A service-connected disability is one that was incurred in or aggravated by active service, one that may be presumed to have been incurred during such service, or one that was proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.312. The death of a veteran will be considered as having been due to a service- connected disability when such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). The service-connected disability will be considered the principal (primary) cause of death when such disability, either 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). The service-connected disability will be considered a contributory cause of death when it contributed so substantially or materially to death that it combined to cause death, or 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). The debilitating effects of a service-connected disability must have made the Veteran materially less capable of resisting the fatal disease or must have had a material influence in accelerating death. See Lathan v. Brown, 7 Vet. App. 359 (1995). There are primary causes of death, which, by their very nature, are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service- connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(3), (4). The appellant contends that the Veteran's exposure to Agent Orange and hypertension in service caused or contributed substantially or materially to his death. As noted, service treatment records are not referable to complaints or diagnosis of, or treatment for, hypertension, heart, renal, or prostate disorders. Service personnel records are entirely negative for any report of the Veteran's exposure to Agent Orange. Post service, the VA medical records document the Veteran's treatment for hypertension, starting in approximately 1973. Coronary artery disease with bypass surgery was first noted in 1992, prostate cancer was initially reported in 1997, congestive heart failure was initially evidenced in 1998, and renal carcinoma was noted in 2004. Moreover, in April 2005, a VA examiner reviewed the Veteran's medical records, and noted two occasions of elevated diastolic blood pressure (88 and 90) while the Veteran was on active duty. The VA examiner said that all other blood pressure readings were excellent and opined that the Veteran's coronary artery disease was likely caused by hypertension but "hypertension was not caused by or a result of active duty". Furthermore, according to the August 2012 report, a VA physician concluded that it less likely than not that the Veteran's service-connected sinusitis and hemorrhoids with anal fistula contributed materially to his cause of death from congestive heart failure, with conditions of renal cell carcinoma and prostate cancer, as underlying causes of death. The VA examiner explained that there was no evidence of infection of the Veteran's sinuses in his final admission and essentially normal hemoglobin and hematocrit would preclude bleeding from hemorrhoids with anal fistula contributing to congestive heart failure. There is no competent medical evidence of record that refutes the April 2005 and August 2012 VA examiners' opinions. Essentially the only evidence of record supporting the appellant's contentions and claim is her own lay opinion. With regard to specific evidence, the Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). The Federal Circuit has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court indicated that varicose veins was a condition involving "veins that are unnaturally distended or abnormally swollen and tortuous." Such symptomatology, the Court concluded, was observable and identifiable by lay people. Because varicose veins "may be diagnosed by their unique and readily identifiable features, the presence of varicose veins was not a determination 'medical in nature' and was capable of lay observation." Thus, the veteran's lay testimony regarding varicose vein symptomatology in service represented competent evidence. The Federal Circuit, in Jandreau v. Nicholson, 492 F. 3d at 1372, determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. In this instance, the only contrary opinion provided is that of the appellant and endorsed by her accredited representative. Yet, merely the claim has been made that the appellant's husband's death was caused by or the result of his alleged exposure to Agent Orange and hypertension problems experienced during active military service. However, the matter at hand involves complex medical assessments that require medical expertise. See Jandreau. The appellant is not competent to provide more than simple medical observations. She is not competent to provide complex medical opinions regarding whether his service-connected disabilities and military service caused or contributed substantially or materially to the Veteran's cause of death. In other words, she is not competent to provide an etiological opinion. See Barr. The Board would further address the statements made by the appellant. The Federal Circuit has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d at 1335. This would include weighing the absence of contemporary medical evidence against lay statements and then determining its credibility. See Barr. Even though the appellant is competent to express an opinion concerning the cause of her husband's death, competent evidence is still required to show that there is a nexus between his death and military service. Moreover, competent evidence is also needed to show that military service caused or contributed substantially or materially to the cause of death. Here, the appellant's statements are outweighed by the more probative medical evidence that indicates that the provisions of 38 U.S.C.A. § 1310 do not apply to this matter. The medical evidence is most probative as it was based on a thorough review of the medical history, the complete claims folder, and an opinion with rationale was provided. Since the August 2012 VA physician's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VA physician provided a valid medical analysis to the significant facts of this case in reaching his conclusion. In other words, the VA physician did not only provide data and conclusions, but also provided a clear and reasoned analysis that the Court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). The April 2005 VA physician's opinion was similarly based on a review of the relevant medical history and supported by a sound rationale. Id. Thus, the probative and objective medical opinion of record demonstrates that neither exposure to Agent Orange or hypertension in service, nor service-connected disabilities, caused or contributed materially or substantially to the Veteran's cause of death. Service personnel records do not support the appellant's assertion that the Veteran traveled through Vietnam en route to Osan, Korea, and was exposed to Agent Orange. The appellant was not married to the Veteran at the time and she is not shown to have first hand knowledge of his Viet Nam service. She claims that the Veteran told the RO of his Viet Nam service prior to his death, but there is no record of his claiming service in the Republic of Viet Nam during any of his claims for benefits, his correspondence to the RO, or in treatment records. The Board does not find it likely that he had service in the Republic of Viet Nam under the circumstances. Although the Veteran had hypertension, the April 2005 VA examiner found just two occasions of elevated diastolic blood pressure (88 and 90) while the Veteran was on active duty. In the VA examiner's opinion, the Veteran's coronary artery disease was likely caused by hypertension but "hypertension was not caused by or a result of active duty". Finally, while the Veteran was noted to have sinusitis and hemorrhoids with an anal fistula, the August 2012 VA physician expressly stated that it less likely than not that the Veteran's service-connected sinusitis and hemorrhoids with anal fistula contributed materially to his cause of death from congestive heart failure, with conditions of renal cell carcinoma and prostate cancer, as underlying causes of death. The VA examiner explained that there was no evidence of infection of the Veteran's sinuses in his final admission and essentially normal hemoglobin and hematocrit would preclude bleeding from hemorrhoids with anal fistula contributing to congestive heart failure. Thus, the appellant's arguments that the Veteran's exposure to Agent Orange and hypertension in service caused or materially contributed to his prostate cancer, hypertension, and heart problems fails. In short, a clear preponderance of the evidence is against a finding that the alleged Veteran's exposure to Agent Orange or hypertension in service, or his service-connected sinusitis or hemorrhoids with anal fistula, caused or contributed substantially or materially to his cause of death. The Board recognizes the appellant's sincere belief that the Veteran's death was related in some way to his military service. Nevertheless, in this case the appellant has not been shown to have the professional expertise necessary to provide meaningful evidence regarding a causal relationship between the Veteran's death and his active military service, including his service-connected sinusitis and hemorrhoids with anal fistula, or any purported exposure to Agent Orange. See, e.g., Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied 119 S. Ct. 404 (1998). The Board finds a lack of competent medical evidence to warrant a favorable decision. The Board is not permitted to engage in speculation as to medical causation issues, but "must provide a medical basis other than its own unsubstantiated conclusions to support its ultimate decision." See Smith v. Brown, 8 Vet. App. 546, 553 (1996). Here, a clear preponderance of the evidence is against the appellant's claim of entitlement to service connection for the cause of the Veteran's death. ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs