Citation Nr: 1304048 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 09-43 954 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Valerie J. Bahlkow ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran had active military service from July 1946 to March 1947 and died in September 2007. The appellant, who is the Veteran's widow, appealed a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. In September 2010, the Board remanded the appellant's case to the RO for further development. Thereafter, in April 2012, the Board requested a medical opinion, pursuant to 38 U.S.C.A. § 7109 and as set forth in a designated Veterans Health Administration (VHA) Directive, in response to the appellant's claim of entitlement to service connection for the cause of the Veteran's death. See 38 U.S.C.A. § 7109(a) (West 2002) and 38 C.F.R. § 20.901 (2012). See generally Wray v. Brown, 7 Vet. App. 488, 493 (1995). A VHA medical opinion was rendered in May 2012 and a clarifying statement was received in July 2012. In November 2012, the appellant was given an opportunity to present additional argument. She presented further written argument in December 2012. FINDINGS OF FACT 1. The Veteran died in September 2007 at the age of 79, due to cardio pulmonary arrest due to an acute myocardial infarct and pulmonary edema. Diabetes was also listed as a significant condition contributing to his death. 2. At the time of his death, the Veteran was service-connected for bilateral flat feet and chronic lumbosacral pain syndrome and spinal stenosis and spondylolisthesis associated with bilateral flat feet, evaluated as 30 and 40 percent disabling, respectively. 3. Cardio pulmonary arrest, pulmonary edema, and diabetes, 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 As provided for by the Veterans Claims Assistance Act (VCAA), VA has a 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, § 5103(a) notice must include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or her 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, 352-53 (2007). While there are particularized notice obligations with respect to a claim for DIC benefits, there is no preliminary obligation on the part of VA to conduct a predecisional adjudication of the claim prior to providing a § 5103(a)-compliant notice. Here, the appellant was sent letters in October 2007, September 2010, and October 2010 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The 2010 letters provided notice as to how VA assigns an appropriate effective date. The October 2010 letter meets the criteria set forth by the United States Court of Appeals for Veterans Claims (Court) in Hupp. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the appellant in the development of her claim. This duty includes assisting her in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence relevant to the claim on appeal. As noted above, in September 2010, the Board remanded the appellant's case to the RO for further development that included requesting that she return a completed Appointment of Individual as Claimant's Representative (VA Form 21-22a) and sending her a proper notice letter. There has been substantial compliance with the Board's remand as, in October 2012, the appellant submitted a signed VA Form 21-22a, and was provided with a requisite duty to assist letter. Then, in April 2012, the Board requested a VHA medical opinion regarding the claim on appeal and an opinion was obtained in May 2012, with a clarifying addendum obtained in July 2012. The appellant was provided with a copy of that opinion, and the opportunity to respond; she submitted a written response that was received in January 2013. The May 2012 VHA report, with the July 2012 addendum, is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, provided clinical findings and diagnoses, and offered an etiological opinion with a rationale from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326 (2012). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examinations, to the extent available. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the appellant's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Factual Background and Legal Analysis The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although there is 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 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 July 2008 and December 2012, she asserts that the Veteran's service-connected disabilities caused or contributed to the cardio pulmonary arrest due to myocardial infarct and pulmonary edema that caused his death. In her July 2008 statement, the appellant contends that the Veteran's leg injuries in service caused problems walking and poor circulation that caused his below the knee amputation in 2005. In written statements in support of the appellant's claim, her daughters similarly maintain that the Veteran's service-connected disabilities contributed to or caused his death. Thus, the appellant asserts that the Veteran's death was caused by his service-connected disabilities, particularly, his lumbar spine disability, that limited his ability to exercise that contributed to hypertension, hyperthyroidism, and adult onset diabetes and caused or contributed to his death. The Veteran died in September 2007 at the age of 79. The death certificate indicates that the immediate cause of the Veteran's death was cardio pulmonary arrest due to an acute myocardial infarct and pulmonary edema. Diabetes was also listed as a significant condition contributing to death. During the Veteran's lifetime, he was service-connected for bilateral flat feet and chronic lumbosacral pain syndrome with spinal stenosis and spondylolisthesis associated with bilateral flat feet, assigned 30 and 40 percent disability ratings, respectively. Service treatment records show that, when examined for enlistment into service in July 1946, the Veteran's blood pressure reading was 110/70 and his heart and respiratory systems were normal. In November 1946, he was hospitalized for evaluation of Osgood-Schlatter's disease of both knees. He gave a history of having rheumatic fever as a child. When examined at admission, his heart sounds were normal and his blood pressure was 128/78. In December 1946, the Veteran was hospitalized in another medical facility for further evaluation of his knees. When examined at admission, a heart murmur was detected. Heart sounds had a sinus rhythm and his blood pressure was 145/90. When hospitalized in January 1947 for evaluation of his knees, the Veteran's heart and lungs were normal. There is no further evidence in these clinical records regarding a cardiac or respiratory disorder. The subsequent service treatment records show that the Veteran had Osgood Schlatter's disease for which it was recommended that he be discharged. Post service, an unappealed April 1947 rating decision denied the Veteran's claim of service connection for bilateral Osgood-Schlatter's disease. A July 1951 VA examination report revealed no cardiac enlargement. The Veteran's heart sounds had a regular sinus rhythm and no murmur was detected. His blood pressure was 120/80 and a chest x-ray was negative. Subsequent VA and non-VA medical records show that hypertension was treated since 1975 (see April 30, 1991 statement from Dr. P.M.); prostate cancer was diagnosed in approximately 1996 (see January 2002 VA outpatient record); diabetes mellitus was diagnosed in approximately 1999 (see January 2006 VA examination report of the feet); low back pain started in approximately 2000 (see March 5, 2002 VA outpatient record); hypothyroidism was diagnosed in February 2002 (see February 2002 VA outpatient record); and congestive heart failure was noted in May 2005 private medical records. In an unappealed December 1989 RO rating decision, the RO denied service connection for a heart murmur. A July 1990 Board decision denied service connection for a bilateral knee disorder (and a January 1993 Board decision declined to reopen that claim). An unappealed June 1991 RO rating decision, in pertinent part, denied the Veteran's claim for service connection for hypertension. A July 1991 VA examination report includes a self-reported history of having hypertension since 1946 in military service. A diagnosis of degenerative disc disease of the lumbar spine was noted. More recently, VA and non-VA medical records, dated from 2003 to 2007, include a November 2003 questionnaire completed by the Veteran's treating VA clinic physician for the past eight years who said increased foot pain altered the Veteran's posture and gait and caused secondary low back injury. A March 2004 signed statement from a VA orthopedist notes that the Veteran was obese and diabetic and had peripheral neuropathy and stenosis associated with degenerative disc diseases. The Veteran claimed chronic pain and other symtoms from flat feet. An August 2003 VA examination report was cited as reporting mild to moderate flat feet. In October 2004, the Veteran was examined by H.X., M.D., a neurologist, who advised that he take a baby aspirin of 81 milligrams daily and continue his medications for hypertension and diabetes control. When seen by Dr. H.X., on December 4, 2004, the Veteran complained of back pain for which he received pain management and had epidural injections. He had lumbar disc disease and arthritis. The diagnoses included low back pain. The Veteran was privately hospitalized in January 2005 for treatment of staph cellulitis of the right thigh. February and March 2005 private medical records show complaints of right-sided neck pain. Results of a magnetic resonance image (MRI) revealed an abnormal lesion in the cervical spine with significant degenerative disc disease and spinal canal stenosis. A March 2005 whole body bone scan performed by VA revealed findings consistent with recurrence of metastasis in the Veteran's thoracic spine. The Veteran was privately hospitalized from April to May 2005 and underwent a below the knee amputation in May 2005. He had a known history of diabetes and was treated for an infected foot. He also had a lesion on his thoracic spine and a history prostate cancer. While hospitalized, the Veteran had a transient episode of congestive heart failure postoperatively with an elevated "BNP." A cardiology consultation was provided and his congestive heart failure resolved quietly. At discharge, the Veteran had no complaints, his lungs were clear, and his heart was regular. Discharge diagnoses included peripheral vascular disease, gangrene of his foot, diabetes, hypertension, prostate cancer, and degenerative disk disease. Subsequent VA outpatient records, dated during 2005, show that the Veteran received physical therapy and experienced pain with weight bearing on his left leg. An April 8, 2005, record from a neurosurgeon recommended that the Veteran undergo evaluation for questionable diffuse spinal metastatic disease. In September 2005, the Veteran was examined by a cardiologist, according to a record from J. McC., M.D. He was seen for a right leg injury incurred during a fall. His lungs were clear and cardiac evaluation revealed normal first and second heart sounds with an II/VI mid-peaking systolic murmur heard best at the base. Results of an electrocardiogram (EKG) taken at the time revealed a normal sinus mechanism with an inferior wall myocardial infarction, age indeterminate. It was noted that the Veteran had a history of hypertension, noninsulin diabetes mellitus, significant peripheral vascular disease, status post left below the knee amputation, with a remote inferior wall myocardial infarction, and moderate left ventricular dysfunction presently angina free with no evidence of congestive heart failure on medical therapy. The physician stated that the Veteran was "doing well." When seen in the VA emergency room in January 2006, the Veteran complained of worsening anxiety spells since his May 2005 below the knee amputation. He denied pain anywhere. Upon evaluation, he refused to see a psychiatrist and said he was fine. In February 2006 VA, the Veteran was evaluated for bilateral lower extremity spasms associated with urinary incontinence. When privately treated days earlier for similar complaints, results of a computed tomography revealed degenerative changes at L3/L4 and L4/L5 with a vacuum disc phenomenon, severe narrowing of the intervertebral disc spaces and probable disc extrusion, with Grade 1 spondylolisthesis and disc bulge. Records indicate that the Veteran was evidently privately hospitalized in March 2006 and then resumed VA outpatient treatment. An October 2006 VA outpatient record shows that the Veteran was seen for follow-up. He was doing well recently and made advances in his rehabilitation as he walked using the parallel bars. He denied chest pain and shortness of breath. Upon objective examination, neither a cardiac or respiratory disorder was diagnosed. An April 2007 VA examination report regarding the Veteran's bilateral flat feet indicates he was in a wheelchair. His history of below the knee amputation was noted and that he planned to take physical therapy to try and help him walk on his right leg. Clinical findings do not describe cardiac or respiratory disorders. The examiner indicated that the right flat foot was mild and the Veteran was non-ambulatory. An April 2007 VA psychological examination report notes the Veteran's medical history, including treatment for prostate cancer in the 1990s and a recently discovered metastasis to the spine. He had diabetes and, in approximately 2004, was treated for a staph infection in his leg. The Veteran developed a left foot ulcer and had below the knee amputation in 2005. He reported substantial social withdrawal after the amputation and attributed his limitations to his amputation. The Veteran noted that, prior to 2004, he was very active, despite his back pain and foot problems. A May 2007 VA examination report regarding the Veteran's spine reflects a past medical history of diabetes mellitus, type 2, hypertension, congestive heart failure, hyperlipidemia, spinal stenosis, hypothyroidism, and status post left below the knee amputation in May 2005. Results of x-rays of his spine showed advanced degenerative disk narrowing and facet joint arthritis at L3-L4 and L4-L5 as well as minimal forward listhesis of L4 on L5 with no sign of an associated spondylolysis. Diagnoses included chronic low back pain syndrome, degenerative disk disease, spondylolisthesis, and spinal stenosis. The Veteran used a wheelchair and had limited ambulation. According to a July 2007 VA outpatient physical medicine and rehabilitation record, the Veteran was referred for treatment of functional demise after his recent hospitalization. When seen on August 30, 2007, he reported feeling good and looking forward to using a treadmill. According to the Veteran's death certificate, he was privately hospitalized on September [redacted], 2007, and died two days later from cardio pulmonary arrest due to an acute myocardial infarct due to pulmonary edema. Diabetes was also noted as a significant condition contributing to his death. In an October 2010 signed statement, A.G., M.D., the Veteran's primary care physician, opined that the Veteran's service-connected disabilities were contributing factors to the cause of his death. Dr. A.G. did not provide a rationale for his opinion. As discussed above, upon review of the evidence in this case, in April 2012, the Board sought an opinion from a VHA medical expert as to whether it was at least as likely as not (a 50 percent or higher degree of probability) that the disabilities that caused or contributed to the Veteran's death manifested during his military service or were otherwise related to his active duty. The expert was also asked if it was at least as likely as not that the Veteran's service-connected low back and bilateral feet disabilities proximately caused the disabilities resulting in his death. The Board further asked if it was at least as likely as not that the Veteran's service-connected low back and bilateral feet disabilities aggravated (made permanently worse beyond the natural progression of the disease) the disabilities that caused his death, and if it was at least as likely as not that the Veteran's service-connected low back and bilateral feet disabilities caused or substantially or materially contributed to the cause of the Veteran's death. The claims folder was submitted, along with specific questions, to a physician at a VA Medical Center (VAMC) in Asheville, North Carolina. In the May 2012 opinion, the VHA physician opined it "was NOT likely" that the Veteran's service-connected disabilities caused or substantially contributed to the cause of death or aggravated the progression of atherosclerosis. He further opined that it "was NOT likely" that the factors contributing to the cause of the Veteran's death were manifested or otherwise causally related to his active duty service. The VAMC examiner noted the contributing factors to the cause of the Veteran's death (as described in the death certificate). The VHA physician explained that the identified risk factors for atherothrombosis (contributing to cause of death) included hypertension, diabetes mellitus, hyperlipidemia, and a history of smoking. He also observed that the Veteran's other medical history included peripheral vascular disease, inferior myocardial infarction, left ventribular dysfunction, prostate carcinoma, and hypothyroidism. In a July 2012 addendum, the VHA physician responded to the Board's request to provide a rationale for his opinion. He responded by noting that "[t]here is no pathophysiological mechanism whereby Flat Feet could significantly impact the Contributing Factors to Cause of Death which were listed on the Death Certificate." The VAMC examiner found that '[s]evere limitation of physical activity due to any musculoskeletal pain could Contribute to, but not Cause Diabetes Mellitus, hyperlipidemia, or hypertension." In the VHA physician's opinion "it is unlikely that the factors contributing to the Cause of Death were substantially related to his Service-Connected Disabilities." (Emphasis in the original). In her December 2012 written statement, the appellant pointed to "several inconsistencies" in the VHA examiner's opinion. She stated that the Veteran's history of smoking was "insignificant" as he quit over fifty years earlier. The appellant asserted that the VHA examiner did "not unequivocally rule out that the service connected disabilities contributed" to the Veteran's death "since he uses the word unlikely." The appellant said "[w]e all know that if one cannot exercise or even walk very far, this largely contributes to someone battling hypertension, hypothyroidism and lastly adult onset diabetes". 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 and arteriosclerosis, 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 and pulmonary 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). Again, the appellant contends that the Veteran's service-connected bilateral flat feet and low back disabilities caused or contributed substantially or materially to his death. As noted above, service treatment records show that a heart murmur was detected in December 1946 when the Veteran's blood pressure was 145/90 but do not, otherwise, describe complaints or diagnosis of, or treatment for, hypertension or a heart or respiratory disorder. He was discharged from service due to Osgood Schlatter's disease. Post service, service connection for Osgood Schlatter's disease and a heart murmur was denied in the April 1947 and December 1989 unappealed RO rating decisions; service connection for a bilateral knee disorder was denied by the Board in July 1990; and service connection for hypertension was denied in the unappealed June 1991 RO rating decision. The post service VA and non-VA medical records document the Veteran's treatment for hypertension, starting in approximately 1975. Prostate cancer was noted in 1996; diabetes mellitus was noted in approximately 1999; low back pain was noted in 2000; hypothyroidism was noted in 2002; and congestive heart failure was noted in 2005. In a May 2012 VHA report with the July 2012 addendum, a VA physician concluded that it less likely than not that the Veteran's service-connected bilateral flat feet and low back disabilities contributed materially to his cause of death from cardio pulmonary arrest due to acute myocardial infarction and pulmonary edema, with diabetes as an underlying cause of death. The VA examiner explained that there is no pathophysiological mechanism whereby flat feet could significantly impact the contributing factors to cause of death which were listed on the Veteran's death certificate. According to the VA examiner, severe limitation of physical activity due to any musculoskeletal pain could contribute to, but not cause diabetes mellitus, hyperlipidemia, or hypertension. The VHA physician opined that it is unlikely that the factors contributing to the cause of death were substantially related to the Veteran's service-connected disabilities. Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray v. Brown, 7 Vet. App. at 493. The Board does, in fact, adopt the VHA specialist's opinion on which it bases its determination that service connection the cause of the Veteran's death is not warranted. Since the VHA 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 VHA medical expert provided a valid medical analysis to the significant facts of this case in reaching his conclusion. In other words, the VHA 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); see also Wray v. Brown, 7 Vet. App. at 493. The Board therefore places greater weight on the VHA opinion that finds that the Veteran's service-connected bilateral feet and low back disabilities were not the principal cause of death, did not contribute substantially or materially, did not combine to cause his death, and did not aide or lend assistance to the production of his death, than on the October 2010 opinion rendered by Dr. A.G., the Veteran's treating physician, to the effect that the Veteran's service-connected injuries were contributing factors to the cause of his death. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. at 433. But, we are mindful that we cannot make our own independent medical determinations, and that we must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In evaluating the ultimate merit of this claim, the Board ascribes the greatest probative value to the medical opinion provided by the VHA physician who provided the written opinion. This medical specialist had the opportunity to review all the Veteran's medical records regarding the Veteran's death. He explained that the Veteran's identified risk factors for atherothrombosis included hypertension, diabetes mellitus, hyperlipidemia, and a history of smoking. The VHA physician said there was no pathophysiological mechanism whereby flat feet could significantly impact the contributing factors to cause of death noted on the Veteran's death certificate. According to the VAMC physician, while severe limitation of physical activity due to any musculoskeletal pain could contribute to, but not cause, diabetes mellitus, hyperlipidemia, or hypertension, it was unlikely that the factors contributing to the cause of the Veteran's death were substantially related to his service-connected disabilities. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). With respect to the October 2010 opinion of Dr. A.G., the Veteran's treating physician, who stated that the service-connected injuries were contributing factors to the cause of his death, the Board finds that, given the scope and depth of the VHA examiner's rationale, his opinion carries more weight than that of Dr. A.G. Although service connection was in effect for a bilateral flat feet and a lumbar spine disability, service connection was not in effect for a heart disorder, hypertension, or diabetes, nor did the Veteran ever file a claim for a diabetes or respiratory benefit. In other words, Dr. A.G.'s opinion does not support any theory that would warrant a grant of service connection for the cause of the Veteran's death. The appellant does not claim, and the record does not show, that heart or respiratory disability had its onset in service or is otherwise related to active duty. The only matter truly in dispute is whether the Veteran's service-connected bilateral flat feet and low back disabilities caused or contributed to his death. The Board is persuaded that the VHA examiner's opinion settles this dispute and is the most persuasive evidence of record, in that this physician reviewed all the Veteran's medical records, answered the question and provided a rationale for his opinion. See Prejean v. West, Wray v. Brown, supra. Thus, the probative and objective medical opinion of record demonstrates that the Veteran did not die of a disorder due to his period of active military service or a service-connected disability. While, in his October 2010 statement, Dr. A.G. said that the Veteran's service-connected injuries were contributing factors to the cause of his death, he did not report the Veteran having cardiac or respiratory disability. The Board also notes that there were no pertinent cardiac or respiratory symptoms reported in service, aside from the heart murmur noted in December 1946, and no cardiac disorder or symtoms were reported for more nearly 28 years after discharge (when hypertension was noted in 1975). See e.g., Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability.). Here, the appellant has submitted no medical opinion in support of her claim, other than that of Dr. A.G. But, based on the analysis above, the competent medical evidence of record suggests that the Veteran's death from cardio pulmonary arrest due to an acute myocardial infarct and pulmonary edema, due to diabetes, was not at least as likely as not related to his military service including a service-connected disability. Here, the only probative medical opinion of record is against the appellant's claim. Indeed, the preponderance of the evidence is against a finding that the Veteran's death is related to active service, including a service-connected disability. In so finding, the Board has considered the appellant's contention that a relationship exists between the Veteran's death and military service. In adjudicating this claim, the Board must assess the appellant's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). 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 at 30 (citing Owens v. Brown, 7 Vet. App. at 433); 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. at 470-71; 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 her daughters, and endorsed by Dr. A.G., who failed to provide a rationale for his opinion. As the matter at hand involves complex medical assessments that require medical expertise, the appellant is not competent to provide more than simple medical observations. See Jandreau. 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. Here, the appellant's statements as to causation are not probative evidence. By contrast, the response issued by the VHA reviewer is highly probative, as it was based on a review of the pertinent medical history, and was supported by sound rationale. The Board emphasizes that the VHA physician provided a valid medical analysis to the significant facts of this case in reaching his conclusion. See Nieves-Rodriguez v. Peake, 22 Vet App at 295. Thus, the probative and objective medical opinion of record demonstrates that service-connected disabilities die not cause or contribute materially or substantially to the Veteran's cause of death. Although the Veteran had a heart murmur detected in service, there was no other report of a cardiac disorder, or hypertension, or a respiratory disorder, in the service medical records. In the July 2012 addendum, the VHA examiner stated that there was no pathophysiological mechanism whereby flat feet could significantly impact that contributing causes of death listed on the Veteran's death certificate. The examiner stated that severe limitation of physical activity due to any musculoskeletal pain could contribute to, but not cause, diabetes mellitus, hyperlipidemia, or hypertension. The VHA physician concluded that it was unlikely that the factors causing the Veteran's death were substantially related to his death. While, in her July 2008 written statement, the appellant argued that the Veteran's leg injuries in service caused or contributed to problems walking and poor circulation that caused his below the knee amputation in 2005, hospital records show that the Veteran had history of diabetes and an infected foot when admitted in April 2005. Not one medical record associated with the Veteran's below the knee amputation refers to an in-service leg injury. Thus, the appellant's argument that the Veteran's service-connected disabilities caused or materially contributed to his acute myocardial infarct and pulmonary edema, and diabetes fails. In short, a clear preponderance of the evidence is against a finding that the Veteran's service-connected bilateral flat feet or low back disability 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 neither the appellant nor her representative has 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 bilateral flat feet and low back disability. 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. The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs