Citation Nr: 1304069 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 03-00 501 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran had active military duty from April 1969 to May 1971. He died in September 2008; the appellant is the Veteran's widow. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In October 2009, the appellant testified before a Decision Review Officer at the RO; and in April 2011 she testified at a video conference hearing before the undersigned Veterans Law Judge. Copies of the hearing transcripts are associated with the claims folder and have been reviewed. In April 2011, the appellant submitted additional evidence directly to the Board, with a waiver of initial RO consideration of the evidence. This evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. § 20.1304 (2012). In September 2011 this matter was remanded for further development and to address due process issues. After such was completed the matter was returned to the Board, which determined that further development was needed. In September 2012, the Board issued a VHA letter to obtain an opinion from a medical expert regarding the cause of the Veteran's death. In October 2012 a medical expert opinion was returned to the Board. FINDINGS OF FACT 1. According to the death certificate, the Veteran died on September [redacted], 2008 at the age of 60 due to ventricular fibrillation, with the events or conditions leading to the immediate cause of death listed as severe hypoxemia, aspiration pneumonitis, and severe vomiting. Other significant conditions contributing to death but not resulting in the underlying case were end stage renal disease, and chronic ischemic heart disease. The medical records prior to death revealed long term problems with hypertension and diabetes, which progressed to kidney and heart disease. The Veteran was not service-connected for any of the conditions associated with the immediate or underlying cause or any conditions contributing to death. 2. At the time of his death, the Veteran was service-connected for spondylosis with disc herniation, surgical fusion of L4-5 and S1 and lumbar spine failed back syndrome with degenerative disc disease and intervertebral disc syndrome that was evaluated as 60 percent disabling. After his death, service connection was granted for a nondisplaced fracture of the right great toe, with a noncompensable rating assigned. 3. Diabetes, hypertension, heart disease and renal disease were not present in service, manifested within one year after discharge, nor 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 , 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 October 2008 and October 2011 letters, the Agency of Original Jurisdiction (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 the context of a claim for Dependency and Indemnity Compensation (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 Board remanded this matter in September 2011 in part to ensure proper notice in accordance with Hupp was sent to the appellant. The October 2011 letter provided notice consistent with the United States Court of Appeals for Veterans Claims (Court's) holding in Hupp. Since the Board has concluded that the preponderance of the evidence is against the claim for service connection for the cause of the Veteran's death, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The matter was readjudicated in a June 2012 supplemental statement of the case. 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, Social Security 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. The October 2011 Hupp notice additionally advised the appellant to provide medical consent to allow the RO to obtain additional evidence from Dr. WNS at Heartland Medical pursuant to the directives of the remand and request his complete treatment folder and associate it with the record. As noted above, in September 2011, the Board remanded the appellant's case to the RO for further development, which included obtaining additional evidence from Dr. WNS from 1971 and 1972, and if such records were unavailable, requesting Dr. WNS to explain how he recalls specific dates and diagnoses regarding treatment of the Veteran from the early 1970s. There has been substantial compliance with this remand, as the appellant was sent an appropriate letter in the October 2011 Hupp notice but did not respond to the request to authorize the RO to obtain pertinent medical records from Dr. WNS. In October 2012, a VA physician provided a medical opinion. The Board finds that the October 2012 VA medical opinion 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). The Board finds the duties to notify and assist have been met. II. Factual Background and 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 the December 2009 VA Form I-9, the appellant contends that the Veteran's death is connected to his service-connected lumbar spine disability or medication taken for the disability. It has also been suggested that the Veteran had cardiovascular disease and/or diabetes mellitus that had its onset in service or within the first post service year and caused or contributed to the cause of the Veteran's death. The Veteran died in September 2008. During his life, the Veteran was service-connected for spondylosis with disc herniation, surgical fusion of L4-5 and S1 and lumbar spine failed back syndrome with degenerative disc disease and intervertebral disc syndrome that was assigned a 60 percent schedular rating from April 2001. After his death, service connection was granted for a nondisplaced fracture of the right great toe, claimed as a right foot condition at zero percent from August 1999. The Veteran had no other service-connected disabilities. A total disability rating based on individual unemployability was awarded from May 26, 2006, and the appellant received accrued benefits based on this award. The Certificate of Death lists the Veteran's immediate cause of death or final disease or condition resulting in death as ventricular fibrillation. The underlying cause or disease or injury that initiated events resulting in death or conditions leading to the immediate cause of death are listed as severe hypoxemia, aspiration pneumonitis, and severe vomiting. Other significant conditions contributing to death but not resulting in the underlying case were end stage renal disease, and chronic ischemic heart disease. The Veteran was not service-connected for any of the conditions associated with the immediate or underlying cause or any conditions contributing to death. No autopsy was performed. The appellant has asserted that medications prescribed for the Veteran's service-connected lumbar spine disability caused the side effects (such as elevation in his blood pressure), which precipitated his death. Hearing Transcript (Tr.), pp. 8-9. The appellant testified that the Veteran's doctors indicated to her that the pain from the Veteran's back injury caused his blood pressure to be elevated. Tr., p. 7. The appellant submitted medical statements from the Veteran's treating physician, Dr. WNS. In a March 2011 written statement, Dr. WNS noted that the Veteran had hypertension since 1972. He stated that the Veteran had chronic back pain, and the medication for it had made the blood pressure worse. The hypertension was chronic and incurable, and difficult to control. An August 2003 statement noted that the Veteran was found to have diabetes mellitus while on leave from the military on April 11, 1971. Dr. WNS did not include the treatment records or comment on how he recalled the dates of treatment or diagnosis for pertinent disability. As noted in the discussion of VA's duty to notify and assist pursuant to the VCAA, the appellant did not respond to the VA's request to provide further authorization to obtain records or further medical opinion from this doctor. The duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran's April 1969 entrance examination revealed all normal cardiovascular and endocrine findings, with a blood pressure of 130/82 recorded. His report of medical history was negative for any history of any cardiovascular problems including high blood pressure or of any other systemic problems suggestive of diabetes such as sugar in the blood or urine. Service treatment records do not reflect findings or diagnoses of diabetes mellitus or hypertension. A clinical entry dated on July 20, 1970 noted a family history of diabetes mellitus and noted "will get 5 hr GTT". There is a July 1970 entry requesting blood and urine testing for "?Diabetes". The results of that testing are not of record. It was noted that the urinalysis at the discharge examination in April 1971 was negative for abnormality. An April 27, 1971 mental status entry noted that the Veteran had been transferred from the stockade on April 14, 1971 (3 days after the Veteran was reportedly on leave). This mental status entry determined that there were no disqualifying mental or physical defects sufficient to warrant disposition through medical channels. No mention of any diagnosis of diabetes or hypertension is made. His April 1971 separation examination revealed all normal cardiovascular and endocrine findings, with a blood pressure of 120/78 recorded. His report of medical history was negative for any history of any cardiovascular problems, including high blood pressure, or of any other systemic problems suggestive of diabetes, such as sugar in the blood or urine. The Veteran's service personnel records reflect that the Veteran was subjected to disciplinary actions including Article 15's, summary Court martial's and special Court Martial's for being absent without leave (AWOL) multiple times. In pertinent part, the most recent Court Martial report dated April 9, 1971 adjudicated a guilty plea with a sentence to confinement to hard labor for 3 months, as adjudged on April 7, 1971. The AWOL incident precipitating this Court Martial was for a period from January 19, 1971 to March 4, 1971. Thus the history from Dr. WNS of the Veteran having been diagnosed with diabetes mellitus while on leave from the military on April 11, 1971 is not shown to be based in fact. On VA examination in October 1988, the Veteran reported that he had hypertension and diabetes mellitus from 1974 and had been insulin dependent since 1976. At a Board hearing in August 2003, the Veteran testified that he was diagnosed with diabetes mellitus in 1972 within one year of his service discharge. Private treatment records from the early 1980's through 1999 reflect a long standing history of diabetes hypertension and back pain. His blood pressures frequently had systolic readings over 140 and diastolic readings of 100 or higher. His blood sugars were also frequently elevated above 200, and he was noted to be insulin dependent diabetic in these records. A July 1987 psychiatric record reported the Veteran as having taken insulin injections for the past 5 years. These records also revealed persistent issues with severe low back pain with a November 1992 record documenting treatment for severe lumbar back pain due to herniated disc disease, status post laminectomy. The treatment for the lumbar spine is shown to have been primarily with Tylenol 3 from the 1980's through the 1990's, although there were episodes that prompted treatment with additional medication such as in November 1990, when he received a Demerol injection for back pain following a fall. The records from the 1990's also document treatment for other problems such as mental health issues, but include findings suggestive of a strong family history of diabetes and kidney problems as shown in a January 1994 record discussing the recent death of a sister who died from kidney failure due to diabetes, with 2 other sisters noted to also be on dialysis due to diabetes. The Veteran persisted with diabetes and hypertension through the 2000's. Heart problems were apparent in the early 2000's with an April 2002 record revealing that he underwent heart catheterization which diagnosed recent onset of angina pectoris with possible myocardial infarction, arteriosclerotic heart disease, insulin dependent diabetes mellitus, essential hypertension, and hyperlipidemia. He underwent angioplasty with stenting of the occluded artery, which had an 80 percent narrowing of the right coronary artery. He also persisted with low back pain, which continued to be treated with Tylenol 3 in the early 2000's. He underwent lumbar L5/S1 posterior lumbar fusion surgery in December 2003 for a diagnosed L5/S1 degenerative disc disease. At the time of the November 2003 pre surgical consult and the December 2003 surgery, his medications were reported to be insulin, Cardizem, Prevacid, Cyclobenzaprine and Amitriptyline. His medical history was significant in pertinent part for diabetes, hypertension and heart problems in addition to the lumbar spine degenerative changes. In February 2005 the Veteran was evaluated by a private pain management clinic, with a history of low back pain and lower extremity pain, status post 2 surgeries. He was reportedly needing 4 Hydrocodones a day to treat his chronic back pain. His primary care doctor had tried Durogsic patch. His medical providers were described as not comfortable prescribing regular narcotic treatment although he had no history of chemical dependency or addiction. Following examination, he was diagnosed with lumbar radiculitis and status post laminectomy syndrome. Plans for treatment included beginning low dose Avinzo in combination with Hydrocodone and Remerin for sleep pattern. Low dose Neurontin was also prescribed. Additionally he underwent a series of 3 injections with Lidocaine and Depo Medrol from February to March 2005. Towards the end of 2005, his medication regimen for his lumbar spine changed, with records from November 2005 through December 2006 showing he was now prescribed Hydrocodone for his back. Also in September 2006 a note indicated that Lorcet 10 milligrams may be helping, with very little side effects. Additionally he was prescribed a psychotropic drug Xanax for a psychiatric condition during this time period. By 2007, early kidney failure was apparent, as documented in an August 2007 record treating severe back pain. In September 2007, abnormal liver enzymes were shown to be elevated, with renal failure diagnosed. Physical findings included slightly tender abdomen and slightly irregular heart with systolic murmur shown, and scattered rales on pulmonary exam. The records from October 2007 through December 2007 documented continued renal failure, with care under a nephrologist shown in November 2007. The nephrologist who saw him on November 7, 2007, noted a 35 year history of diabetes, with complications of diabetic retinopathy and neuropathy. He was noted to have taken nonsteriodal pain medications and "Goody Powder" for his back pain for a long time, but stopped about 2 years ago. Following examination, the nephrologist diagnosed chronic kidney disease, most likely from diabetic nephropathy. He was noted to be prescribed Hydrocodone-Acetipminophen in other records from November 2007. A December 2007 treatment note indicated that he would possibly be needing dialysis soon. In February 2008 the Veteran was evaluated by a university cancer specialist for possible multiple myeloma, with findings of monoclonal gammopathy and anemia diagnosed. He was noted to be a long time diabetic with treatment for renal insufficiency. The anemia was deemed to be likely due to diabetes and renal insufficiency. Follow-up records from May 2008 and August 2008 continued with this diagnosis with the same opinion as to the cause of the anemia. Other complications manifesting in early 2008 included a diagnosis of congestive heart failure (CHF) for which he was hospitalized in March 2008 following a sudden onset of dyspnea. The diagnosis was hypertension, uncontrolled, diabetes, CHF, chronic kidney disease-severe, cellulitis of the leg from ankle knee and thigh, anemia iron deficiency, long term medications (high risk) and ischemic heart disease. In May 2008 the Veteran was seen for severe lumbar pain, with a long history of renal failure noted. He also was noted to have CHF, edema of the ankles and shortness of breath. He was told not to take any Lasik as it was affecting his kidneys. A long history of arthritis of the back and legs was described as causing a lot of anxiety, nervousness and difficulty sleeping. The assessment included degenerative disc disease, renal failure, CHF and anxiety reaction. The records immediately preceding the Veteran's death reveal on that on September [redacted], 2008, he was taken to the hospital emergency room (ER) following a seizure with history of vomiting at prior to arrival with possible aspiration. He had no prior history of seizures, but continued seizing briefly in the ER. He was hypotensive and mildly bradycardiac, but became apneic with poor air movement before that and rhythm deteriorated to ventricular fibrillation which did not convert and full cardiopulmonary resuscitation was initiated but was stopped and he was pronounced dead after there was no pulse or response for over a half hour. In October 2012 an opinion was obtained by a medical expert following review of the claims folder. The doctor (examiner) reviewed the history of the Veteran's death on September [redacted], 2008, with an apparent seizure which led to ventricular arrthymia and aystole. He became unresponsive after the seizure and had apparently vomited at the time of onset. Soon after arrival at the ER, he developed bradycardia, then subsequently had pulseless electrical activities followed by ventricular tachycardia and fibrillation. Cardiopulmonary resuscitation was initiated but he went into asystole and was then pronounced dead. The cause of death was reported as ventricular fibrillation, results of severe hypoxia, aspiration pneumonitis and vomiting. Historically the Veteran was noted to be service connected in 1999 for back pain, with treatment with Tylenol # with Codeine in the 1990's. He had been treated with a Hydrocodone and Acetaminophen (H & C) combination in various dosages through most of the 2000's until his death. Amitriptyline was added to this combination in 2003. He was under the care of pain management in 2005. This H & C combination was continued, with additions of long acting morphine, gabapentin and mirtazipine tried, but he apparently discontinued these additions thereafter. The pain care records were noted to have been lost to a flood prior to 2007, thus the duration of this treatment combination was unknown. The examiner described the Veteran as having a history of hypertension since 1972 and type II diabetes since 1974. His blood pressure had been poorly controlled, with a note from January 8, 2001 describing his blood pressure as persistently elevated, commenting on an elevated blood pressure of 190/118. The documented blood pressures were well above normal for the majority of his office visits, typically in the severe range. His diabetes was also poorly controlled initially with Hgb A1C noted to be 11.3 on April 29, 2002, but later achieved therapeutic goal. An evaluation by a nephrologist on November 7, 2003 for chronic kidney disease contained a note which mentioned that the use of Naproxen had been discontinued 2 years prior to the evaluation date, with the cause of the kidney disease deemed most likely from diabetic nephropathy. The examiner noted a strong family history reported in a May 5, 2008 office note that stated he would need hemodialysis eventually since 5 of his sisters also had diabetic nephropathy with such dialysis. This suggested a strong family history of diabetes leading to renal failure as a long term complication. The examiner also discussed the question regarding the etiology of the Veteran's cardiac disease. Since hypertension is one of the underlying precipitating factors for coronary artery disease, the question of uncontrolled blood pressure due to back pain was raised. The examiner stated that although general pain can cause an elevation of blood pressure, persistent hypertension can and should be controlled with conventional antihypertensive therapy. There was no documentation of problems with hypotension typically expected for those who have intermittent elevated blood pressure that are inadequately placed on antihypertensive agents. Thus suboptimal treatment of hypertension was evident. The examiner addressed the final event, indicating that the Veteran suffered from seizure which led to cardiac arrest or asystole. There was a question whether his treatment of back pain at the time, during which he was treated with hydrocodone and acetaminophen only, caused a seizure. The examiner stated that it was highly unlikely that he developed a seizure due to regular use of opioid medication, particularly because his medication regimen involved daily dosing. There was no evidence to support that opioid medication, hydrocodone in particular, may cause seizure with regular use. In fact, side effects become minimal after prolonged use of such medications. The vomiting, which led to his aspiration and hypoxia, was probably induced by the seizure, rather than by adverse effects of the medication. The examiner noted that the Veteran already suffered from chronic congestive heart failure, ischemic heart disease and chronic kidney disease which were direct results of his chronic uncontrolled hypertension and long standing diabetes mellitus, perhaps aggravated by tobacco abuse. The examiner concluded that there is no evidence that the Veteran's back pain led to his death, either by the condition or its treatment. The Veteran was debilitated by multiple chronic illnesses that simply could not be linked to therapeutic medications of the past or present. The immediate cause of death is the result of his underlying chronic illnesses such as end stage renal disease and ischemic heart disease as indicated on his death certificate. There was no evidence to support that chronic use of opioids cause ischemic heart disease or renal failure. His chronic medical conditions were the results of his underling medical conditions such as longstanding diabetes mellitus, uncontrolled hypertension and tobacco use. Pursuant to 38 U.S.C.A. § 1110 ; 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. 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 diabetes, and cardio-vascular renal disease, including hypertension, 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). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (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. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). 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. 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). Based on review of the foregoing, the Board finds that service connection is not warranted for cause of the Veteran's death. First the Board notes that the appellant neither claims, nor does the evidence suggest, that the service connected nondisplaced fracture of the right great toe has in any way caused or contributed to the Veteran's death. None of the pertinent evidence has shown any significant treatment or symptomatolgy for this disorder which has been assigned a noncompensable rating. In regards to the claimed contributing disorders of cardiovascular disease/hypertension and/or diabetes, service treatment records do not reflect complaints or diagnosis of, or treatment for, hypertension or heart disorders, or for diabetes other than the questionable entry for diabetes noted in July 1970, without definitive diagnosis shown elsewhere in service, including on separation. Post service, the private medical records document the Veteran's treatment for diabetes, hypertension and back pain, since the early 1980's, with a history reported by the Veteran in the October 1988 VA examination of both the hypertension and diabetes having been diagnosed in 1974, more than a year after service. There are no records from within the first year post service (1972) showing a diagnosis of diabetes or cardiovascular renal disease including hypertension. There is no medical evidence to support the Veteran's history reported in the August 2003 hearing of having been diagnosed with diabetes within a year of his discharge. While the examiner providing a medical expert opinion in October 2012 described the Veteran as having hypertension since 1972 and diabetes since 1974, the history of onset of hypertension in 1972 is inconsistent with more contemporaneous reports and is not credible. The only support for the onset of diabetes having begun during the presumptive period was the Veteran's lay history. Likewise the appellant has submitted contentions in the December 2009 VA form I-9, that the Veteran's hypertension began during the presumptive period. Under certain circumstances, a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). Competency is a question of fact, which is to be addressed by the Board. Jandreau at 1377. In this case, the specific onset date of a diagnosis of either diabetes or hypertension cannot be determined by the Veteran as a lay person based on an inference, which is based personal observation without having specialized education, training, or experience. 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). Furthermore, the history of onset provided by the Veteran is noted to have been inconsistent, with the medical history he provided in the October 1988 shown to be outside the one year presumptive date for the diabetes and the hypertension. Accordingly the Board finds that the preponderance of the evidence is against a finding that service connection for cause of death based on the onset of diabetes or cardiovascular-renal disease including hypertension during service or within the presumptive period. There is also no evidence of a seizure disorder shown in service or at any time prior to his death, with the seizure activity documented on the day of his death shown to have not previously existed. Moreover, according to the October 2012 VHA report, a VA physician concluded that it was not as least likely as not that the Veteran's service-connected lumbar spine disorder, including mediations taken to treat this disorder, caused or contributed substantially or materially to his cause of death. The examiner who provided the October 2012 medical opinion pursuant to the VHA request discussed the contributing factors to the Veteran's death, to include chronic kidney disease deemed to be of diabetic origin, with a strong family history of diabetic nephropathy requiring dialysis noted. Regarding the etiology of the cardiac disease the examiner determined that there was evidence that the Veteran's treatment for his hypertension was suboptimal, as it should have been controlled with conventional antihypertensive therapy. The examiner found that this, rather than his back pain was the cause of his cardiac disease, although acknowledging that pain can temporarily raise blood pressure readings. The examiner pointed to evidence suggesting suboptimal treatment of the blood pressure, to include lack of evidence of occasional episodes of hypotension. As for whether the medications used to treat his lumbar spine disorder caused or contributed to the Veteran's death, the examiner explained that the Veteran was debilitated by multiple chronic illnesses that could not be linked to his therapeutic medications, and that the death was caused by these chronic illnesses including end stage renal failure and ischemic heart disease. The examiner pointed out that there was no evidence that chronic use of opioids cause such chronic illnesses. The examiner also determined that the final seizure episodes culminating in death likewise were not likely caused by his medications to treat his lumbar spine, as regular use of such medications is not shown to cause seizures. In providing the opinion that the Veteran's death was less than likely caused by or the result of his service connected lumbar spine disorder and treatment therein, the VA examiner provided detailed rationale to support such opinion. In support of the claim, the medical statements from Dr. WMS from August 2003 and March 2011 were submitted. These opinions stating that the Veteran's medication for the chronic back pain worsened his hypertension are not supported by a clear rationale. Further, the history upon which Dr. WNS based an opinion that the Veteran had been diagnosed with diabetes while on leave from the military in April 11, 1971, is shown to be inaccurate as rebutted by the service personnel records showing that around that time he was sentenced to confinement to hard labor for 3 months, pursuant to a Court Martial dated April 9, 1971. The appellant has not cooperated with further attempts to obtain additional clarifying evidence from Dr. WNS. In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The opinion is considered probative if it is definitive and supported by detailed rationale. Id. at 448-9. The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further, a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). However, a medical opinion may not be discounted solely because the examiner did not review the claims file. Id. at 304. Where a medical expert has fairly considered all the evidence, her 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.488, 493 (1995). The Board does, in fact, adopt the opinion of the October 2012 VA examiner on which it bases its determination that service connection for the cause of the Veteran's death is not warranted. Since the opinion of the VA physician from the October 2012 VHA opinion was based on a review of the pertinent medical history in the claims folder and electronic record, and was supported by sound rationales, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VA medical expert provided valid medical analyses to the significant facts of this case in reaching the final conclusions. In other words, the VA physician did not only provide data and conclusions, but also provided clear and reasoned analyses, 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; see also Wray v. Brown, 7 Vet. App. at 493. The Board therefore places greater weight on the opinion of the VA physician, that finds that it was less likely as not that the Veteran's service-connected lumbar spine disorder and treatment therein, caused or contributed substantially or materially to his cause of death, than on the opinions rendered by Dr. WNS to the effect that medication used to treat his lumbar spine aggravated the hypertension, and thus contributed to 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. The Board is persuaded that the opinion of the VA physician from the October 2012 VHA examination is most persuasive in that this clinician reviewed all the Veteran's medical records and provided a rationale for the opinion given. See Prejean v. West, Wray v. Brown, supra. 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 lumbar spine disorder and medications taken to treat this disorder therein. 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