Citation Nr: 1306441 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 06-36 863 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Jeffrey J. Bunten, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty from November 1942 to February 1946. The appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri which denied the appellant's application to reopen a claim of entitlement to service connection for the cause of the Veteran's death. The appellant testified at a hearing before the Board in September 2007. In February 2008, the Board reopened the appellant's claim of entitlement to service connection for the cause of the Veteran's death and then denied the claim on the merits. Thereafter, the appellant filed an appeal to the United States Court of Appeals for Veterans Claims (Court). By Court order in August 2008, a July 2008 Joint Motion for Partial Remand was granted, and the appellant's claim was remanded to the Board for additional development. In February 2009, the Board remanded the appellant's claim for further evidentiary development consistent with the July 2008 Joint Motion for Partial Remand. In February 2010, the Board again denied the appellant's claim. Thereafter, the appellant again filed an appeal to the Court. In a November 2010 Joint Motion for Remand, the appellant's claim was remanded to the Board for additional development. In April 2011, the Board remanded the appellant's claim for additional development consistent with the November 2010 Joint Motion for Remand. The case is once again before the Board for adjudication. FINDINGS OF FACT 1. The Veteran died in October 1995; the immediate cause of death was diffuse large cell lymphoma. 2. At the time of the Veteran's death, service connection was in effect for blindness of the right eye rated as 40 percent disabling; marked deformity of the left wrist rated as 30 percent disabling; aneurysm of the right arm rated as 10 percent disabling; left otitis media with perforation and constant tinnitus rated as 10 percent disabling; liver injury due to gunshot wound rated as 10 percent disabling; facial injury due to gunshot wound rated as 10 percent disabling; scar of the left forearm rated as 10 percent disabling; foreign body of the left eye rated as 10 percent disabling; and defective hearing of the right ear rated as noncompensably (0 percent) disabling; the combined rating for these disabilities was 80 percent disabling. 3. The competent evidence does not show that the Veteran's death was caused by an illness or disease incurred in or aggravated by active duty service including exposure to radiation or embedded shrapnel. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1110, 1310 (West 2002); 38 C.F.R. §§ 3.303, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). Certain additional notice requirements attach in the context of a claim for Dependency Indemnity and Compensation (DIC) benefits based on service connection for the cause of death. Generally, notice for a DIC case 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. The content of the notice letter will depend upon the information provided in the claimant's application. Hupp v. Nicholson, 21 Vet. App. 342 (2007); 38 U.S.C.A. § 5103(a) (West 2002). The appellant was provided with the notice criteria required by Hupp in correspondence dated March 2009. Hupp v. Nicholson, 21 Vet. App. 342 (2007). The RO sent correspondence in February 2002, June 2005, and March 2009 and a rating decision in September 2005. Those documents discussed specific evidence, particular legal requirements applicable to the claim, evidence considered, pertinent laws and regulations, and reasons for the decision. VA made all efforts to notify and to assist the appellant with evidence obtained, the evidence needed, and the responsibilities of the parties in obtaining the evidence. The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The appellant has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the August 2012 statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained numerous opinions from both munitions experts and VA physicians. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the appellant is required to fulfill VA's duty to assist her in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In addition, certain chronic diseases may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection for a disability claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by three different methods. Hilkert v. West, 12 Vet. App. 145 (1999); aff'd, 232 F.3d 908 (Fed. Cir. 2000). First, there are certain types of cancer that are presumptively service connected specific to radiation-exposed veterans under 38 U.S.C.A. § 1112(c); 38 C.F.R. § 3.309(d). Second, direct service connection may be established under 38 C.F.R. § 3.303(d) by showing that the disease or malady was incurred during or aggravated by service. Third, service connection may be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is a "radiogenic disease." 38 C.F.R. § 3.311(b)(2),(4) (2012). 38 C.F.R. § 3.311 (2012) sets forth special development procedures for claims based on exposure to ionizing radiation. These procedures apply only if the veteran suffers from a "radiogenic disease" which first became manifest within a specified period. The term "radiogenic disease" includes lymphomas. §38 C.F.R. § 3.311(b)(2)(xxii) (2012) Pursuant to 3.311(a)(2) (2012), radiation dose data information shall be requested from the Department of Defense for claims based on participation in atmospheric nuclear testing or the American occupation of Hiroshima or Nagasaki, Japan, prior to July 1, 1946. 38 C.F.R. § 3.311(a)(2)(i) and (ii) (2012). In all other claims, any available records concerning the veteran's exposure to radiation during service shall be requested. 38 C.F.R. § 3.311(a)(2)(iii) (2012). These records normally include, but are not limited to, the veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service treatment records, and other records which may contain information pertaining to the veteran's radiation dose in service. After being obtained, all such records shall be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. The appellant in this case does not contend that the Veteran participated in atmospheric nuclear testing or the American occupation of Hiroshima or Nagasaki, Japan. Rather, the appellant contends that the Veteran was exposed to high doses of radiation because he had to have numerous x-rays of the abdomen performed in service to monitor shrapnel embedded in his liver. VA has established special procedures to follow for those seeking compensation for diseases related to exposure to radiation in service. See Veterans' Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, 98 Stat. 2725 (1984); 38 C.F.R. § 3.311. This regulation provides that: In all claims in which it is established that a radiogenic disease first became manifest after service . . . and it is contended the disease is a result of exposure to ionizing radiation in service, an assessment will be made as to the size and nature of the radiation dose or doses. When dose estimates provided . . . are reported as a range of doses to which a veteran may have been exposed, exposure at the highest level of the dose range reported will be presumed. 38 C.F.R. § 3.311(a)(1). This regulation establishes a series of chronological obligations upon both parties. Wandel v. West, 11 Vet. App. 200 (1998). First, there must be evidence that the veteran suffered from a radiogenic disease. 38 C.F.R. § 3.311(b)(2), (4). This disease must manifest within a certain time period. 38 C.F.R. § 3.311(b)(5). Once a claimant has established a diagnosis of a radiogenic disease within the specified period and claims that the disease is related to radiation exposure while in service, VA must then obtain a dose assessment. 38 C.F.R. § 3.311(a)(1). After it is determined by the dose assessment that the veteran was exposed to radiation, the RO is then required to refer the case to the Under Secretary for Benefits for further consideration. 38 C.F.R. § 3.311(b). When the claim is referred, the Under Secretary for Benefits shall consider the claim with reference to the factors specified in 38 C.F.R. § 3.311(e) and may request an advisory opinion from the Under Secretary for Health. 38 C.F.R. § 3.311(c)(1). After referral, the Under Secretary for Benefits must then determine the likelihood that the claimant's exposure to radiation in service resulted in the radiogenic disease. 38 C.F.R. § 3.311(c)(1). This section provides two options: (i) If after such consideration the Under Secretary for Benefits is convinced sound scientific and medical evidence supports the conclusion it is at least as likely as not the veteran's disease resulted from exposure to radiation in service, the Under Secretary for Benefits shall so inform the regional office of jurisdiction in writing. The Under Secretary for Benefits shall set forth the rationale for this conclusion, including an evaluation of the claim under the applicable factors specified in paragraph (e) of this section. (ii) If the Under Secretary for Benefits determines there is no reasonable possibility that the veteran's disease resulted from radiation exposure in service, the Under Secretary for Benefits shall so inform the regional office of jurisdiction, in writing, setting forth the rationale for this conclusion. 38 C.F.R. § 3.311(c)(1). Since this determination relies heavily on medical and scientific findings and analysis, the Under Secretary for Benefits may request an advisory opinion from the Under Secretary for Health to assist in carrying out the obligation imposed by this regulation. 38 C.F.R. § 3.311(c)(1) (authorizing the Under Secretary for Benefits to request an advisory opinion from the Under Secretary for Health). A surviving spouse of a qualifying veteran who died of a service-connected disability is entitled to receive Dependency and Indemnity Compensation benefits. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312 (2012). In order to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by active service was either the principal or contributory cause of death. To constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b) (2012). To be a contributory cause of death, the evidence must show that the service-connected disability contributed substantially or materially to the cause of death, or that there was a causal relationship between the service-connected disability and the veteran's death. 38 C.F.R. § 3.312(c) (2012). To be a contributory cause of death, the service-connected disability must be shown to have combined with the principal cause of death, that it aided or lent assistance to the cause of death. It is not sufficient to show that it casually shared in producing death; instead, a causal relationship must be shown. 38 C.F.R. § 3.312 (2012). Service-connected disabilities affecting vital organs should receive careful consideration as a contributory cause of death. That requires a determination as to whether there were debilitating effects and a general impairment of health caused by the service-connected disability which rendered the veteran less capable of resisting the effects of an unrelated disability. 38 C.F.R. § 3.312 (c)(3) (2012). In cases where the primary cause of death is by its very nature so overwhelming that eventual death is anticipated irrespective of coexisting disabilities, there must be a determination as to whether there is a reasonable basis that a service-connected disability had a material effect in causing death. In that situation, it would not generally be reasonable to hold that a service-connected condition accelerated death unless the condition affected a vital organ and was itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4) (2012). The appellant contends that the Veteran's death from diffuse large cell lymphoma was either due to exposure to ionizing radiation from multiple x-rays performed in service or in the alternative that his lymphoma resulted from retained shrapnel in his liver. Another theory put forth is that the Veteran's lymphoma manifested in service as evidenced by an elevated white blood cell count on one occasion. A review of the Veteran's service treatment and service personnel records reflects that the Veteran's military occupation specialty was a gunner in the infantry and he received a variety of wounds in service referred to as "shell wound (high explosive)" from an 88 mm shell in February 1945. The Veteran's decorations and citations include the Purple Heart, American Campaign Medal, Combat Infantryman Badge, World War II Victory Medal, and Good Conduct Medal. The records also reflect that a urinalysis performed in March 1945 revealed "rare WBC" and blood cell count on February 23, 1945, revealed a WBC of 11,300. The service treatment records are negative for any reference to treatment for lymphoma. VA treatment records reflect that the Veteran was seen for an abdominal mass in March 1995 and thereafter diagnosed with high grade diffuse large cell malignant lymphoma of the pancreas. Associated with the claims file is a dose estimation provided by L. McGuire, M.S., DABMP dated in May 2000. Ms. McGuire reviewed a list of x-rays derived from the Veteran's service treatment records which reflects that the Veteran underwent x-rays in service on seventeen different occasions. Of those seventeen x-rays, the Veteran underwent x-rays of his abdomen on two occasions. Ms. McGuire indicated that she provided dose estimates using data from the 1970 XES study scaled for the 1940s. Using bone marrow dose as a surrogate, Ms. McGuire indicated that the dose estimate for the Veteran was 15 rads and represents the dose to the abdomen/whole body. Associated with the claims file is an opinion from S. M., M.D., M.P.H., the Chief Public Health and Environmental Hazards Officer dated in May 2000. Dr. M. indicated that the Director of VA National Health Physics Program estimated that the Veteran was exposed to a dose of ionizing radiation of 15 rads associated with x-ray examinations. Dr. M. indicated that the Committee on Interagency Radiation Research and Policy Coordination (CIRRPC) Science Panel Report Number 6, 1988, does not provide screening doses for lymphoma. According to information in Health Effects of Exposure to Low Levels of Ionizing Radiation (BEIR V), 1990, page 330, no form of lymphoma other than multiple myeloma has been consistently increased following radiation. The Mettler Upton textbook Medical Effects on Ionizing Radiation, 2d edition, 1995, pages 119 and 120, also notes a lack of consistent association between radiation exposure and non-Hodgkin's lymphoma. Based on information from the Toxicological Profile for Ionizing Radiation, Agency for Toxic Substances and Disease Registry, 1999, Table 3-9, page 162, it is estimated that there is about a 6 percent likelihood that development of lymphoma is related to exposure to a dose of ionizing radiation of 15 rads. Dr. M. concluded that it is unlikely that the Veteran's lymphoma can be attributed to exposure to ionizing radiation in service. In March 2002, an opinion was obtained from a VA physician. The physician reviewed the claims file and the Veteran's relevant medical history and noted that the Veteran incurred shrapnel wounds to the left arm, face, and right eye and he sustained a penetrating wound to the abdomen that perforated his liver. The physician noted that the appellant claimed that the excessive number of x-rays the Veteran had in service led to his lymphoma or that the foreign shrapnel bodies contributed to his lymphoma. The physician noted that nothing in the record suggests that the Veteran received any inappropriate dosing of x-rays and it appears that the majority of the Veteran's x-rays were confined to x-rays of the extremities. The physician noted that the Veteran was diagnosed with large cell lymphoma of the pancreas in May 1995. The examiner concluded that there is nothing in the record to suggest that the Veteran's large cell lymphoma was caused by any of his service-connected injuries, was worsened by his service-connected injuries, or accelerated his death. The physician noted that the Veteran's service-connected injuries consisted largely of extremity injuries with no significant symptomatology from the liver laceration that would have contributed to the Veteran's demise. The physician noted that the Veteran's principal cause of demise was directly associated with large cell lymphoma and it does not appear that x-rays taken in service contributed. An advisory opinion was obtained from R. J. H., the Director of Compensation and Pension Services in January 2003. Mr. H. reviewed the record and included reference to the dose estimate based on exposure to ionizing radiation from x-rays and the Veteran's relevant medical history in service. Mr. H. referenced the opinion from Dr. M. and included reference to the medical literature upon which Dr. M. based her opinion. Mr. H concluded that based on the medical opinion from Dr. M. and following review of the evidence in its entirety, there is no reasonable possibility that the Veteran's lymphoma resulted from radiation exposure in service. In a December 2006 opinion, T. Martinez, Ph.D., DABT, ATS, a toxicologist and pharmacologist submitted a statement in which he opined that it is more likely than not that the Veteran's lymphoma was caused or aggravated by the embedded shrapnel from his military service. Dr. Martinez reviewed the Veteran's records and noted the appellant's theories regarding the cause of the Veteran's death. He included numerous articles which document that embedded weapons grade tungsten alloy shrapnel induces cancer of various types in experimental animals. He noted that the onset of cancer is dependent on the amount, solubility, and species and that human beings seem more resistant and delayed effects are the norm. He reported that the heavy metal tungsten alloy particles, which contain tungsten, nickel, and cobalt are used in armor-piercing munitions. Further, that combination has shown synergistic effects on both gene induction and expression to produce neoplastic transformation. Dr. Martinez investigated to see whether tungsten alloys were used in German anti-tank munitions during World War II. He acknowledged that after late 1943-early 1944 German industry was cut off from their main sources of supply in Spain and Portugal but existing supplies continued to be used and limited production continued as some weapons systems were not effective without these munitions. Dr. Martinez noted that abdominal x-rays and magnetic resonance imaging (MRI) studies done in 1995 indicate that there were shrapnel fragments in the Veteran's right upper quadrant consistent with the liver. He indicated that it is not a valid argument that there was no shrapnel in the pancreas because the liver and pancreas are in close approximation and tungsten in known to leach out of sequestration sites and travel to other parts of the body. He conceded that no one measured the Veteran's tungsten serum level during his treatment. Dr. Martinez agreed with VA experts that there is a 6 to 8 percent likelihood that radiation exposure in service was a cause or contributing factor in the Veteran's development of lymphoma. He noted that even old x-rays machines from the World War II era did not produce amounts [of ionizing radiation] that would be expected to cause radiation poisoning. Additionally, most of the Veteran's x-rays in service were done of peripheral areas of the body which would have limited the dose to the abdomen. He concluded that radiation may have played an adjuvant or even a synergistic role in combination with the shrapnel but he did not believe that it was the central cause of the Veteran's lymphoma. He acknowledged that other possible causes of lymphoma are immunodeficiency diseases (inherited, acquired, or autoimmune), viral association, and chemicals or drugs. No other cause for the Veteran's lymphoma was ever identified by his treating physicians so Dr. Martinez concluded that he was left with only the tungsten alloy and shrapnel connection. He opined that it is more likely than not that the Veteran's lymphoma was caused and/or aggravated by the embedded shrapnel from his military service. Numerous articles regarding the effects of tungsten on the development of various cancers including metastatic high-grade rhabdomyosarcomas and childhood leukemia were associated with the opinion from Dr. Martinez. At a hearing before the Board in September 2007, the appellant testified that she married the Veteran in December 1946 and she witnessed him picking pieces of shrapnel out of his hands, arms, and fingers for many years. She indicated that the Veteran had a number of wounds to his abdomen and many scars on the front part of his stomach from the embedded shrapnel. In March 2009, an opinion was obtained from E. H., the Curator of the U.S. Army Ordnance Museum. Mr. H indicated that it is very unlikely that tungsten would have splintered and created "shrapnel" or caused such a wound. He stated that tungsten is so hard that it will penetrate several inches of hardened steel without degradation. The 88mm gun referred to in the Veteran's service records was known for its multi functional capabilities including anti-tank (armor piercing (AP)), anti-aircraft (AA), and field artillery. Mr. H indicated that the only time 88mm would have used the AP ammunition is against armored vehicles. He stated that only the AP projectiles had a tungsten core and no one produced ammunition containing tungsten for high explosive shrapnel shells. He included an illustration of a tungsten core 88 mm AP round. In January 2012, another medical opinion was obtained from a VA physician who reviewed the claims file and opined that it is less likely than not that the Veteran's lymphoma was incurred in or caused by the claimed in-service injury, event, or illness. The rationale for the opinion is that the "rare WBC" in a urinalysis refers to the quantity not the quality or nature of the WBC. He indicated that occasional WBC's in urinalysis test are not uncommon and in all subsequent urinalyses in the service treatment records no WBC's were detected. Further, WBC elevations above normal often occur with infections or trauma to the body. On February 10, 1945, the Veteran was admitted to a military hospital with shrapnel wounds to the abdomen, leg, and face. The wounds were debrided and sutures were placed. The physician concluded that an elevation of WBC's to 11,300 on February 23, 1945, is not surprising and was most likely in response to the inflammation of the wounds. He stated that all later WBC counts in service were normal. An opinion was obtained from G. H., of the U.S. Army Ordnance Training and Heritage Center. Mr. H. reviewed the March 2009 opinion from Mr. E. H., and concurred that there is no plastic cover or filler and the tungsten core is extremely hard and not prone to breaking up on impact with armor steel or any other surface. The aerodynamic body breaks away on impact and the core penetrates, if not passing completely through the target as in the case where it penetrates a tank and bounces around inside. Mr. H. stated that this type of ammunition was very expensive and the German gun crews were very deliberate in choosing a type of round suited to the target at hand. He noted that tungsten core AP rounds would not normally be used on soft targets such as light vehicles, buildings, earth fortifications, or troops in the open. Mr. H. indicated that 88mm anti-aircraft guns proved versatile and were often used as anti-tank (AT) or as field artillery. Tanks carried a mix of HE [high explosive] and AP type rounds for use on targets other than armor. Further, all of the various 88mm guns, AA, AT, and tank main guns used the exact same projectiles and the various 88mm AT rockets were all chemical action weapons (i.e., shape charge using a high heat, metallic gas stream to burn a small hole in armor plate which produced a lot of blast but no significant shrapnel). Mr. H indicated that he could only assume that the Veteran's service records which reference the specific caliber of gun with a high explosive round were correct based on the extent of the Veteran's injuries all over the upper body. He concluded that it was unlikely to have been an AP round of any kind due to the extent of fragmentation causing the Veteran's injuries. The Board concludes that the greater weight of probative medical evidence weighs against a finding that the Veteran's cause of death was caused by or related to his military service including exposure to ionizing radiation or due to embedded shrapnel. As an initial matter, the Board finds that the appellant's opinion is insufficient to provide the requisite etiology of the cause of the Veteran's death because such matters require medical expertise. 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512 (2004); Routen v. Brown, 10 Vet. App. 183 (1997) (layperson is generally not capable of providing opinions on matters requiring medical knowledge, such as the condition causing or aggravating the symptoms); Bostain v. West, 11 Vet. App. 124 (1998); Stadin v. Brown, 8 Vet. App. 280 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, the appellant's statements regarding the Veteran's cause of death being related to his active service, including exposure to ionizing radiation or as due to embedded shrapnel, are merely speculation as she is not medically qualified to prove a matter requiring medical expertise, such as an opinion as to etiology. With regard to whether the Veteran's diffuse large cell lymphoma is related to exposure to ionizing radiation, the medical opinion from the Dr. M., Chief Public Health and Environmental Hazards Officer indicates that it is unlikely that the Veteran's lymphoma can be attributed to exposure to ionizing radiation in service based on the dose estimate provided by a physicist with expertise in such matters. The March 2002 VA physician also concluded that it is not likely that x-rays in service contributed to the Veteran's death due to large cell lymphoma. Both opinions include medical rationales for the conclusions. Moreover, Dr. Martinez agreed that the dose estimate provided by the physicist was appropriate and he concluded exposure to ionizing radiation was not the central cause of the Veteran's lymphoma. In the absence of a medical opinion linking the Veteran's cause of death to his exposure to ionizing radiation as a result of x-rays performed in service, the Board finds that the Veteran's exposure to ionizing radiation did not contribute substantially or materially to the cause of the death, nor is there a causal relationship between lymphoma and exposure to ionizing radiation in service. With regard to the theory that the Veteran's lymphoma was caused by retained shrapnel incurred in service, the Board finds that while Dr. Martinez concluded that it is more likely than not that the Veteran's lymphoma was caused or aggravated by the embedded shrapnel he incurred during his military service, Dr. Martinez based his opinion on the theory that the Veteran's embedded shrapnel was made of a tungsten alloy. However, two different U.S. Army munitions experts opined that it is unlikely that the shrapnel incurred by the Veteran consisted of tungsten alloy. The munitions experts both provided complete rationales for their conclusions. Specifically, it was indicated that it is very unlikely that tungsten would have splintered and created "shrapnel" or caused wounds such as those incurred by the Veteran. Both experts indicated that tungsten is so hard that it will penetrate several inches of hardened steel without degradation. The opinions indicate that no one produced ammunition containing tungsten for high explosive shrapnel shells. The March 2009 expert also indicated that German gun crews were very deliberate in choosing the type of round suited to the target at hand and that tungsten core AP rounds would not normally be used on soft targets such as light vehicles, buildings, earth fortifications, or troops in the open. The Board accepts the munitions experts' opinions as being the most probative evidence on the subject, as they were based on a review of all historical records, and contain detailed rationales for the conclusions. Boggs v. West, 11 Vet. App. 334 (1998). Because of the depth of the opinion reports, and the fact that the opinions were based on a review of the applicable record and their expertise in the area of munitions, the Board finds such opinions are probative and material to the appellant's claim. Owens v. Brown, 7 Vet. App. 429 (1995). The Board does not question the expertise of Dr. Martinez. However, his opinion is based on the inaccurate premise that the Veteran's embedded shrapnel was made of a tungsten alloy which, as noted has been disproved by two munitions experts. Consequently, the Veteran's embedded shrapnel did not contribute substantially or materially to the cause of the Veteran's death, nor is there a causal relationship between lymphoma and embedded shrapnel. The Board has considered the articles submitted by Dr. Martinez. However, medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459 (1996); Libertine v. Brown, 9 Vet. App. 521 (1996). Here, crucially, the excerpts which have been cited to by Dr. Martinez relate to the effects of tungsten alloy and the development of very specific types of cancer among which lymphoma is not included. Furthermore, while some of the articles provide a link between embedded shrapnel made of tungsten and the development of certain types of cancer, as noted, two experts in U.S. Army munitions have determined that the Veteran's embedded shrapnel was not made of tungsten alloy. Thus, the Board finds that these excerpts are not probative regarding the etiology of the Veteran's lymphoma. Finally, with regard to the theory that the Veteran's lymphoma began in service, the only medical opinion of record indicates that it is less likely than not that the Veteran's lymphoma was incurred in or caused by service. The examiner reviewed the Veteran's claims file and noted the relevant findings in service and provided a complete rationale for the conclusion that the urinalysis which revealed rare WBC and the elevated WBC in service on one occasion did not represent lymphoma. The appellant has not submitted any competent evidence which provides a basis for the conclusion that the cause of the Veteran's death was caused or aggravated by his active service. The Board is very sympathetic to the appellant for the loss of her husband. Unfortunately, for the reasons and bases set forth above, the Board must conclude that the preponderance of the evidence is against the appellant's claim, and service connection for the cause of the Veteran's death must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3 (2012). ORDER Entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs