Citation Nr: 1318699 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 09-27 832 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and her son ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from March 1952 to July 1979. He died in June 2008, and the appellant is his surviving spouse. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision RO in Muskogee, Oklahoma that denied service connection for the cause of the Veteran's death (which is one basis for Dependency and Indemnity Compensation (DIC)). The appellant and her son testified at a videoconference hearing at the RO in Muskogee, Oklahoma in April 2011, before the undersigned Veterans Law Judge (VLJ) of the Board. The transcript of this hearing has been associated with the claims file. In July 2011, the Board remanded this case to the RO via the Appeals Management Center (AMC) for additional development. The case was subsequently returned to the Board, and in a January 2013 decision, the Board granted entitlement to service connection for posttraumatic stress disorder (PTSD) for accrued benefits purposes, denied entitlement to a rating in excess of 40 percent for service-connected prostate cancer for accrued benefits purposes, and remanded the issue of entitlement to service connection for the cause of the Veteran's death for additional development. In a January 2013 rating decision, the AMC effectuated the Board's decision, and granted service connection for PTSD, effective August 16, 2007, for accrued benefits purposes. The case was subsequently returned to the Board. FINDINGS OF FACT 1. The Veteran served on active duty from March 1952 to July 1979, including service in Vietnam. 2. The Veteran's established service-connected disabilities include PTSD, prostate cancer, tinnitus, tinea pedis, and erectile dysfunction. 3. The Veteran died suddenly at home in June 2008, many years after separation from service. 4. The Veteran's death certificate listed the immediate cause of death as "unknown," possibly due to an abdominal aortic aneurysm rupture, due to or as a consequence of hypertension. 5. The weight of the competent and probative evidence shows that the Veteran's service-connected disabilities were not a cause of his death and did not substantially or materially contribute to his death. CONCLUSION OF LAW A service-connected disability was not a principal or contributory cause of the Veteran's death. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1310 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating claims 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 obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). In Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007), the Court held that in cases specifically involving claims for DIC benefits, this VCAA notice must include: (1) a statement of the conditions, if any, for which the Veteran was service connected at the time of his death; (2) an explanation of the evidence and information required to substantiate the DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate the DIC claim based on a condition not yet service connected. These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the claimant is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). With respect to the claim for service connection for the cause of the Veteran's death, the appellant was provided with pre-adjudication notice in August 2008, prior to the January 2009 decision on appeal. Additional notice was provided in letters dated in February 2009, October 2011, and March 2013. These letters advised her of the type of evidence needed to substantiate her claim for DIC and explained what evidence VA was obligated to obtain or to assist her in obtaining and what information or evidence she was responsible for providing. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. The October 2011 letter complied with Dingess and Hupp, and the March 2013 letter provided additional notice pursuant to Hupp, after the recent award of service connection for PTSD for accrued benefits purposes. Since providing this additional notice, the AMC has readjudicated her claim in an April 2013 supplemental statement of the case. See Mayfield IV and Prickett, supra. The appellant has received all required notice and has had a meaningful opportunity to participate effectively in the development and adjudication of her claim and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Moreover, she has not made any pleading or allegation of insufficient VCAA notice or shown that any such deficiency is unduly prejudicial, meaning outcome determinative of her claim. And as the pleading party, she, not VA, has this burden of proof. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also fulfilled its duty to assist the appellant by obtaining all relevant evidence in support of her claim, which is obtainable, and therefore appellate review may proceed without prejudicing her. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). The RO and AMC obtained the Veteran's service treatment records (STRs), VA medical records, and identified private treatment records, and two VA medical opinions regarding the cause of the Veteran's death. As well, the appellant has submitted personal statements and testimony, letters from the Veteran's physician, a letter from another private doctor, and a copy of the Veteran's death certificate. In DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008), the Federal Circuit Court held that 38 U.S.C. § 5103A(a) does not always require VA to assist the claimant in obtaining a medical opinion or examination for a DIC claim, but that it does require VA to assist a claimant in obtaining such whenever it is necessary to substantiate the DIC claim. The Federal Circuit Court added that there was no duty to provide a VA opinion in a DIC claim under 38 U.S.C.A. § 5103A(d) since this provision is explicitly limited to claims for disability compensation, which is defined as a monthly payment made by VA to a Veteran, and therefore does not pertain to a DIC claim. Id. See also Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008) (holding that, in the context of a DIC claim, VA must also consider that 38 U.S.C. § 5103A(a) only excuses VA from making reasonable efforts to provide an examination or opinion when no reasonable possibility exists that such assistance would aid in substantiating the claim). Here, VA obtained two medical opinions regarding the cause-of-death claim in September 2009 and November 2011, based upon a review of the claims file and medical evidence. This case was remanded in July 2011 and January 2013 to provide the appellant with additional VCAA notice regarding her claims, and to obtain another medical opinion on the cause-of-death claim, and this has been done. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board therefore is satisfied that the duty to assist the appellant with her claim has been satisfied. 38 U.S.C.A. § 5103A. At this time, the Board also notes that it is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Board finds that this was done at the April 2011 Board hearing. Moreover, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. Neither the appellant nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the April 2011 Board hearing. II. Analysis The law provides DIC benefits for a spouse of a Veteran who dies from a service-connected disability. See 38 U.S.C.A. § 1310. A service-connected disability is one that was incurred in or aggravated by active military service or, in the case of cardiovascular-renal disease, including hypertension, which may be presumed to have been incurred in service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year after discharge from service). This presumption, however, is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.303(a), 3.307, 3.309(a). The Veteran's death certificate shows that he died at home in early June 2008. The immediate cause of death was listed as "unknown." The physician who completed the death certificate indicated that the death was possibly due to an abdominal aortic aneurysm rupture, due to or as a consequence of hypertension. Other significant conditions contributing to death but not resulting in the underlying cause included low back pain with leg pain. The appellant believes the Veteran's death was related to his service-connected prostate cancer and was not due to an abdominal aortic aneurysm. See the appellant's September 2008 statement, and her hearing testimony in April 2011. She essentially contends that the Veteran had active prostate cancer which caused his death. The death of a Veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. See 38 C.F.R. § 3.312(a). For a service-connected disability to be considered the principal or primary cause of death, it must singly, or with some other condition, be the immediate or underlying cause, or be etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which contributed substantially or materially to cause death, or aided or lent assistance to the production of death. See 38 C.F.R. § 3.312(c). 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. Id. It is recognized there are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated regardless 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)(4). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); 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); see also Jandreau, supra. The Veteran served on active duty from March 1952 to July 1979. STRs are negative for hypertension and for an abdominal aortic aneurysm, and on retirement medical examination in April 1979, his blood pressure was 132/80. In an April 1979 report of medical history, the Veteran denied a history of high or low blood pressure. There is no evidence of hypertension in the first post-service year, or for several years after the Veteran's retirement from service. In his original Veteran's Application for Compensation or Pension (VA Form 21-526) received in September 1988, the Veteran only claimed service connection for a fungus of the feet, and did not claim service connection for any other disability. On VA examination in November 1988, the Veteran reported that he took medication for high blood pressure, and on examination, his blood pressure was 130/80. Medical records on file reflect that the Veteran was diagnosed with prostate cancer in November 2006, and underwent a prostatectomy. The Veteran filed a claim for service connection for prostate cancer in January 2007. He enclosed a December 2006 letter from his private physician, J.E.M., MD, who indicated that the Veteran had prostate cancer. Private medical records from Dr. M. dated from 2006 to 2007 reflect treatment and follow-up care for prostate cancer. An October 2006 prostate-specific antigen (PSA) was 9.7, and a prostate biopsy showed adenocarcinoma and prostatitis. The Veteran underwent robotic prostatectomy in November 2006. Pathology reports taken immediately after surgery showed extracapsular penetration with some vesicle invasion. A February 2007 note reflects that the Veteran had done well since his prostatectomy, and he had gained complete control. On VA prostate examination in April 2007, the Veteran reported that he had residuals from his treatment for prostate cancer, including occasional incontinence and constant leakage. The malignancy was in full remission for four months with the residual of a dark stain appearing on the pad at times. He told the examiner that his doctor was not sure and could not guarantee that the cancer was all gone. On examination, a PSA test was 0.1 ng/ml, which the examiner indicated that was within normal limits. The examiner diagnosed status post prostate cancer and surgery with residuals of scars, impotency, and incontinence. The residual sequelae from the prostate problem were urinary incontinence and erectile dysfunction. The examiner indicated that the prostate cancer was in remission, that the Veteran had surgery in November 2006, and the treatment was complete at this time. In a May 2007 treatment note, Dr. M. indicated that that the Veteran's bladder control was good, he only wore one pad per day and did not always get it wet. His PSA during the prior month was 0.1, and the doctor was worried about it coming up too quickly, and arranged for another test. However, a May 2007 PSA taken that day was less than 0.1. There are no subsequent records of treatment for prostate cancer from Dr. M. By a letter to the RO dated in May 2007, Dr. M. stated that the Veteran underwent a radical prostatectomy in November 2006, and the surgery was successful. However, his pathology report showed that he had extracapsular extension of cancer and also seminal vesicle invasion. He stated, "He is extremely high risk for having recurrent cancer and by no means is he cured of the cancer at this point." A May 2007 VA urology note reflects that the urology department had received Dr. M.'s letter showing that the Veteran had good urinary control and excellent PSA response. The Veteran's private primary care physician, Dr. F., diagnosed him with history of prostate cancer in March 2007. In a July 2007 note, Dr. F. diagnosed hypertension, peripheral edema and history of mild hyperlipidemia. She noted that he was status post prostate surgery over six months ago, but did not diagnose any residuals. Rather, she indicated that overall his health remained good. In September 2007, although she diagnosed several other conditions, she did not diagnose prostate cancer. In May 2007, the Veteran requested a higher rating for service-connected prostate cancer, contending that his cancer was not cured. In contrast, on initial VA psychiatry evaluation in August 2007, the Veteran reported that he had prostate cancer but said he was currently in full remission and doing well. VA medical records dated in 2008 are negative for recurrence of prostate cancer. A January 2008 primary care note reflects that the Veteran was seen for a recheck and laboratory tests. Laboratory tests showed that his PSA was .05. The physician diagnosed urinary tract infection and history of prostate cancer. VA medical records reflect that on May 19, 2008, the Veteran was seen for complaints of low back pain since doing exercises on Friday night. He reported that he was seen at a private hospital emergency room and diagnosed with muscle strain. He complained of low back pain with radiating pain down the back of his legs when he stood or walked. On examination of the abdomen, there was a 4-5 centimeter midline pulsation. He denied nausea, vomiting or abdominal pain. His blood pressure was 136/73. His current medications included daily medication for hypertension. He said his pain was at a level of 8. On examination, there was normal alignment and curvature of the lumbar spine, and the pain localized to the L5 level. There was no tenderness, mass, or spasm. The abdomen had normal bowel sounds, and a 4-5 centimeter midline pulsation. There was no tenderness or organomegaly. A report of a May 19, 2008 X-ray study of the lumbosacral spine reflects that the Veteran had low back pain and a pulsatile abdomen. The X-ray study showed lumbar degenerative changes and an apparent abdominal aorta diameter of about 4 centimeters. The clinical diagnostic assessment on May 19, 2008 was (1) low back pain, with symptoms more consistent with low back pain and sciatica rather than an abdominal aortic aneurysm, and (2) possible abdominal aortic aneurysm. An ultrasound was ordered with respect to the latter assessment. There are no subsequent VA treatment records of the Veteran. A June [redacted], 2008 VA medical note reflects that a telephone call was received from the medical examiner, who informed the VA Medical Center of the Veteran's death at home from natural causes. It was noted that his last VA medical appointment was on May 19, 2008. In an addendum, it was indicated that the death certificate would be sent to a VA physician for signature. The Veteran's death certificate shows that he died at home in early June 2008. The immediate cause of death was listed as "unknown." The VA physician who completed the death certificate indicated that the death was possibly due to an abdominal aortic aneurysm rupture, due to or as a consequence of hypertension. Other significant conditions contributing to death but not resulting in the underlying cause included low back pain with leg pain. An autopsy was not conducted. By a letter dated in April 2009, Dr. M. stated that the Veteran had Gleason's Grade 7 cancer with seminal vesicle invasion, extracapsular invasion and high grade PIN, and this was not contained after the surgery. He needed to have follow-up with either hormone therapy or radiation. He opined that "Prostate cancer could have contributed to his death." By a letter dated in July 2009, a private physician, Dr. E., indicated that he had reviewed private and VA medical records relating to the Veteran. He noted that the Veteran's PSA was 0.05 in January 2008 (and that a normal range is from 0 to 4). He noted that the Veteran had a new onset of pain in May 2008. He opined that the Veteran had metastatic prostate cancer when he died. He said that the Veteran was correctly assigned 100 percent when he was undergoing treatment, and was correctly assigned 50 [sic] percent disability after his treatment was finished. He opined that the Veteran's back pain was probably not an acute disc injury or acute sciatica, and that the size of his abdominal aorta was normal for a man of his age. He opined that the probably did not have an abdominal aortic aneurysm contributing in any way to his demise. He stated that the Veteran's demise was sudden and opined that it was probably a cardiovascular event. He also opined that his back pain was probably caused by metastatic prostate cancer. He stated, "the pain in his back would have accelerated and caused his hypertension to elevate. The pain, which was not relieved by medications and was at a high level, would have caused greater high blood pressure and would have contributed to the cardiovascular event, which caused his sudden death." He concluded that the Veteran's prostate cancer caused back pain, which elevated his blood pressure, which caused an acute cardiovascular event causing his death. A September 2009 VA medical opinion indicated that the VA examiner had reviewed the Veteran's claims file and medical records. She summarized the medical records, and indicated that there was no chemical evidence of prostate cancer at the time of the Veteran's death, as a private treatment record from 5 months prior to his death indicated a low PSA level. She found no other evidence of metastasis of prostate cancer per review of the record or any evidence suggestive of metastasis in the record. Therefore it was her opinion that it was less likely than not that the Veteran's cause of death was due to prostate cancer. The rationale for the opinion was that there was no chemical evidence of prostate cancer recurrence, objective evidence of metastatic disease, or symptoms suggestive of metastatic disease. During her April 2011 videoconference hearing before the Board, the appellant asserted that the Veteran's post-operative prostate cancer had recurred prior to his death. She and her son testified that the Veteran said that his cancer had recurred before he died. They testified that VA doctors did not examine the Veteran after his death. They stated that the Veteran died at home and was taken directly to the funeral home, and that an autopsy was not done. They contended that he had recurrent prostate cancer which caused his death. A November 2011 VA medical opinion reflects that the examiner reviewed the Veteran's claims file, including the April and July 2009 private medical opinions. The VA examiner indicated that the Veteran's medical records did not support the supposition that there was metastatic disease, noting that the Veteran had a low PSA just months before his death, and an X-ray study did not show metastatic disease. The VA examiner also noted that the Veteran had a pain score of 8 on May 19, 2008, with a blood pressure of 136/73, and therefore there was no sign that the back pain was causing an elevation of his blood pressure. All in all, there is no indication of a metastatic lesion of the spine to cause back pain. Therefore there exists no physiological link between the Veteran's service-connected prostate cancer and the cardiovascular event which resulted in his death. The examiner opined that it is less likely than not that the Veteran's service-connected prostate cancer caused pain in his back. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the appellant, and the appellant's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). It is entirely within the Board's province to give more probative weight to certain pieces of evidence than others, so long as the Board provides adequate reasons and bases. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The claims file contains evidence both in favor of and weighing against the claim. Evidence weighing in favor of the claim includes the private medical opinions by Drs. M. and E., and the statements and testimony by the appellant and her son. Evidence weighing against the claim includes the medical records showing an absence of treatment for recurrence of prostate cancer after the November 2006 prostatectomy, the normal PSA findings after the surgery, and the VA medical opinions dated in September 2009 and November 2011. As noted above, the Veteran's VA and private medical records are negative for treatment of recurrent prostate cancer after his prostatectomy in November 2006. The evidence also reflects that the Veteran's PSA tests were consistently within normal limits after the surgery in November 2006, as noted by the two VA examiners, as well as his VA treatment providers in 2007 and 2008. After the surgery, private and VA medical records reflect only follow-up treatment, including PSA tests which showed normal findings. VA and private doctors diagnosed him with "history of" prostate cancer. See March 2007 note by Dr. F., and January 2008 VA primary care note. In April 2007, the VA examiner indicated that his treatment for prostate cancer was complete. The Board observes that Dr. M. made contradictory findings in his May 2007 and April 2009 letters. In the former, he indicated that the Veteran was at high risk for recurrent cancer (strongly suggesting there was no current cancer), while in the latter, he indicated that the cancer was not contained after the surgery. However, he did not discuss the recent normal PSA findings in the second letter. In contrast, as noted above, in May 2007, he informed the VA urology department that the Veteran had good urinary control and excellent PSA response. These discrepancies reduce the probative value of the April 2009 letter. Further, in his April 2009 letter, he merely stated that the Veteran's prostate cancer "could have" contributed to his death. This statement, by its own language, is nothing more than equivocal speculation, which is also unsupported by an adequate rationale, and it lacks probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Beausoleil v. Brown, 8 Vet. App. 459 (1996). Dr. E. is not shown to have treated the Veteran, although he did review and discuss some of the Veteran's medical records. The Board finds that the probative value of his July 2009 opinion is reduced because he does not indicate any medical findings in the record to support his conclusion that there was metastatic disease causing back pain. Moreover, he also indicated that the Veteran's PSA was in the normal range in January 2008, a few months prior to his death. Upon review of all of the evidence of record, the Board finds that the weight of the evidence does not show that the Veteran had local reoccurrence or metastasis of resected prostate cancer following his prostatectomy in November 2006. The Board finds that the September 2009 and November 2011 VA medical opinions carry more probative weight than that of Drs. M. and E., as the November 2011 examiner, in particular, had the benefit of reviewing the Veteran's claims file and all of his medical records and the statements and testimony by the appellant and her son. The opinions are well reasoned, detailed, and consistent with the other evidence of record. Prejean v. West, 13 Vet. App. 444 (2000). But, even more importantly, these commenting VA examiners sufficiently discussed the underlying medical rationale of the opinions, which, rather than mere review of the claims file, is more so where the probative value of the opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Green v. Derwinski, 1 Vet. App. 121 (1991). Upon review of all of the evidence of record, the Board finds that the weight of the evidence does not show that the Veteran had recurrence or metastasis of resected prostate cancer following his prostatectomy in November 2006, and does not show that a service-connected disability caused his death. The Board finds that the November 2011 VA medical opinion carries more probative weight than that of Drs. M. and E., as the November 2011 examiner, in particular, had the benefit of reviewing the Veteran's claims file and all of his medical records and statements to the RO. The opinion is well reasoned, detailed, and consistent with the other evidence of record. Prejean v. West, 13 Vet. App. 444 (2000). This commenting VA examiner sufficiently discussed the underlying medical rationale of the opinion, which, is where the probative value of the opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Green v. Derwinski, 1 Vet. App. 121 (1991). Having said that, the Board also has considered the lay statements and testimony of the Veteran and her son in support of her claims. However, this case at hand is not the type of situation discussed in Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) and a number of other related cases holding that lay evidence may be sufficient to establish this required nexus (i.e., link) between the Veteran's military service and his disability and/or death. See also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); and Barr v. Nicholson, 21 Vet. App. 303 (2007). Because this cause-of-death claim concerns his fatal conditions that are not readily amenable to mere lay diagnosis or probative comment on their etiology, the appellant has to have supporting medical evidence - which, for the reasons and bases discussed, she does not or, at least, sufficient to refute the findings of the VA examiners that found no recurrent prostate cancer and no link between the postoperative service-connected disability of prostate cancer and his sudden death in June 2008. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom, i.e., need for supporting medical nexus evidence, in a claim for rheumatic heart disease). It is not shown that the service-connected disabilities of residuals of prostate cancer, tinnitus, tinea pedis, erectile dysfunction and PTSD caused or substantially or materially contributed to the Veteran's death. See 38 C.F.R. § 3.312. The weight of the competent and probative evidence establishes that a disability incurred in or aggravated by service did not cause or contribute to the Veteran's death, and thus service connection for the cause of his death is not warranted. The preponderance of the evidence is against the claim; thus the benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs