Citation Nr: 1321623 Decision Date: 07/05/13 Archive Date: 07/12/13 DOCKET NO. 07-04 955 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and V.G. ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from May 1966 to March 1969. The Veteran died in March 2005. The appellant is his surviving spouse. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2006 decision of the Newark, New Jersey, Regional Office (RO) of the Department of Veterans Affairs (VA). In May 2008, the appellant testified before the undersigned in Washington, D.C. at a Board hearing. In March 2009 and January 2013, the Board remanded this case. FINDINGS OF FACT 1. At the time of the Veteran's death, service connection was in effect for impingement of the lateral malleolus on the calcareous, right ankle, rated as 40 percent disabling; posttraumatic stress disorder (PTSD), rated as 30 percent disabling; bilateral pes planus, rated as 30 percent disabling; tinnitus, rated as 10 percent disabling; and hearing loss, rated as noncompensably disabling. 2. In an October 2011 rating decision, service connection for coronary artery disease, as related to herbicide exposure, was granted with a 30 percent rating assigned effective March 9, 2003, until the Veteran's death on March [redacted], 2005. 3. The Veteran had an overall 90 percent combined rating when he died, as well as a total disability rating based on individual unemployability. 4. The Certificate of Death reflects that he died at the age of 58 in March 2005. The immediate cause of death was sepsis due to or a consequence of renal failure due to or a consequence of respiratory failure due to or a consequence of hypoglycemia. There were no significant conditions contributing to death. 5. The Veteran's terminal causes of death were not related or attributable to his service. 6. His service-connected disabilities were not the immediate or underlying cause of his death, were not etiologically related to the cause of his death, did not contribute substantially or materially to his death, and were not of such severity that they resulted in debilitating effects and a general impairment of health to an extent that rendered him materially less capable of resisting the effects of other disease causing death. CONCLUSION OF LAW A disability due to disease or injury incurred in or aggravated by service, or that may be presumed to have been incurred in or aggravated by service, did not cause or contribute substantially or materially to the Veteran's death. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 1310 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303. 3.304, 3.307, 3.309, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act (VCAA) VA has met all statutory and regulatory notice and duty to assist obligations. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the appellant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These 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). So 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, this 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, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the appellant 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). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the claimant, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In Hupp v. Nicholson, 21 Vet. App. 342 (2007), the United States Court of Appeals for Veterans Claims (Court) issued certain directives pertinent to cases where the issue is entitlement to service connection for the cause of a Veteran's death. The Court held that there is no preliminary obligation on the part of VA to perform, what in essence would be, a predecisional adjudication of a claim prior to providing section 5103(a) notice. Although section 5103(a) does not require a "predecisional adjudication" of the evidence in each case, the notice must be responsive to the particular application submitted. See Kent v. Nicholson, 20 Vet. App. 1, 9 (2006) ("The legislative interest underlying the VCAA notice requirement is the intent of Congress to provide [claimants] a meaningful opportunity to participate in the adjudication of claims"). This means there is a middle ground between a predecisional adjudication and boilerplate notice with regard to the amount of detail and degree of specificity VA must provide for section 5103(a)-compliant notice. The Court later stated that a more detailed notice potentially discourages a claimant from submitting additional or corroborative notice and is contrary to the VCAA's purpose. However, according to Hupp, in Dependency and Indemnity Compensation (DIC) cases where a Veteran was service-connected during his or her lifetime, the Court found that section 5103(a) notice must include: (1) a statement of the conditions, if any, for which the Veteran was service-connected at the time of his or her 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. Where on the other hand a Veteran was not service-connected during his or her lifetime, the same did not apply. The Court held that, in these other cases, an original claim for DIC imposes upon VA no obligation to inform a DIC claimant who submits a nondetailed application of the specific reasons why any claim made during the deceased Veteran's lifetime was not granted. Further, section 5103(a) preadjudication notice, the Secretary or VA is not required to inform a DIC claimant of the reasons for any previous denial of a Veteran's service-connection claim. In this case, the Veteran was service connected for various disabilities. The appellant was sent preliminary VCAA notice in January 2006 that did not address Hupp considerations. However, the required Hupp notice was subsequently provided later in May 2009, followed by additional VCAA notification in April 2011. After being provided those notices, the appellant had opportunity to submit additional evidence and/or argument in response, so she has had a meaningful opportunity to participate effectively in the development and adjudication of her cause-of-death claim and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Those VCAA letters, especially in combination, indicated the type of evidence and information needed to substantiate her claim and apprised her of her and VA's respective responsibilities in obtaining this supporting evidence. The letters also notified her that an effective date for the award of benefits will be assigned if service connection is granted, in compliance with Dingess, which was also a May 2011 remand directive. Thus, in providing her these Hupp and Dingess notices, there was compliance with these remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board itself commits error as a matter of law when it fails to ensure compliance, and further remand will be mandated). See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Chest v. Peake, 283 Fed. App. 814 (Fed. Cir. 2008); and D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Regarding the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008), the United States Court of Appeals for the Federal Circuit (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 (service connection), which is defined as a monthly payment made by VA to a Veteran, and therefore does not pertain to a DIC claim. Id. In Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008), the Federal Circuit Court held 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 when no reasonable possibility exists that such assistance would aid in substantiating the claim. Nevertheless, in this case the Board remanded the claim to obtain a medical opinion, and then again remanded the claim for a clarification addendum. The remand directives have been satisfied. As noted, the appellant was afforded a Board hearing before the undersigned in May 2008. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above 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. Here, during the hearing, while the VLJ did not specifically note the basis of the prior determination and the element of the claim that was lacking to substantiate the claim for benefits, the issue on appeal was identified and the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the appellant nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or has identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the appellant, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate the claim for benefits. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. In summary, the Board finds that it is difficult to discern what additional guidance VA could have provided to the appellant regarding what further evidence she should submit to substantiate her claim. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances when a remand would not result in any significant benefit to the appellant). Service Connection for the Cause of the Veteran's Death Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. In order to establish service connection for the cause of the Veteran's death, applicable law requires that the evidence show that a disability incurred in or aggravated by his service either caused or contributed substantially or materially to his death. For a service-connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. In order 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). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it 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). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). Where the service-connected condition affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100-percent disabling, debilitation may be assumed. Id. There are primary causes of death that 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 itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). When, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As held in Davidson, section 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence" such as actual treatment records). The Veteran is competent to report the Veteran can observe and feel through the senses. See Layno. 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). Once evidence is determined to be competent, the Board must determine whether the evidence also is credible, as only then does it ultimately have probative value. See Layno (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, 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 Court, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly 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 Veteran, and the Veteran's demeanor when testifying at a hearing when he/she has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, aff'd per curiam, 78 F.3d 604(Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any issue material to the determination is resolved in the claimant's favor. 38 C.F.R. § 3.102. The Certificate of Death reflects that he died at the age of 58 in March 2005. The immediate cause of death was sepsis due to or a consequence of renal failure due to or a consequence of respiratory failure due to or a consequence of hypoglycemia. There were no significant conditions contributing to death. At the time of the Veteran's death, service connection was in effect for impingement of the lateral malleolus on the calcareous, right ankle, rated as 40 percent disabling; PTSD, rated as 30 percent disabling; bilateral pes planus, rated as 30 percent disabling; tinnitus, rated as 10 percent disabling; and hearing loss, rated as noncompensably disabling. In an October 2011 rating decision, service connection for coronary artery disease, as related to herbicide exposure, was granted with a 30 percent rating assigned effective March 9, 2003, until the Veteran's death on March [redacted], 2005. The appellant claims that the Veteran died due to Paget's disease which a private physician has indicated is related to Agent Orange exposure. A review of the record reflects that Dr. B.D. submitted a letter in January 2008 which stated that the Veteran was seen in late 2004 for acute renal failure (ARF) and was discovered to have Paget's disease which in turn resulted in heart failure and also renal failure. The physician opined that the Veteran's exposure to defoliants put him at a higher risk for developing these diseases. A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence establishing he was not exposed to any such agent during that service. The last date on which he shall be presumed to have been exposed to an herbicide agent shall be the last date on which he served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. If a Veteran, who served in the Republic of Vietnam during the Vietnam era was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), Type II diabetes mellitus, and chronic lymphocytic leukemia. 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The Secretary of VA has determined there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449 (1996). Section 2 of the Agent Orange Act of 1991, Pub. L. 102-4 (Act), codified in pertinent part at 38 U.S.C.A. §§ 1116(b) and (c), provides that whenever the Secretary determines, based on sound medical and scientific evidence, that a positive association (i.e., the credible evidence for the association is equal to or outweighs the credible evidence against the association) exists between exposure of humans to an herbicide agent and a disease, the Secretary will publish regulations establishing presumptive service connection for that disease. If the Secretary determines that a presumption of service connection is not warranted, he is to publish a notice of that determination, including an explanation of the scientific basis for that determination. The Secretary's determination must be based on consideration of reports of the National Academy of Sciences (NAS) and all other sound medical and scientific information and analysis available to the Secretary. Although 38 U.S.C. § 1116 does not define "credible," it does instruct the Secretary to "take into consideration whether the results [of any study] are statistically significant, are capable of replication, and withstand peer review." Simply comparing the number of studies which report a positive relative risk to the number of studies which report a negative relative risk for a particular condition is not a valid method for determining whether the weight of evidence overall supports a finding that there is or is not a positive association between herbicide exposure and the subsequent development of the particular condition. Because of differences in statistical significance, confidence levels, control for confounding factors, bias, and other pertinent characteristics, some studies are clearly more credible than others, and the Secretary has given the more credible studies more weight in evaluating the overall weight of the evidence concerning specific diseases. Section 3 of the Act directs the Secretary of VA to seek to enter into an agreement with the NAS to review and summarize the scientific evidence concerning the association between exposure to herbicides used in the Republic of Vietnam and each disease suspected to be associated with such exposure. Claims based on Agent Orange exposure are unique in that entitlement, under the presumptions codified in 38 U.S.C.A. § 1116 and 38 C.F.R. §§ 3.307 and 3.309, is based on an analysis of scientific evidence. Section 3 of the Agent Orange Act of 1991 directed the Secretary of VA to seek to enter into an agreement with NAS to review and summarize the scientific evidence concerning the association between exposure to herbicides used in the Republic of Vietnam and each disease suspected to be associated with such exposure. The Secretary determined, based on sound medical and scientific evidence, that a positive association (i.e., where the credible evidence for the association was equal to or outweighed the credible evidence against the association) existed between exposure to an herbicide agent and the disorders listed in the statute. See 64 Fed. Reg. 59232, 592233 (Nov. 2, 1999). In addition, the Secretary has published a list of specific conditions for which a presumption of service connection based on exposure to herbicides used in Vietnam during the Vietnam era is not warranted. These include hepatobiliary cancers, nasal/nasopharyngeal cancer, bone cancer, female reproductive cancers, breast cancer, renal cancer, testicular cancer, leukemia, abnormal sperm parameters and infertility, cognitive and neuropsychiatric disorders, motor/coordination dysfunction, chronic peripheral nervous system disorders, metabolic and digestive disorders, immune system disorders, circulatory disorders, respiratory disorders (other than certain respiratory cancers), skin cancer, gastrointestinal tumors, bladder cancer, brain tumors, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 64 Fed. Reg. 59232-59243 (1999). Recent action concerning herbicide-related disability has been undertaken by VA. On October 13, 2009, in accordance with authority provided in 38 U.S.C. § 1116, the Secretary of VA announced his decision to establish presumptions of service connection, based upon exposure to herbicides within the Republic of Vietnam during the Vietnam era, for three new conditions: ischemic heart disease, Parkinson's disease, and B cell leukemias. On August 31, 2010, VA published a final rule amending 38 C.F.R. § 3.309(e) to add hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease to the list of diseases presumptively associated with exposure to certain herbicide agents. 75 Fed. Reg. 53202. The term ischemic heart disease includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable, and Prinzmetal's angina. The Veteran was presumed exposed to herbicides during service. The record indicates that he had in-country service in the Republic of Vietnam from November 1966 to November 1967. The Veteran has been service connected for coronary artery disease based on that exposure, which will be addressed below. However, with regard to Paget's disease, although the private physician indicated that he felt that the Veteran was at a higher risk for developing Paget's disease, he did not definitively opine that Paget's disease in general or in this specific case, was due to inservice herbicides exposure. Moreover, the Board finds that the extensive medical research conducted in delineating the presumptive disorders has limited those disorders to the aforementioned list. Paget's disease is not a presumptive disorder and the Board finds that the VA examiner's statement, which is not definitive, is less probative regarding whether Paget's disease is etiologically linked to herbicide exposure than the findings of the Secretary of VA in conjunction with NAS. In addition, those findings are also supported by a November 2010 opinion of a VA examiner who opined that the Veteran's Paget's disease was not related to herbicide exposure. Thus, even though the Veteran had Paget's disease, it was not etiologically connected to presumed inservice herbicide exposure. Further, none of the Veteran's service-connected disabilities, other than the coronary heart disease which will be addressed below, are due to herbicide exposure. Also, none of the causes of death listed on the Certificate of Death are presumptive disorders. Moreover, the appellant, while certainly sincere in her contentions, does not possess medical expertise and her opinion is also less probative than the findings of the Secretary of VA in conjunction with NAS. Likewise, correspondence from the Veteran's friend V.G., asserting that the Veteran had Paget's disease due to Agent Orange, also is based on his personal opinion, which is of less probative value than the findings of the Secretary of VA in conjunction with NAS. See generally Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The appellant also submitted treatise evidence which pertains to herbicide exposure as well as treatise evidence pertaining to liver disease and Paget's disease. These articles do not establish that Paget's disease or liver disease is caused by Agent Orange exposure. The Board will now consider direct service connection. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Turning to the other evidence of record, the STRs do not reflect any complaints, findings, treatment or diagnosis of renal, liver, or pulmonary disorders. In fact, the Veteran's discharge examination only revealed normal findings in that regard. Post-service, an October 2004 general medical examination specifically revealed no pulmonary disability nor was any renal or liver dysfunction identified. Private records dated just prior to death reflected that the Veteran was admitted for hospitalization on March 20, 2005. He developed hypotension, respiratory failure, refractory shock, progression of liver failure, and renal failure. The Veteran continued to deteriorate and died. The records noted that the Veteran had endured chronic illnesses including right heart failure, Paget's disease, renal failure, and liver failure, and had been living with a borderline quality of life for month. In November 2010, VA obtained a medical opinion based on a review of the record. The Veteran's service-connected disabilities were noted. In addition, the findings on the Certificate of Death were listed. In pertinent part, the following inquiry was posed of the examiner: The AMC should obtain a VA medical opinion to determine if the Veteran's Paget's disease was more likely than not, less likely than not, or at least as likely as not, related to presumed inservice herbicide exposure or otherwise to service. The examiner should also opine as to whether it is more likely than not, less likely than not, or at least as likely as not, that any of the Veteran's service-connected disabilities played any role in causing/contributing to cause his death. The examiner should be requested to opine as to whether the Veteran's service-connected disabilities contributed substantially or materially to death, or aided or lent assistance to the production of death; whether the service-connected disabilities resulted in debilitating effects and general impairment of health to the extent that it rendered the Veteran less capable of resisting the effects of either disease or injury primarily causing death; and/or whether the service-connected disabilities were of such severity as to have a material influence in accelerating death. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. In response, in November 2010, a VA examiner indicated that the Veteran had multiple comorbidities when he died, including end-stage renal disease/chronic renal failure; chronic liver disease/liver failure due to cirrhosis of the liver, and chronic hepatic encephalopathy; hypertension, coronary artery disease, myocardial infarction, cardiomyopathy, right-sided heart failure, and atrial fibrillation; and other problems, including anemia, Paget's disease, and gout. The examiner opined that the Paget's disease was not at least as likely as not related to service, including herbicide exposure, and that the Veteran's service-connected disabilities did not contribute substantially or materially to death, or aided or lent assistance to the production of death, resulted in debilitating effects and general impairment of health to the extent that they rendered the Veteran less capable of resisting the effects of either disease or injury primarily causing death and were not of such severity as to have a material influence in accelerating death. The examiner noted that the Veteran had end-stage renal disease/chronic renal failure, and was on hemodialysis. The examiner indicated that there was no cure for chronic kidney disease and the nature course of the disease is to progress until dialysis or transplant is required. The examiner also noted that major organ failures are affected by any renal failure and that a patient with chronic kidney disease are at a much higher risk than the general population to develop heart attacks and a stroke as well as life-threatening metabolic complications. The examiner stated that the Veteran had chronic liver disease/hepatic failure because of cirrhosis of the liver and was in chronic hepatic encephalopathy. In sum, the examiner opined that the most likely causes and contributing factors to the Veteran's death were renal failure, liver failure and its complications, and respiratory failure. Subsequent to obtaining that VA opinion, the RO granted service connection for coronary artery disease as due to herbicide exposure, as noted. Since the VA examiner did not specifically address whether the Veteran's coronary artery disease disabilities contributed substantially or materially to death, aided or lent assistance to the production of death, resulted in debilitating effects and general impairment of health to the extent that they rendered the Veteran less capable of resisting the effects of either disease or injury primarily causing death or were of such severity as to have a material influence in accelerating death, the Board determined that that a medical addendum be obtained from a VA cardiovascular examiner to answer those questions. In February 2013, the medical opinion was provided based on a thorough review of the record. The examiner noted that the Veteran had multiple medical problems, including end-stage renal disease, hemodialysis status, complicated with multiple episodes of catheter-related sepsis, Paget's disease complicated with arteriovenous malformations and high output heart failure, end-stage liver disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), hypertension, anemia, and gout. The examiner stated that the Veteran passed away from sepsis shock related to Gram negative bacterium in March 2005. Microbiology results demonstrated the presence of Klebsiella pneumonia, resistance to multiple drugs. This organism with the same antibiotic resistance pattern was cultured on prior visits and he had a history of recurrent catheter-related infections. With regard to cardiac conditions, the examiner identified three: atrial fibrillation, cor pulmonale, and high output heart failure. The examiner stated that the Veteran's cardiac conditions were related to pulmonary disability including COPD and pulmonary hypertension, as well as Paget's disease. The examiner stated that the Veteran did not have coronary artery disease and there was :"zero" possibility that a coronary artery disability contributed substantially or materially to death. In fact, the examiner indicated that it was possible that service connection should not have been established for coronary artery disease. In sum, the examiner opined that cardiac disability was not due to coronary artery disease. Thus, while coronary artery disease is a presumptive disorder, it had no etiological relationship to death. In sum, the STRs do not reveal any complaints, findings, treatment, or diagnosis of any renal, liver, or lung-related disability. Post-service, the Veteran's renal, liver, and lung-related disabilities developed years after service. There is no competent evidence establishing a nexus connection between renal, liver, or lung-related disability, including those listed on the Certificate of Death, and service. Although the one private examiner suggested that the Veteran's herbicide exposure put him at a higher risk to develop Paget's disease, as noted, the Board finds that the more probative evidence in this case shows this was not the case. Otherwise, there is no medical opinion in the appellant's favor. Although she believes that the Veteran's death was related to inservice herbicide exposure or otherwise to service, her opinion it outweighed by the more probative medical opinions cited above. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ( "[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, the VA opinions are based on the Veteran's medical history, are fully articulated, and are supported by a reasoned analysis. The Board therefore attaches significant probative value to the VA opinions, and the most probative value in this case, as they are well reasoned, detailed, consistent with other evidence of record, and included access to, and review of, the accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). As noted, the private opinion is much less definitive and thorough and did not address all of the medical factors in this case. With regard to the appellant's statements, the Federal Circuit Court has recognized that, in some cases, lay testimony falls short in proving an issue that requires medical knowledge. See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010). The question of an etiological relationship between the cause of the Veteran's death and service is an etiological one requiring medical expertise that the appellant simply has not been shown to possess. Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309 (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Further, and as explained, the appellant stated that the causal connection between the Veteran's death and the Veteran's service was predicated on him having been exposed to herbicides which resulted in his terminal conditions, but this has not been found to be the case here. Alternatively, it may be shown that the Veteran's service-connected disabilities, impingement of the lateral malleolus on the calcareous of the right ankle, PTSD, bilateral pes planus, tinnitus, hearing loss, and coronary artery disease, caused or contributed substantially or materially to his death and/or these disabilities were of such severity that they resulted in debilitating effects and a general impairment of health to an extent that rendered him materially less capable of resisting the effects of other disease causing death. However, there has been no suggestion or indication that this is the case. The terminal medical records and Certificate of Death includes none of the Veteran's service-connected disabilities. Further, and as explained, the most probative evidence establishes that the Veteran's cardiac conditions present prior to death were due to pulmonary disability and Paget's disease, not coronary artery disease. Thus, the Board concludes that the service-connected disabilities were not the immediate or underlying cause of death and were not etiologically related to the cause of death. Furthermore, the fatal disease processes were not manifest during service nor related or attributable to service. The Veteran's service-connected disabilities did not contribute substantially or materially to cause his death and were not of such severity that they resulted in debilitating effects and a general impairment of health to an extent that rendered him materially less capable of resisting the effects of other disease causing death. The Board therefore concludes that the preponderance of the evidence is against this claim for cause of death, so there is no reasonable doubt to be resolved in the claimant's favor. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 53 (1990). ORDER The claim for service connection for the cause of the Veteran's death is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs