Citation Nr: 1325990 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 09-43 564 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from June 1955 to January 1976. He died in October 2008, and the appellant is his surviving spouse. This claim initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board remanded the case for further development in January 2012. That development was completed, and the case has since been returned to the Board for appellate review. In addition to the paper claims file, there is a Virtual VA paperless file associated with the Veteran's case. A review of the documents in the paperless claims file reveals VA treatment records that are relevant to the issue on appeal. The Appeals Management Center (AMC) considered those records and readjudicated the claim in a February 2013 supplemental statement of the case. Thus, there is no prejudice in proceeding with a decision on the claim that considers such evidence. FINDINGS OF FACT 1. The Veteran's death certificate shows that he died in October 2008, and the immediate cause of death was listed as a blunt force closed head injury. A medical history of hypertension and diabetes mellitus were also included in the section for other significant conditions contributing to death but not resulting in the underlying cause of death. 2. At the time of the Veteran's death, service connection had been established for type II diabetes mellitus with peripheral neuropathy of the feet, diabetic retinopathy, and impotence, 3. The Veteran's service-connected type II diabetes mellitus did not cause his death, played no substantial or material part in his death, and did not otherwise materially accelerate his death. 4. The cause of the Veteran's death developed many years after service and was not the result of a disease or injury incurred in active service CONCLUSION OF LAW The requirements for service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §§ 1110, 1131, 1154, 1310 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it 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(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The United States Court of Appeals for Veterans Claims (Court) held in Hupp v. Nicholson, 21 Vet. App. 342 (2007), that additional notice requirements apply in the context of a claim for Dependency Indemnity and Compensation (DIC) benefits based on service connection for the cause of death. In particular, notice should 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 Court stated that the content of the notice letter will depend upon the information provided in the claimant's application and that the letter should be "tailored" to be responsive to the details of the application submitted. While there are particularized notice obligations with respect to a claim for DIC benefits, there is no preliminary obligation on the part of VA to conduct a predecisional adjudication of the claim prior to providing compliant notice. In this case, the RO did provide the appellant notice in October 2008 and January 2012 letters. Those letters informed her of the evidence needed to substantiate her claim for service connection for the cause of the Veteran's death and explained how to establish entitlement to DIC benefits based on a service-connected disability established during the Veteran's lifetime. These letters also notified her of the division of responsibilities in obtaining the evidence and explained how disability ratings and effective dates are determined. In the January 2012 remand, the Board directed that the appellant be sent an additional notice letter that complied with the Court's holding in Hupp. In compliance with the remand, the AMC sent the appellant the January 2012 letter, which advised her of what information and evidence was needed to substantiate her claim for the cause of the Veteran's death, including a statement of the condition for which the Veteran was service-connected at the time of his death (diabetes mellitus); an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet-service connected. See Hupp, 21 Vet. App. at 342. Furthermore, regarding the timing of the notice, the claim was readjudicated in a February 2013 supplemental statement of the case (SSOC), thereby curing any timing deficiency. For these reasons, the Board finds that the duty to notify has been satisfied in this case. In addition, the duty to assist the appellant has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the appellant's claim. A copy of the Veteran's death certificate has also been obtained and associated with the claims file. Moreover, traffic and investigative reports related to the Veteran's death have been secured. The appellant and her representative have not identified any outstanding, available records that are pertinent to the issue currently on appeal. Furthermore, in compliance with the January 2012 remand, a VA medical opinion was obtained in January 2013. For the reasons explained further below, the Board finds that the January 2013 VA medical opinion is adequate to make a decision on this claim. In the January 2012 remand, the Board remanded the claim for development, to include affording the Veteran a VA examination to address the central question in this case - whether it was at least as likely as not that the Veteran's service-connected diabetes mellitus caused his death, contributed substantially or materially to his death, or aided or lent assistance to the production of his death. The examiner was specifically requested to discuss the Veteran's glucose level on the day of his accident. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the January 2013 VA examination is adequate to decide the case because, as discussed below, it was based upon consideration of the Veteran's pertinent medical history, as well as the appellant's lay assertions, and the examiner sufficiently addressed the central question in this case to allow the Board to make a fully informed determination. Id. Therefore, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2012). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The death of a veteran will be considered as having been due to a service-connected disability where the evidence establishes that such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a) A principal cause of death is one which, singularly or jointly with some other condition, was the immediate or underlying cause of death, or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which contributes substantially or materially to death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). It is not sufficient to show that the service-connected disability casually shared in producing death; rather, it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1). Service-connected disabilities 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 was resulting debilitating effects and general impairment of health to the extent that would render the person less capable of resisting the effects of either disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of co-existing conditions, but, even in such cases, there is for consideration whether there may be reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. 38 C.F.R. § 3.312(c)(4). In this case, the Veteran's death certificate shows that he died in October 2008, and the immediate cause of death was listed as a blunt force closed head injury. It was noted that the injury occurred in September 2008 when the Veteran was a driver in a multiple vehicle accident. There were no conditions listed as an underlying cause leading to the Veteran's death. A medical history of hypertension and diabetes mellitus were listed as other significant conditions contributing to death but not resulting in the underlying cause. The certificate also shows that an autopsy was not performed. At the time of his death, service connection had been established for type II diabetes mellitus with peripheral neuropathy of the feet, diabetic retinopathy, and impotence. That disability was assigned a 20 percent rating. Post-service medical records show that the Veteran used insulin injections to regulate his blood sugar levels and to control his service-connected diabetes mellitus. The appellant does not refute that the Veteran died of a blunt force closed head injury as a result of an automobile accident. Instead, she contends that the Veteran went into diabetic shock or a diabetic coma that caused the accident, thereby leading to the head injury when he failed to react to a situation while he was driving. In support of her claim, she submitted evidence that the Veteran had an elevated blood glucose level of 251 mg/dL at the time of the accident. She also asserted that the Veteran's service-connected type II diabetes mellitus was not under good control and that his blood sugar levels fluctuated, which caused him to feel sick, dizzy, and confused. VA treatment records show blood glucose readings of 152 mg/dL in March 2007, 277 mg/dL in November 2007, 96 mg/dL in December 2007, 114 mg/dL in January 2008, 117 mg/dL and 96 mg/dL in May 2008, 127 mg/dL in June 2008, and 131 mg/dL in July 2008. The reference range was 65 mg/dL (low) to 110 mg/dL (high). A traffic homicide investigation report compiled by the local police department in March 2009 included statements from witnesses and copies of Florida traffic crash reports completed on the day of the accident. In the report, the traffic homicide investigator noted that the Veteran sustained serious injuries in the motor vehicle accident and died14 days later as a result of those injuries. The investigative officer indicated that he spoke with the appellant in November 2008 at which time she stated that the Veteran had blood drawn at the Orlando VA Medical Center during a check-up on the morning of the accident. She reported that the Veteran stopped for lunch following his appointment and returned home to take a nap until approximately 4:00 P.M. She indicated that he then watched the news until 5:00 P.M. At approximately 6:20 P.M., the Veteran left his home to visit some local veterans clubs. He was involved in the motor vehicle accident at 6:36 P.M. In the traffic homicide investigative report, the investigative officer noted that two vehicles were stopped for a red light, and after the light turned green, the first vehicle proceeded through the intersection in a southbound direction, which was then followed by the Veteran's vehicle. The Veteran's vehicle struck the other vehicle in the rear "for an unknown reason." The Veteran's vehicle turned in a counterclockwise motion and was facing northbound when it was struck by a third vehicle. When the third vehicle hit the Veteran's vehicle, he was thrown from the driver's seat to the passenger side of his vehicle as a result of the impact. His head hit the passenger's side front window causing it to break. The Veteran's false teeth were found on the front corner of the dashboard on the passenger side. Medical personnel on the scene reported that the Veteran was found lying against the passenger side door. The investigative officer noted that he kept in contact with the private hospital's intensive care unit where the Veteran was being treated from the day of the accident. He spoke with a nurse in October 2008 at which time he was informed that the Veteran had died and that his body had been transferred to the Medical Examiner's Office. He noted that he received results from the Medical Examiner's Office that indicated that the Veteran's cause of death was a blunt force closed head injury and that the manner of death was ruled an accident that occurred as a result of a vehicular crash. In the investigative summary, he concluded that, for "an unknown reason," the Veteran's vehicle struck another vehicle and the Veteran was found to have violated a Florida statute for careless driving for striking another vehicle in the rear; however, no citation was issued due to the death of the Veteran. Private ambulance treatment records dated in September 2008 documented that the ambulance was dispatched in response to an emergency call following a motor vehicle accident. The paramedics arrived at the scene of the accident and found the Veteran "slumped over" in the passenger seat of a van. The paramedic reported that the Veteran appeared to have been the unseatbelted driver of the motor vehicle that struck another motor vehicle at a high rate of speed. The air bags deployed, and the Veteran had been thrown to the passenger seat of the vehicle. He had an injury to the right temple area and a right elbow fracture. A blood glucose check revealed a reading of 251 mg/dL. Private hospital records from the day of the accident in September 2008 show that the Veteran arrived at the emergency department via ambulance. An initial emergency room note documented that there was speculation that the Veteran was the unrestrained driver of a vehicle involved in the motor vehicle accident. It was noted that he was found in the passenger seat and that his head hit the passenger side window or door frame. The noted medical history included a stroke 13 years earlier, difficulty with his right arm and leg, and diabetes mellitus. A September 2008 private computerized tomography (CT) scan of the Veteran's brain performed after his arrival in the emergency department of the private hospital showed an intraventricular hemorrhage in the right lateral ventricle and small punctuate areas of focal hemorrhage likely representing small axonal shear injury-type hemorrhages. The interpreting radiologist noted that the CT scan revealed signs of "significant head trauma." An emergency department note showed that the Veteran suffered a head injury and was found to have a Glasgow coma scale of 3 at the scene of the accident. He was intubated at the scene and met the trauma alert criteria. The examining physician noted that the CT scan of the brain showed intraventricular bleeding and a few punctuate hemorrhages. The Veteran was admitted in critical condition. On the day following the accident, in an intensive care unit consultation report, the examining physician reported the Veteran remained intubated, mechanically ventilated, and sedated. He noted that the Veteran was hyperkalemic at the time of admission to the hospital and indicated that he was started on Kayexalate. His serum potassium was within normal range on the morning following the accident. No evidence of arrhythmias was noted overnight. The physician also indicated that the Veteran's past medical history was unknown; however, based on the medications he had been on, it appeared that he had a history of essential hypertension. Laboratory results showed a random glucose reading of 218 mg/dL, and the urinalysis was "essentially negative." The diagnoses were motor vehicle accident, respiratory failure, severe traumatic brain injury, left distal clavicular fracture, glucose intolerance, and encephalopathy. The physician noted that the cardiovascular system was hemodynamically stable, and intravenous Vasotec was ordered as needed for blood pressure control. Regarding the Veteran's glucose intolerance, Accu-Checks and subcutaneous insulin were initiated. One day after the accident, a CT scan of the brain showed central and cortical atrophy and cortical contusions with a small intraventricular component on the right side of the orbitofrontal region. Four days after the accident, a CT scan of the brain showed no significant change in the acute intraventricular hemorrhage or tiny right frontal contusions. A mucosal thickening was noted involving the maxillary, ethmoid, and sphenoid sinuses. Six days after the accident, a CT scan of the brain showed similar findings. The intraventricular hemorrhage remained unchanged. Punctate areas in the frontal regions suggested a subtle contusion and findings of similar character in the corpus collosum posteriorly. Additionally, an incidental venous angioma in the deep white matter in the right parietal lobe was noted. An October 2008 CT scan revealed a slight decrease in the intraventricular hemorrhage, new punctuate focus of mild hyperdensity in the right frontal lobe representing a small amount of subarachnoid or parenchymal hemorrhage, and an unchanged prominence of the right frontal extra-axial space that likely represented a subdural hygroma. In an October 2008 private hospital discharge summary report, the course of the Veteran's hospitalization was documented. The physician noted that the Veteran received a guarded prognosis after he was admitted to the intensive care unit. Critical care continued, and the Veteran improved with therapy. He withdrew to pain and moved spontaneously, but he would not follow commands. No acute events were noted prior to the Veteran's expiration. The admitting diagnosis was listed as a closed head injury, and the principal diagnosis was listed as a traumatic brain hemorrhage. The secondary diagnoses included pulmonary insufficiency after trauma; pneumonia; malnutrition, bacteremia; cerebral laceration and contusion; open wound of elbow; closed fracture of the clavicle; hypertension; controlled type II diabetes; hypercholesterolemia; late effects of cerebrovascular disease; cervical intervertebral disk degeneration; hyperpotassemia; intestine disaccharidase deficiency; old myocardial infarction; staphylococcus infection; anemia; heart rhythm disorder or bradycardia; history of tobacco use; and motor vehicle collision, injuring passenger. In an October 2008 statement, the appellant contended that the Veteran's service-connected diabetes mellitus contributed to his automobile accident by causing a stroke or blood sugar change that led to his inability to react. In a November 2009 statement included in her substantive appeal, the appellant contended that the Veteran went into "diabetic shock" that "caused him to fail to react to the situation-thus the automobile accident which ultimately resulted in his death." She observed that the private ambulance reports showed that the Veteran's blood glucose level was 251 mg/dL when the paramedics treated him. She indicated that a review of the Veteran's medical records showed that his blood sugar levels were not under good control and noted that his treating physicians "kept changing his [medication] doseage to try to get him stabilized." She reported that, when the Veteran's blood sugar was between 150 to 160 mg/dL, he was sick, dizzy, and confused. The appellant contended that, because the Veteran's blood glucose level was 251 mg/dL at the time of the accident, he was "more than confused and dizzy-causing the accident" that caused his death. She also stated, "I am not trying to say he died of the [d]iabetes [m]ellitus but that his condition, confusion[,] and/or stroke, etc., caused the accident, thereby materially and substantially contributing to the [d]eath." In a January 2010 statement, the appellant reported that she spent almost half of her life with the Veteran and knew when he was sick. She stated that, when his blood sugar level was 140 mg/dL, he was "sick and confused." She also indicated that, during the last couple of weeks of his life, he had increased urinary frequency and thirst. In January 2010, the appellant submitted an internet article that discussed diabetic comas in type II diabetics. The author of the article stated, "Diabetic coma-also known as hyperglycemic hyperosmolar nonketotic syndrome-is a serious complication that can happen to a person with type 2 diabetes who is ill or stressed. Diabetic coma occurs when the blood sugar gets too high and the body becomes severely dehydrated." In a February 2012 statement, the appellant stated that she believed the Veteran "passed out" before he hit his head during the accident. She stated that he was a "big man" and was unable to fully use his right leg and arm due to a stroke; therefore, she contended that there was "no way he could have gotten from the driver[']s seat, over a consol[e] in the middle of a van[,] to the passenger[']s seat[,] which is the side he hit his head on[,] unless he was limp." In a January 2013 VA medical opinion, the examiner opined that the motor vehicle crash and blunt force closed head injury resulting in the Veteran's death was not caused by or a result of his service-connected type II diabetes mellitus. He noted the appellant's assertion that the Veteran's blood glucose level was high on the day of the motor vehicle accident and that he may have gone into diabetic shock prior to the accident. He provided the following response: 'Diabetic shock' is a term commonly misunderstood by the lay public to be synonymous with diabetic ketoacidosis (only seen in type 1 diabetes) and hyperosmolar nonketotic coma (seen in type 2 diabetes). It is not the same thing. 'Diabetic shock' by definition, is blood sugar low enough to result in lightheadedness or fainting (typically below 30 mg/dL). So the [V]eteran's widow's contention that his blood sugar was both high enough to cause him to go into hyperosmolar nonketotic coma and low enough to be due to diabetic shock at the same time is medically impossible, as the two conditions are mutually exclusive. It should be noted that the [V]eteran's VA medical record is silent for any history of instances of hypoglycemia requiring medical attention. As to the appellant's contention that the Veteran's blood sugar of 251 mg/dL was high enough to result in diabetic hyperosmolar nonketotic coma, the VA examiner noted that serum blood sugars of greater than 600 mg/dL over several days are necessary to achieve this result. He stated that there was no objective evidence that the Veteran's blood sugar ever reached that level. He reported that he reviewed the Veteran's hemoglobin A1c and serum glucose laboratory readings within his VA treatment notes for four years prior to the accident that resulted in his death and the appellant's statements that the paramedics at the scene of the accident measured the Veteran's blood sugar at 251 mg/dL. He stated, "It is nearly impossible for hyperosmolar nonketotic coma to manifest at this serum glucose level." He also reported: At no time in the [V]eteran's medical record was the [V]eteran's serum glucose noted to be above 277 mg/dL (a one-time maximum reading noted [in] November 2007) which corresponded to [a] hemoglobin A1c reading of 11.0 [percent] on that same date. The A1c reading is consistent with that glucose level, in this examiner's experience. Additionally, it should be noted that the [V]eteran's hemoglobin A1c was gradually decreasing subsequent to the [] November 2007 high and was noted to be 7.7 [percent] [in] May 2008, indicating that the [V]eteran's diabetes was under better control, generally. The [V]eteran's serum glucose readings of that same period ranged from 96 mg/dL (lowest reading [in] May 2008) to 131 mg/dL (highest reading [in] August 2008). The VA examiner also stated that the appellant's contentions that the Veteran would become "sick and confused" when his blood sugar levels were 140 mg/dL were "inconsistent with usual medical findings in diabetic patients, whose blood glucose levels can be well into the 250 [to] 300 [mg/dL] range with minimal symptoms." He noted that typically the minimal symptoms included polyuria and polydipsia, which the appellant noted the Veteran was experiencing in the weeks leading up to his death; however, VA treatment records were silent for any significant complaints on the previous instance when the Veteran's glucose level reached 277 mg/dL. With respect to the death certificate, the VA examiner stated that the cause of death listed was "blunt force closed head injury" with no underlying conditions leading to the cause of death listed. He noted that the death certificate listed a medical history of hypertension and diabetes as "[o]ther significant conditions contributing to death but not resulting in the underlying cause" of death, but it was "merely a list of the [V]eteran's comorbid conditions and not meant to infer those conditions as underlying and potentially precipitating [the] cause of death." He stated, "This is also a common misconception along the lay public, not used to dealing with death certificates." The VA examiner provided the following summary in his report: After extensively reviewing the [V]eteran's medical record, the current medical literature regarding the expected symptoms of uncontrolled diabetes, and the investigative report of the accident that resulted in the [V]eteran's death, this examiner is forced to opine that the crash resulting in the [V]eteran's death was neither caused by or directly related to his service-connected diabetes. In light of the evidence discussed above, the Board notes that the most probative evidence weighs against a finding that the Veteran's service-connected diabetes mellitus caused or contributed to his death. In his January 2013 medical opinion, the VA physician determined that the Veteran's death was directly related to his blunt force closed head injury and that it was not related to his service-connected diabetes mellitus. He noted that, although the death certificate listed a medical history of hypertension and diabetes mellitus as "[o]ther significant conditions contributing to death but not resulting in the underlying cause" of the Veteran's death, it was "merely a list of the [V]eteran's comorbid conditions and not meant to infer those conditions as underlying and potentially precipitating [the] cause of death." This evidence weighs against the appellant's claim in that the examiner found that the Veteran's diabetes mellitus did not contribute at all to the Veteran's death, let alone that it contributed "substantially or materially" to his death as the provisions of 38 C.F.R. § 3.312 require. Moreover, the VA examiner specifically addressed the appellant's contention that the Veteran may have gone into diabetic shock or a diabetic coma prior to the car accident due to his uncontrolled diabetes, and he noted the private ambulatory report that included a blood glucose reading of 251 mg/dL taken by the responding paramedics shortly after the accident. The VA examiner explained that it was medically impossible for the Veteran to go into diabetic shock when he had a blood glucose level of 251 mg/dL, as diabetic shock, by definition, requires blood sugar low enough to result in lightheadedness or fainting, which he noted was typically below 30 mg/dL. He also noted that VA treatment notes show no history of episodes of hypoglycemia requiring medical attention. Further, he noted that serum blood sugars of greater than 600 mg/dL over several days were necessary to result in diabetic hyperosmolar nonketotic coma and observed there was no objective evidence that the Veteran's blood sugar ever reached that level. He noted that VA treatment records showed the Veteran's serum glucose levels ranged from 96 mg/dL to 131 mg/dL from May 2008 to August 2008. He also noted that the Veteran had a "one-time maximum" serum glucose reading above 277 mg/dL in November 2007, which corresponded to a hemoglobin A1c reading of 11.0 percent on the same date. However, the Veteran's hemoglobin A1c gradually decreased subsequent to the November 2007 high and was noted to be 7.7 percent in May 2008, "indicating that the [V]eteran's diabetes was under better control, generally." He reported that it was "nearly impossible" for hyperosmolar nonketotic coma to manifest at a serum glucose level of 251 mg/dL. The VA examiner also addressed the appellant's contentions that the Veteran became "sick and confused" when his blood sugar levels rose to 140 mg/dL. He noted that the appellant's contentions were "inconsistent with usual medical findings in diabetic patients, whose blood glucose levels can be well into the 250 [to] 300 [mg/dL] with minimal symptoms." He acknowledged the appellant's reports that the Veteran experienced symptoms of polyuria and polydipsia in the weeks leading up to his death; however, he noted that VA treatment notes were silent for any significant complaints on the previous instance when the Veteran's glucose levels reached 277 mg/dL in November 2007. As the VA examiner based his conclusion on the evidence of record and specifically considered the appellant's arguments, his opinion negating the appellant's assertion that the Veteran's service-connected diabetes contributed "substantially or materially" to the cause of his death is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Lay witnesses may be competent to opine on some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the statements of the appellant and her representative pertain to internal medical processes, and thus, they are of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308 (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). Moreover, the Board finds that the January 2013 VA examiner's medical opinion outweighs the lay statements made by the appellant and her representative. In this regard, the examiner reviewed the Veteran's medical history and all available evidence and relied on his medical knowledge and expertise in rendering his opinion. He also provided a clear and thorough rationale that specifically refuted the allegations of the appellant. Thus, the examiner's opinion is entitled to more probative value in this case. The Board also acknowledges that the appellant submitted an internet article that discussed diabetic coma in type II diabetics. "Competent medical evidence" may mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. See 38 C.F.R. § 3.159(a)(1). However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998). A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon subjective facts rather than unsubstantiated lay opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). In this case, however, the article is general in nature, and no medical professional has related the information contained therein to the Veteran. Rather, the January 2013 VA examiner specifically addressed the content of the article in his opinion and opined that it was "nearly impossible" for hyperosmolar nonketotic coma to manifest at the Veteran's measured blood glucose level of 251 mg/dL on the day of the accident. Therefore, the Board concludes that the internet article is entitled to little probative weight. Finally, there is no evidence or argument that the immediate or contributory cause of death was itself related to service. The death certificate, traffic homicide report, and medical evidence show that the Veteran died as a result of a closed head injury from a motor vehicle accident. The car accident occurred many years after his military service in September 2008. In fact, the appellant does not contend otherwise. See November 2009 statement. Moreover, the evidence does not show, and the appellant has not contended, that the Veteran's cause of death was related in any way to his service-connected peripheral neuropathy of the feet, diabetic retinopathy, and impotence. For the foregoing reasons, the Board concludes that the preponderance of the evidence is against the claim for service connection for the cause of the Veteran's death. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F. 3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs