Citation Nr: 1335015 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 09-31 846 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for accrued benefit purposes. 2. Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Sonia, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1942 to February 1946. He died in March 2008. The appellant is the surviving spouse. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The RO denied service connection for the Veteran's cause of death and denied entitlement to an initial disability rating in excess of 30 percent for PTSD for accrued benefit purposes. The Board notes that the RO had granted service connection for the Veteran's PTSD in January 2008, prior to his death. In February 2013, the Board requested an expert medical opinion concerning a question in the appellant's appeal. The opinion was received in April 2013. However, further clarification was needed, and an additional opinion was received in June 2013. The Board has not only viewed the Veteran's physical claims file, but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran died in March 2008. 2. The Veteran's death certificate lists the immediate cause of death as acute myocardial infarction with cardiomyopathy, with underlying causes of coronary artery disease and diabetes; other significant conditions listed as contributing to death, but not resulting in the underlying cause, was chronic renal failure. 3. At the time of his death, the Veteran was service-connected for PTSD and had a claim for an initial increased rating in excess of 30 percent for PTSD pending. 4. The appellant is the Veteran's surviving spouse, who requested accrued benefits within one year of the date of his death. 5. The Veteran's PTSD symptoms included depressed mood, suspiciousness, sleep impairment, mild memory loss, decreased concentration and cognitive function; the Veteran's PTSD did not result in more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to his symptoms. 6. The Veteran's service-connected PTSD did not cause or contribute substantially or materially to cause the Veteran's death. 7. The conditions ultimately resulting in the Veteran's death were unrelated to his military service and not shown to have manifested to a compensable degree within a year of his separation from service. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating in excess of 30 percent PTSD for accrued benefit purposes have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §1110, 1310 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Accrued Benefits Claim Periodic monetary benefits (other than insurance and servicemen's indemnity) to which an individual was entitled at death under existing ratings or decisions and under laws administered by the VA Secretary, or those based on evidence in the file at date of death and due and unpaid for a period not to exceed two years, shall, upon the death of such individual, be paid to the surviving spouse or other appropriate party. See 38 U.S.C.A. § 5121 (West 2002); 38 C.F.R. § 3.1000 (2013). While an accrued benefits claim is separate from a Veteran's claim filed prior to death, the accrued benefits claim is derivative of the Veteran's claim; thus, an appellant takes the Veteran's claim as it stood on the date of death, but within the limits established by law. Application for accrued benefits must be filed within one year after the date of death. A claim for death pension, compensation, or dependency and indemnity compensation, by an apportionee, surviving spouse, child or parent is deemed to include claim for any accrued benefits. 38 C.F.R. § 3.1000(c) (2013). Here, the Veteran had a pending claim for entitlement to an initial disability rating in excess of 30 percent for PTSD at the time of his death. Specifically, the Veteran requested a higher rating for PTSD in February 2008 following the RO's initial rating decision of January 2008 in which he was granted a 30 percent rating effective September 30, 2007. The Veteran died in March 2008, and the appellant filed a claim for death benefits in August 2008, which would include a claim for accrued benefits. Therefore, the appellant filed a claim for accrued benefits within one year of the Veteran's death. As such, the Board will consider whether the Veteran was entitled to an initial disability evaluation in excess of 30 percent for the his PTSD for accrued benefits purposes based on the evidence of record at the time of the Veteran's death in March 2008. See 38 C.F.R. § 3.1000 (2013). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). When entitlement to compensation has been established and a higher initial evaluation is at issue, the level of disability at the time entitlement arose is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consideration must also be given to a longitudinal picture of the Veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Moreover, if the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Pursuant to the rating criteria, PTSD is evaluated under a general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 30 percent disability evaluation is assigned where the evidence demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent disability evaluation is assigned where the evidence demonstrates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is assigned where the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. The rating agency shall also consider the extent of social impairment, but not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Moreover, the list of symptoms under the rating criteria is meant to be examples of the symptoms that would warrant the evaluation, but they are not meant to be exhaustive. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). In assessing the evidence of record, it is also important to note that the Global Assessment of Functioning (GAF) Scale reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the DSM-IV). A score of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242-44 (1995). A score of 51 to 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. A score of 61 to 70 is defined as some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Id. Turning to the evidentiary record, the Veteran underwent a psychological evaluation in August 2007. During the evaluation, the Veteran indicated he had a "happy" marriage. He noted that most of his family lived locally and were very supportive; he also stated he had a few friends. However, the Veteran reported increased avoidance behavior since returning to the military and that his physical limitations further prevented him from participating in social outings. The Veteran specifically indicated that he felt depressed because he "can't get out and walk." The examiner noted that the Veteran exhibited a bright affect, and his speech was normal. In addition, the examiner indicated that the Veteran became tearful when discussing combat and that the Veteran reported intrusive thoughts and nightmares. The Veteran explained his nightmares included thoughts of a ship bombing he survived during service. Because his ship was bombed around Christmas, the Veteran indicated such thoughts were more pronounced around the holidays. The Veteran also reported decreased energy, survivor's guilt, hypervigilance, and sleep disturbance; he denied active suicidal ideation. The examiner concluded that the Veteran's depression was likely secondary to his PTSD but that it was also related to his functional decline associated with his stroke. In September 2007 and October 2007, the Veteran and the appellant met with a VA psychologist. The Veteran indicated he felt embarrassed that his wife had to assist him with cleaning himself and managing his incontinence. The Veteran expressed an interest in becoming more productive and helping his wife. The couple also identified activities they could complete together at home, where they both felt more comfortable. However, they also identified activities to complete outside of the home, such as going out to breakfast. In November 2007, an occupational therapy treatment record noted that the Veteran sustained a stroke in April 2007 and identified cognitive deficits causing late effects in cerebrovascular disease. A history of depression and PTSD was noted. The Veteran appeared alert and orientated with impaired short term memory and decreased insight and judgment. At that time, the Veteran also reported becoming upset while watching a war documentary; the Veteran had to change the channel. In December 2007, while a resident at the Colorado VA Medical Center (VAMC) Nursing Home, the Veteran indicated he preferred one to one visitation rather than participating in group activities. Instead, the Veteran watched golf programs, read books, and completed word search games. The Veteran and the appellant also received counseling at the Denver VAMC Nursing Home in December 2007. The appellant requested the session because she observed that the Veteran was eating less, and he also expressed suicidal ideation on Christmas Eve. During the meeting, the Veteran explained that he did not want to be a burden to his wife. The Veteran asserted that he was not refraining from eating or drinking to starve or dehydrate himself; he complained his food was bland. The prospect of long-term care and nursing home care was also discussed; both the Veteran and the appellant were against such a placement. Also in December 2007, the Veteran underwent a mental examination to evaluate possible depression, PTSD, and cognitive deficits. The examiner found that the Veteran experienced moderate social and emotional difficulties. He had difficulty talking about his time in the military and reported nightmares, especially around Christmas because of the anniversary of the traumatic event/stressor. The examiner noted that the Veteran had some difficulty with concentration and computation and was disorientated as to the date. The examiner concluded that the Veteran's PTSD would cause occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks, but generally there was satisfactory functioning for routine behavior; total occupation and social impairment was attributed to his cognitive disorder. The Veteran was assigned a GAF score of 61 due to his PTSD, and a GAF score of 41 due to his cognitive disorder, providing evidence against this claim. In January 2008, VA treatment records note that the Veteran again expressed being a "burden" to the Nursing Home staff and his wife. However, the Veteran was described as responsive and oriented to person, place, and time. His short term memory was fair with some confusion noted. After a review of the lay and medical evidence of record, the Board finds that prior to his death, the Veteran met the criteria for an initial disability rating of 30 percent, but no higher, for his service-connected PTSD. See 38 C.F.R. § 4.130. As described above, the evidence shows that the Veteran experienced symptoms such as depressed mood, suspiciousness, sleep impairment, survivor's guilt, and some memory loss associated with his PTSD. In terms of social and occupational impairment, the Veteran reported avoidance behavior, but he also indicated that he was happy in his marriage and had a supportive family. He stated he had a few friends. While in the nursing home, he watched television and played word search games. The Board recognizes that the Veteran had cognitive difficulties, as noted by a GAF score of 41 in December 2007, which reflects severe symptoms. However, that GAF score was linked to cognitive deficits resulting from his cerebrovascular accident, not PTSD. The Veteran was also assigned a GAF score of 61 due to PTSD, which reflects only mild symptoms; less than a month later, the Veteran was described as oriented to person, place, and time in VA treatment records, providing more evidence against this claim. Taking into consideration the Veteran's GAF scores, and all other evidence of record, as discussed above, the Board finds that the Veteran's PTSD more approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to his symptomatology, thus meeting the criteria for a disability rating of 30 percent, but no higher, under Diagnostic Code 9411. 38 C.F.R. § 4.3, 4.7, 4.130. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and therefore, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3, 4.7. Moreover, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds no other diagnostic codes would be appropriate to evaluate the Veteran's PTSD. See Schafrath, 1 Vet. App. at 595. The Board has also considered whether an extraschedular evaluation is warranted for PTSD. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director of the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular scheduler standards. 38 C.F.R. § 3.321(b). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. Here, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence for the entire rating period on appeal, the Veteran's PTSD manifested depressed mood, sleep impairment, mild memory loss, hypervigilance, and avoidance of crowds. These symptoms are part of the schedular rating criteria. In addition, the levels of occupational and social impairment are explicitly part of the schedular rating criteria, which also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App. at 442; see also 38 C.F.R. § 4.21. Therefore, the Veteran's symptoms such as avoidance of crowds, decreased interest in social activities, and decreased concentration are all taken into consideration as the Board contemplates occupational and social impairment. Additionally, the Board has considered GAF scores, which are incorporated through the DSM-IV as part of the schedular rating criteria, as reflective of the degree of severity of psychiatric symptoms or overall functional impairment caused by PTSD. Also, evidence of record does not indicate that the Veteran was ever hospitalized for his PTSD and does not reflect marked interference with employment. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Finally, the Board has considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the evidence of record indicates the Veteran retired in 1991. Moreover, neither the Veteran nor the appellant alleged that he was unemployable on account of his service-connected disabilities, including his PTSD. Thus, the Board finds that Rice is inapplicable in this case. Cause of Death The appellant seeks service connection for the cause of the Veteran's death. She has linked the Veteran's service-connected PTSD to his heart disease, which ultimately led to his death. Specifically, the appellant emphasizes the opinion of "Dr. S," who stated: "[The Veteran] spent the final years of his life surrounded by anger with survivors' guilt, heavy drinking, secondary hypertension, multiple heart problems and finally having a myocardial infarction. He developed renal failure, and his final debilitating illness was a cerebrovascular accident." Dr. S also attached articles discussing increase risk for heart disease for male combat veterans. To establish service connection for the cause of the Veteran's death, the evidence must show that a disability incurred in or aggravated by active service either caused or contributed substantially or materially to cause death. 38 U.S.C.A. § 1310. A service-connected disorder is one that was incurred in or aggravated by active service; one for which there exists a refutable presumption of service incurrence, such as cardiovascular disease, if manifested to the required degree within a prescribed period from the veteran's separation from active duty; or one that is proximately due to or the result of, or aggravated by, a service-connected disability. 38 U.S.C.A. § 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309, 3.310(a). Service connection may also be established if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that he still has such a disorder. 38 C.F.R. § 3.303(b). Such evidence must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. See, e.g., Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). A service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other disorder, was the immediate or underlying cause of death or was etiologically related thereto. 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, or 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. As previously discussed, the Veteran died in March 2008. His death certificate lists the immediate cause of death as acute myocardial infarction with cardiomyopathy, with underlying causes of coronary artery disease and diabetes; other significant conditions listed as contributing to death, but not resulting in the underlying cause, was chronic renal failure. At the time of his death, the Veteran was service-connected for PTSD. With regard to the question of whether a service-connected disability was the principal or contributory cause of death, the Board finds that the evidence shows that the Veteran's service-connected PTSD was not (1) singly or jointly with some other condition, the immediate or underlying cause of the Veteran's death or was etiologically related thereto or (2) contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production fo death. See 38 C.F.R. § 3.312. The claims file was sent for an expert opinion to assess the likelihood of an etiological relationship between the Veteran's PTSD and his fatal conditions. The examiner reviewed the claims file, including the letter written by Dr. S and the articles he referenced therein, and considered the appellant's contention, specifically that there was a link between the Veteran's PTSD and his heart problems. In April 2013, the examiner explained that while PTSD may contribute adverse effects on the cardiovascular system, as asserted in the articles submitted by the appellant; however, such literature did not consider diabetes mellitus, which was a condition the Veteran suffered from at the time of the death. Instead, the examiner noted, it is "well documented that because of diabetes mellitus, heart disease has often established itself prior to a diagnosis of diabetes and eventually leading to renal failure." The examiner concluded that it was possible that PTSD may contribute to adverse effects on the cardiovascular system, but the examiner could not establish such effects as the definite contributory factor to cause stroke and acute myocardial infraction. Further clarification was requested in May 2013. The Board communicated to the examiner that a "definite" relationship between PTSD and myocardial infarction was not required; adequate evidence establishing such an etiological relationship must only arise to the level of relative equipoise. Moreover, the examiner was asked to clarify whether it was at least as likely (a 50% or greater chance) as not that the Veteran's PTSD caused or aggravated myocardial infarction, coronary artery disease, diabetes mellitus, and contributory renal failure (the conditions listed as fatal on the death certificate). In June 2013, the same examiner reviewed the claims file and literature referenced in this case. The examiner opined that it is less likely than not that the Veteran's PTSD was a causative or aggravating factor in the development and progression of the Veteran's acute myocardial infarction, coronary artery disease, diabetes mellitus, and chronic renal failure. The Board finds that the VA opinion is adequate because the examiner reviewed the Veteran's relevant medical history, recorded pertinent examination findings, and provided a sufficient analysis to support the conclusion rendered. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Therefore, the VA April/June 2013 opinion provides highly probative evidence against the assertion that the Veteran's service-connected disability caused or contributed substantially or materially to cause the Veteran's death. The Board notes that the appellant is competent to describe symptoms she observed, including during the years since the Veteran's discharge, based on her personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the question of causation in this case involves a complex medical issue that is beyond the personal knowledge of the appellant. Thus, she is not competent to address the medical etiology of the cause of the Veteran's death. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the appellant's opinion is not competent or probative evidence supporting her claim. The Board also finds that the evidence demonstrates that the Veteran did not sustain an acute myocardial infarction, coronary artery disease , diabetes or chronic renal failure in service; that symptoms of such conditions were not chronic in service; and that symptoms of such conditions were not continuous after separation from service. Service treatment records do not reveal any complaints, treatment, or diagnosis for symptoms of acute myocardial infarction, coronary artery disease, diabetes mellitus, or chronic renal failure. In fact, the February 1946 separation examination contained clinical evaluations of the cardiovascular system and genitourinary system; both were found to be normal and urinalysis for sugar was negative. Moreover, no pertinent abnormalities were noted, providing more evidence against this claim. Over sixty years later, in April 2007, the Veteran was treated for an apparent cerebrovascular accident (CAV). Records from Rose Medical Center reference two CT scans that did not show evidence of a stroke. However, the Veteran did demonstrate deterioration of mental status and manifestations of a stroke, to include left-sided weakness. Upon discharge, the Veteran was diagnosed with several conditions, including CAV, acute renal failure and chronic renal insufficiency, diabetes mellitus, coronary artery disease and history of congestive heart failure. The evidentiary record also includes a December 2007 compensation examination to address, in pertinent part, the Veteran's congestive heart failure, coronary artery disease, diabetes, and chronic renal insufficiency. Although the Veteran had difficulty recalling specific information regarding treatment for these conditions, the examiner was able to identify relevant information and offer some diagnoses. In terms of heart disease, the Veteran indicated that he had a heart surgery around 1992; the examiner stated that a review of the Veteran's medical records showed he underwent a triple coronary artery bypass in 1992. The Veteran also denied any history of myocardial infarction and stated he did not currently, or in the recent past, experience chest pain. Furthermore, he denied having any tightness, fullness, squeezing, achy, heaviness or unusual feelings anywhere in his chest. The examiner concluded that the Veteran had a history of coronary artery disease, which was asymptomatic at that time. Regarding diabetes mellitus, the examiner indicated the Veteran was first diagnosed with diabetes mellitus in 1990 or 1991. Finally, the examiner could not identify a date of onset for the Veteran's chronic renal insufficiency. However, the examiner stated that the Veteran's "EGFR is sufficiently low that a decision re hemodialysis is appropriate now." In short, the 2007 examination provided a detailed review of the Veteran's medical problems, which were indeed severe. However, the Veteran's own statements, as well as the medical evidence referenced by the examiner, do not link his conditions to an in-service injury or disease, providing more evidence against this claim. After the CAV, the Veteran's VA treatment consisted of several periods in which he was admitted and discharged from nursing home care, particularly in late 2007 and early 2008. The treatment records indicate that the Veteran received such treatment because of weakness and functional decline associated with his past CAV. He also received ongoing treatment for his diabetes mellitus during that time. For example, in January 2008, the Veteran's diabetes was described as "in fair control for geriatric patient," and he was provided with a diabetic diet. In March 2008, the Veteran was diagnosed with congestive heart failure and discharged with cardiac medications. He died shortly thereafter. Thus, after a full review of the record, the Board finds that service connection for the cause of the Veteran's death is not warranted. First, with regard to whether the Veteran's fatal conditions were related to active service on a direct basis, the evidence does not show a nexus relationship between the Veteran's active service and his acute myocardial infarction with cardiomyopathy, coronary artery disease, diabetes melitis, or chronic renal failure. There is nothing to suggest a link to service other than the appellant's lay assertions, which are not competent evidence regarding a complex medical question such as the etiology of different conditions affecting different bodily systems over sixty years after active service. Moreover, service treatment records reflect no complaints of, treatment for, or diagnosis of any of the conditions listed on the Veteran's death certificate, or any symptoms reasonably attributed to them; nor has the appellant so maintained. In addition, she does not argue that symptoms consistent with cardiovascular problems, diabetes mellitus or renal failure were continuous from service, and the record does not support that they were. In short, the service treatment records, post-service records and VA opinion provide highly probative evidence against this claim, indicating problems that caused the Veteran's death that began decades after service with no indicated connection with service or a service-connected problem, thereby outweighing the appellant's claim. Thus, direct service connection is not warranted. Further, because the cause of death, namely acute myocardial infarction with cardiomyopathy, is not shown to have existed in the first year post-service (he was not diagnosed for more than sixty years after discharge), presumptive service connection under 38 C.F.R. § 3.309(a) for a cardiovascular-renal disease is not warranted. In fact, the evidence shows that none of the conditions identified on the Veteran's death certificate manifested to a compensable degree within one year of separation from service. Therefore, service connection for the cause of the Veteran's death on a one-year presumptive basis is denied. For the reasons and bases discussed above, the Board finds that a preponderance of the evidence is against the claim for service connection for the cause of the Veteran's death, and this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2013). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 2107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). As discussed below, VA has fulfilled its duties under the VCAA. When VA receives a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159 (b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of the 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In the context of a claim for DIC benefits, § 5103(a) notice must include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). In the context of an appeal of the initial evaluation following the grant of service connection, the courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice absent VCAA notice. Harman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). Here, the RO provided notice to the Veteran in March 2008 regarding what evidence was required to substantiate the claim, and of his and VA's respective duties for obtaining evidence. The letter also included the type of evidence necessary to establish a disability rating and effective date. The Veteran died a few weeks later; further notice was not sent to the appellant. However, to the extent that the notice is not fully compliant with Hupp, under the circumstances of this case, any such error does not require a remand because the error did not affect the essential fairness of the adjudication. Specifically, the record reflects that any defect was cured by the actual knowledge of the appellant as statements she and her representative made reflect that she understood all of the elements to establish service connection for the cause of the Veteran's death. The appellant has clearly demonstrated that she was aware that the Veteran was service-connected for PTSD. In August 2008 the appellant, through her representative, requested accrued benefits for PTSD based on the November 2008 rating decision that denied the Veteran's claim for a rating higher than 30 percent. Moreover, the appellant has argued that the Veteran died as a result of heart disease, which she has linked to his service-connected PTSD; she submitted a medical opinion in support of her contention. As such, the record reflects that she had actual knowledge of the information and evidence needed to substantiate the claim for service connection for the cause of the Veteran's death. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The duty to assist also includes providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In connection with the current appeal, the evidence of record includes the Veteran's service treatment records, statements in support of the claim by the Veteran and his representative, statements in support of the claim by the appellant, the Veteran's VA treatment records, and the Veteran's private medical records. As noted above, the evidentiary record also contains an adequate VA opinion addressing the cause of the Veteran's death. The Veteran has not identified, and the record does not otherwise indicate, any existing, pertinent evidence that has not been obtained. The record also presents no basis for further development to create any additional evidence to be considered in connection with the matters currently under consideration. Hence, no further notice or assistance to the Veteran is required for fair adjudication of the Veteran's claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER An initial rating in excess of 30 percent for service-connected PTSD is denied for the purposes of accrued benefits. Entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs