Citation Nr: 1341176 Decision Date: 12/13/13 Archive Date: 12/20/13 DOCKET NO. 11-23 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran had active service from December 1951 to December 1955. He died in February 2010. The appellant is the Veteran's widow. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in St, Paul, Minnesota. The Louisville, Kentucky, RO subsequently assumed jurisdiction. In February 2012, the appellant appeared at a videoconference hearing at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In March 2013, the Board requested a Veterans Health Administration (VHA) opinion as to the cause of the Veteran's death and its relationship to his period of service and/or his service-connected skin disorder. The requested opinion was received in July 2013. An addendum opinion was received in November 2013, with the amendment identifying the health care provider who prepared the opinion with no substantive changes. In October 2013, the appellant provided additional written argument along with duplicate copies of previously submitted opinions and stated that she was waiving review by the RO and wished that the Board proceed immediately with adjudication of the appeal. As such, the matter is now ready for appellate review. 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 February 2010. 2. The immediate cause of death listed on the death certificate was acute leukemia due to or as a consequence of essential thrombocythemia/myelofibrosis. 3. At the time of Veteran's death, service connection was in effect for chronic eczematoid dermatitis, rated as 60 percent disabling. 4. The first objective medical evidence of a diagnosis of acute leukemia and/or essential thrombocythemia/myelofibrosis was not until many decades after service. Acute leukemia and/or essential thrombocythemia/myelofibrosis were not present in service or for many years later, and are not related to a disease or injury in service. 5. A service-connected disability was not the immediate or underlying cause of the Veteran's death, nor was a service-connected disability etiologically related to the cause of the Veteran's death. 6. A service-connected disability did not affect a vital organ, accelerate the Veteran's death, or contribute to his death in any manner. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran's death are not met.. 38 U.S.C.A. §§ 1110, 1310 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty To Assist and Notify The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice 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; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 has been amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). In a claim for Disability and Indemnity Compensation (DIC) benefits, VA's notice requirements include (1) a statement of the conditions, if any, for which a veteran was service-connected at the time of his 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. See Hupp v. Nicholson, 21 Vet. App. 342 (2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. In a June 2010 letter, the RO provided the appellant with notice that informed her of the evidence needed to substantiate the claim of entitlement to service connection for the cause of the Veteran's death. The letter also told her what evidence she was responsible for obtaining and what evidence VA would undertake to obtain. The letter told the appellant that to substantiate the claim there must be medical evidence showing that service-connected condition caused or contributed to the Veteran's death, that is, that the Veteran died from a service-connected injury or disease. To the extent that any 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 actual knowledge on the part of the claimant because the statements of the appellant and her representative throughout the appeal reflect that the appellant understood all of the elements to establish service connection for the cause of the Veteran's death. Statements of the appellant and her representative, to include multiple written statements and testimony, indicate that the appellant was clearly aware of the evidence and information required to substantiate a claim for service connection for the cause of the Veteran's death. For example, the appellant on numerous occasions noted that service connection was in effect for the Veteran's eczematoid dermatitis. She also stated on numerous occasions that it was her belief that his service-connected disability contributed to his death. As such, the record reflects that the appellant had actual knowledge of the information and evidence needed to substantiate the claim for service connection for the cause of the Veteran's death. VA has a duty to assist a claimant in the development of the claim. This duty includes assisting the appellant in the procurement of service treatment records and pertinent treatment records and providing a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All available VA and private treatment records have been obtained. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the general duty to assist provision, 38 U.S.C.A. § 5103A(a), rather than the provision specifically addressing when medical examinations are required in compensation claims, 38 U.S.C.A. § 5103A(d), is applicable to claims for service connection for the cause of the Veteran's death. Wood v. Peake, 520 F.3d 1345, 1347 (Fed. Cir. 2008); DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008). While 38 U.S.C.A. § 5103A(a) does not always require VA to assist a claimant in obtaining a medical examination or assistance, such assistance is required whenever a medical opinion is necessary to substantiate the claim, and VA is excused from providing such assistance only when no reasonable possibility exists that such assistance would aid in substantiating the claim. Wood, 520 F.3d at 1348. The AMC/RO obtained a VA opinion and that the Board obtained a VHA opinion as to the relationship, if any, between the Veteran's cause of death and his period of service and/or service-connected skin disorder. The VHA report and opinion provided the necessary detail to properly assess the appellant's claim and is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The appellant also appeared at a videoconference hearing before the undersigned Veterans Law Judge at the local hearing office in February 2012. In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer (DRO) or Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the issue on appeal and informed the appellant and her representative what was needed for service connection for the cause of the Veteran's death. In addition, 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) nor 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 her claim for benefits. In addition, the Veteran was represented by an accredited representative. 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). The appellant has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments presented by both her and her representative and by testimony at the February 2012 videoconference hearing. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the appellant have been met, and no further action is necessary to assist the appellant in substantiating this claim. Cause of Death Dependency and Indemnity Compensation (DIC) will be paid to the surviving spouse of a veteran if the veteran dies of a service connected disability. 38 U.S.C.A. § 1310. In order to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 C.F.R. § 3.312(a). 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). In order to be a contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially to cause death, or that there was a causal relationship between the service-connected disability and the veteran's death. 38 C.F.R. § 3.312(c)(1). If the service-connected disability affected a vital organ, consideration must be given to whether the debilitating effects of the service-connected disability rendered the veteran less capable of resisting the effects of other diseases. 38 C.F.R. § 3.312(c)(2). Service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The cause of death listed, leukemia, is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as leukemia, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether service connection for the cause of the Veteran's death is warranted falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." The Board may not reject the credibility of the appellant's lay testimony simply because it is not corroborated by contemporaneous medical records. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (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"). Service connection may 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 when the evidence establishes that such disability was either the principal or a contributory cause of death. The service-connected disability is considered the principal cause of death when such disability, either singly or jointly with another condition, was the immediate or underlying cause of death or was etiologically related to the cause of death. To be a contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially to cause death, 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 is must be shown that there was a causal connection. 38 C.F.R. § 3.312. Generally, minor service-connected disabilities, particularly those of a static nature or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. Service-connected diseases or injuries 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 diseases or injury primarily causing death. 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. 38 C.F.R. § 3.312(c)(3). In terms of a DIC claim based on cause of death, the first requirement, "evidence of a current disability, will always have been met (the current disability being the condition that caused the veteran to die)". Carbino v. Gober, 10 Vet. App. 507, 509 (1997), aff'd sub nom. Carbino v. West, 168 F.3d 32 (Fed. Cir. 1999). The immediate cause of death listed on the death certificate was acute leukemia due to or as a consequence of essential thrombocythemia/myelofibrosis. There were no other causes listed. At the time of Veteran's death, service connection was in effect for eczematoid dermatitis, rated as 60 percent disabling. The appellant is the Veteran's surviving spouse. She contends that the Veteran's service-connected chronic eczematoid dermatitis was an early manifestation of the Veteran's underlying hematologic disorder, and therefore, service connection for the cause of the Veterans' death is warranted. The medical evidence confirms that the Veteran was treated for a myeloproliferative disorder characterized as essential thrombocythemia beginning in 2003 and the myeloproliferative disorder was associated with a paraneoplastic folliculitis. In the April 2010 hospital death summary it was noted that in the two weeks prior to the Veteran's hospital admission on February 3, 2010, he developed severe bone pain. A bone marrow aspirate and biopsy performed during this hospitalization revealed that the Veteran's myelofibrosis had evolved into an acute myelogenous leukemia. The summary indicated that when the Veteran was admitted, pain control was the immediate issue addressed. The Veteran's clinical condition steadily declined during hospitalization and he died on February [redacted], 2010. As noted above, at the time of the Veteran's death, service connection was in effect for chronic eczematoid dermatitis, rated as 60 percent disabling. Service connection for dermatophytosis of the left hand, quiescent, was initially granted in March 1956. In a March 1956 VA examination report it as indicated that the skin disorder was manifested by dryness and scaling of the left hand. At the time of a September 1958 VA examination, the Veteran was noted to have dermatophytosis of the left hand and foot, mild. The dermatitis was on the left ring finger and on the mid-dorsal area of the left foot. It was described as macular, papular, slightly erythematous, crusting lesions with some vesicular changes. In support of her claim, the appellant submitted a June 2010 medical opinion from the Veteran's oncologist, T. H., M.D. Dr. H. reported that he had treated the Veteran for several years and that the Veteran had a myeloproliferative disorder characterized initially by thrombocytosis and then subsequently by myelodyplasia and ultimately leukemia. Dr. H. also noted that the Veteran had chronic eczematoid dermatitis and he believed this condition was a paraneoplastic condition caused indirectly by the myeloproliferative disorder and the myelodysplasia. He stated that patients with myeloproliferative disorders, myelodysplasias, and leukemias could sometimes develop paraneoplastic skin conditions possibly related to their immune-compromised state or possibly related to an autoimmune phenomenon triggered by the underlying hematologic condition. He indicated that based upon the clinical evidence, he was convinced that the Veteran's chronic eczematoid dermatitis was the result of his underlying hematologic condition, which again was a myeloproliferative disorder/myelodysplasia characterized by an abnormality in the oncogene c-mpl, which ultimately evolved into acute myelogenous leukemia. In a July 2010 letter, M. W., M.D., the Veteran's dermatologist, indicated that the Veteran had been a patient of his for several years. He reported that he had seen the Veteran for a cutaneous lymphoproliferative disorder. He noted that there was some concern that this might evolve into a cutaneous lymphoma. Dr. W. stated that during his treatment of the Veteran, it was his opinion that the Veteran's lymphoproliferative disorder was related to his underlying myeloproliferative disease for which the Veteran was seeing an oncologist. He noted that while the Veteran was being treated for his myeloproliferative disorder, there was improvement in his cutaneous lymphoproliferative/pseudolymphoma. Therefore, he felt that the Veteran's cutaneous condition was most likely related to his underlying blood disorder. In conjunction with the claim, a VA medical opinion was obtained in July 2011. The VA physician indicated that she had reviewed the medical evidence in the claims folder. She observed that the medical records showed that the Veteran developed a papular skin eruption on the anterior and posterior thorax and face in 2002, which was extremely pruritic. A biopsy was subsequently performed and it was felt that the folliculitis was probably a paraneoplastic syndrome. The examiner observed that an October 2004 medical oncology record indicated that the Veteran saw several dermatologists, including the Mayo Clinic, with a clear cut diagnosis not being made. The examiner also observed that the October 2003 Mayo Clinic records indicated that the Veteran was evaluated for a severe pruritic rash which affected the face, chest, and back. Diagnoses made included sweet syndrome and eosinophilic folliculitis. It was further noted that the past medical history was significant for a pruritic rash affecting the hands and abdomen in the Philippines in 1953 and 1954, with the rash being apparently different than the current rash. The assessment was severe pruritic rash etiology uncertain. The VA physician opined that it was less likely than not that the service-connected chronic eczematoid dermatitis caused or contributed to the Veteran's cause of death. The VA physician opined that the Veteran's actual cause of death was most likely pneumonia, renal failure, or bacteremia. She stated that the underlying acute myelogenous leukemia with the 15 percent blasts in the bone marrow certainly contributed to the cause of death. The VA physician further opined that the eczematoid dermatitis did not cause the Veteran's death. She noted that the medical records showed that the Veteran's rash associated with the myeloproliferative disorder, myelodysplasia, and leukemia diagnosis first manifested in 2001, and that there was some confusion as to the etiology of the rash. The VA physician observed that even the evaluating doctor at the Mayo Clinic indicated that the Veteran's recent rash (from 2001) was different from the rash he had in the 1950's. The VA physician opined that the rash the Veteran had in the military, diagnosed as eczema and dermatophytosis, was different than the paraneoplastic skin condition related to an immune-compromised state or autoimmune phenomenon triggered by the underlying hematologic condition. As a result, she stated that the cause of the Veteran's death was less likely than not caused by the rash that the Veteran had in service. In March 2013, the Board requested that a VHA opinion be obtained as to the cause of the Veteran's death. It was requested that an oncologist review the claims file and address the following questions: (1) Based upon a review of the available medical evidence, please identify the cause of the Veteran's death. (2) Is it at least as likely as not (50 percent probability or greater) that the Veteran's service-connected chronic eczematoid dermatitis caused or contributed substantially or materially to the immediate cause of the Veteran's death? (3) Is it at least as likely as not (50 percent probability or greater) that the Veteran's service-connected chronic eczematoid dermatitis that first manifested in the 1950's was a manifestation of or was caused by the Veteran's underlying hematologic condition which was myeloproliferative disorder/myelodysplasia characterized by an abnormality in the oncogene c-mpl, and acute myelogenous leukemia? (4) Is it at least as likely as not (50 percent probability or greater) that a disability that was incurred in or aggravated by the Veteran's active service caused or contributed substantially or materially to the immediate cause of the Veteran's death? In response to the question as to the cause of the Veteran's death, the VHA physician, an oncologist, observed that according to the death summary dictated by Dr. H. in April 2010, the cause of the Veteran's death was most likely complications related to the Veteran's essential thrombocythemia. The complications included kidney failure and infection requiring intravenous hydration and antibiotics. The VA physician noted the death certificate listed acute leukemia as the cause of death, which she found to be incorrect. She observed that a bone marrow biopsy was performed 11 days prior to the Veteran's death, with the final diagnosis from the pathology report being "myeloproliferative disorder in transformation to acute myeloid leukemia". She observed that the pathologist's additional comments stated that " the overall features on the biopsy are consistent with a fibrotic stage of chronic myeloproliferative disorder ... the presence of up to 15 percent CD34+ immature cells in the biopsy suggests that the patient is transforming to an acute myeloid leukemia". The VA physician cited to several treatment records and medical treatises in support of her statement that while the Veteran's myeloproliferative disorder was progressing towards acute myeloid leukemia, it did not meet the criteria for acute myeloid leukemia at the time of the Veteran's death despite what was stated in the death certificate. As to the question of whether it was at least as likely as not that the Veteran's service-connected eczematoid dermatitis caused or contributed substantially or materially to the immediate cause of death, the examiner indicated that it was less likely that the Veteran's eczematoid dermatitis caused or contributed substantially or materially to the Veteran's immediate cause of death. The examiner stated that the cause of the Veteran's death was most likely complications related to the Veteran's essential thrombocythemia. In conjunction with her opinion, the examiner cited to certain treatment records and medical treatises to support her opinion. As to the question of whether the Veteran's environmental exposure during his Air Force service increased his risk in developing essential thrombocythemia, the examiner stated that the immediate cause of the Veteran's death, which was essential thrombocythemia, developed around 2002, and was independent of any environmental or occupational exposure during and after his Air Force service. In support of her opinion the examiner referenced several articles and the Veteran's service medical records, which revealed no evidence of exposure to any materials associated with essential thrombocythemia. The examiner also indicated that it was less likely that the Veteran's service-connected chronic eczematoid dermatitis that first manifested in the 1950's was a manifestation of or was caused by the Veteran's underlying hematologic condition which was myeloproliferative disorder/myelodysplasia characterized by an abnormality in the oncogene c-mpl, and acute myelogenous leukemia. The examiner indicated that the Veteran did not develop thrombocythemia until after February 2001. Its development was independent of any environmental or occupational exposure during and after his Air Force service. Therefore, the Veteran's service-connected chronic eczematoid dermatitis, and any environmental or occupational exposure during and after his Air Force service that might have caused his chronic eczematoid dermatitis was not in any way associated with the development of essential thrombocythemia. The examiner noted that as explained in the answer to question one, the Veteran did not have myelodysplasia or acute myelogenous leukemia. The examiner also indicated that it was less likely that a disability that was incurred in or aggravated by the Veteran's active service caused or contributed substantially or materially to the immediate cause of the Veteran's death. The examiner stated that the cause of the Veteran's death was most likely complications related to the essential thrombocythemia. She stated that the Veteran's service-connected disability and any environmental or occupational exposure during and after his Air Force service that might have caused his disability (chronic eczematoid dermatitis) were not in any way associated with his subsequent development of essential thrombocythemia. Therefore, the Veteran's disability, chronic eczematoid dermatitis, and its underlying cause were independent of the Veteran's cause of death. As to Dr. H's June 2010 statement, the VHA examiner indicated that the Veteran did not have myelodysplasia. She further noted that while the Veteran's essential thrombocythemia showed evidence of progression to acute myeloid leukemia at the time of his death, it did not met the criteria for acute myeloid leukemia. To say that the Veteran had acute myeloid leukemia was incorrect. She further indicated that to claim that the Veteran's essential thrombocythemia had an earlier manifestation in the form of eczematoid dermatitis 45 years before his essential thrombocythemia developed was not logical. She further noted that the Veteran's service-connected eczematoid dermatitis and any environmental or occupational exposure during and after his Air Force service were not in any way associated with the subsequent development of essential thrombocythemia. As to the July 2010 letter from Dr. W., the VHA examiner indicated that there was no conclusive evidence that any of the Veteran's skin disorders were a lymphoproliferative disorder. The VHA examiner indicated that she had reviewed all of the skin biopsies from July 2002 to September 2009. In support of her opinion, the examiner referenced numerous reports and findings of the biopsies as well as the varying diagnoses. She indicated that based upon the findings, the opinion that the Veteran had a cutaneous lymphoproliferative disorder and that this disorder was a paraneoplastic process related to the underlying proliferative disorder was not made on strong pathological evidence. She observed that the various skin lesions that were biopsied from July 2002 to September 2009 likely included more than one skin disorder. It may have included the skin disorder previously diagnosed as chronic eczematoid dermatitis. She further noted that there were other diagnoses that were likely acquired in more recent years (after 2001). She stated that the range of diagnoses was so wide that it suggested the characteristics of the skin disorders were not uniform and might not always clearly fit any one diagnosis. The examiner noted the wide range of diagnoses and indicated that it was questionable whether anyone could make a definitive statement on the correct diagnoses of the Veteran's skin lesions. The examiner stated that if the diagnoses of skin lesions were not well established, how strongly could anyone make a claim on the skin lesions' relations (e.g., paraneoplastic manifestations) to the Veteran's hematologic disorder (i.e., essential thrombocythemia). She indicated that while it had been reported in medical literature that thrombocythemia could cause paraneoplastic manifestations in organs such as the skin, the diagnoses of the Veteran's skin lesions and their connection as a paraneoplastic manifestation of his essential thrombocythemia were less than certain. The VHA examiner also noted other inconsistencies including the onset of dermatitis or folliculitis for which the Veteran received care in 2002, as having developed one year earlier by Dr. H., implying an onset in 2001. The examiner further observed that the Veteran reported a 2 year history of pruritic rash in January 2004, implying an onset in 2001-2002. The examiner also observed the wife's testimony that the Veteran had been treated for a skin condition throughout the years following his discharge, on a regular basis, with the condition worsening and becoming more serious. She noted that the clinician's notes seemed to suggest the skin lesions had an onset in 2001 or 2002, while the wife seemed to suggest that they had been occurring off and on since 1951 to 1955. The Board finds that the weight of the evidence demonstrates that acute leukemia and/or essential thrombocythemia/myelofibrosis, which ultimately caused the Veteran's death, did not have their onset in service or within one year following service. There were no objective medical findings of these disorders in service or in the years immediately following service. The medical evidence of record does not demonstrate evidence of acute leukemia until many years following service and in close proximity to the Veteran's death. Moreover, the VHA examiner has indicated that while the Veteran was progressing to the acute leukemia stage, the required medical findings for leukemia never occurred prior to the Veteran's death. Furthermore, there has been no objective medical finding or opinion that the Veteran's acute leukemia developed in service or in close relationship to service. In addition, the appellant has not contended that the Veteran's acute leukemia had its onset in service or in close proximity to service. As to essential thrombocythemia/myelofibrosis, listed as the underlying causes which led to the Veteran's death, the weight of the evidence does not demonstrate that either of these disorders developed in service or in close proximity to the Veteran's period of service. Neither of these disorders was diagnosed for many years following service. While the Board notes that the Veteran's private physician has indicated that the Veteran's thrombocythemia is related to his service-connected eczematoid dermatitis, as will be discussed below, the Board is giving more probative weight to the opinion from the July 2013 VHA examiner that it is less likely that there is a relationship between these two disorders. The Board has considered the appellant's contentions that the Veteran's chronic eczematoid dermatitis was an early manifestation of the Veteran's underlying hematologic disorder which ultimately led to the development of the acute leukemia. There is no evidence that she is qualified to render a medical opinion as to the etiology of the cancer which led to the Veteran's death. As noted above, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to whether the Veteran's acute leukemia and or thrombocythemia are related to service or the service-connected eczematoid dermatitis, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 at 1377. Next, service connection may be granted when the evidence establishes a medical nexus between the cause of the Veteran's death, to includes as a result of a service-connected disability. In this regard, the Veteran submitted statement from Dr. H. essentially indicating that the Veteran's chronic eczematoid dermatitis was the result of a hematologic condition which was a myeloproliferative disorder/myelodysplasia characterized by an abnormality in the oncogene c-mpl which ultimately evolved into acute myelogenous leukemia. As noted above, the Veteran also submitted a letter from Dr. W. indicating that he had treated the Veteran for a cutaneous lymphoproliferative disorder which was related to his underlying myeloproliferative disease for which he was being treated by an oncologist and that it was his belief that his cutaneous condition was most likely related to his blood disorder. The opinion set forth by Dr. H., appears to indicate that the Veteran's chronic eczematoid dermatitis was a manifestation of the myeloproliferative disorder characterized initially by thrombocytosis and then subsequently by myelodysplasia and ultimately leukemia. This is not supported by the evidence of record which shows the development of eczematoid dermatitis in service but no notation of thrombocytosis/myelodysplasia or leukemia until many decades following service. The July 2013 VHA examiner indicated that to claim that the Veteran's essential thrombocythemia had an earlier manifestation in the form of eczematoid dermatitis 45 years before his essential thrombocythemia developed was not logical. She further noted that the Veteran's service-connected eczematoid dermatitis and any environmental or occupational exposure during and after his Air Force service were not in any way associated with the subsequent development of essential thrombocythemia. The Board notes that the Court has repeatedly declined to adopt a "treating physician rule" that would require giving additional evidentiary weight to the opinion of a physician who treats the veteran regularly. See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Harder v. Brown, 5 Vet. App. 183, 188 (1993); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993); Chisem v. Brown, 4 Vet. App. 169 (1993). When evaluating the weight of medical evidence, the Board is guided by the principle that the probative value of a medical opinion largely rests upon the extent to which such opinion is based upon a thorough evaluation of the Veteran's medical history, including but not limited to the medical evidence contained in the claims file. See, e.g. Miller v. West, 11 Vet. App. 345, 348. The Board may examine the factual foundation of a medical opinion, including whether the physician had access to relevant information of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In this regard, the Board finds that the opinion of the July 2013 VHA examiner is more probative than the opinion of Dr. H. The July 2013 VHA examiner reviewed the Veteran's entire claims file, which at the time included his service treatment records, private treatment records, VA treatment records, previous examination reports, opinions from the Veteran's private physicians, and statements and testimony from the appellant. Based on all of the evidence, the examiner rendered an opinion that was supported by a detailed and complete rationale. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Thus, the Board finds this opinion to be the more probative evidence of record. As to Dr. W's statement, the July 2013 VHA examiner indicated that there was no conclusive evidence that any of the Veteran's skin disorders were a lymphoproliferative disorder. In support of her opinion, the examiner referenced numerous reports and findings of the biopsies as well as the varying diagnoses. She indicated that based upon the findings, the opinion that the Veteran had a cutaneous lymphoproliferative disorder and that this disorder was a paraneoplastic process related to the underlying proliferative disorder was not made on strong pathological evidence and that if diagnoses of skin lesions were not well established, how strongly could anyone make a claim on the skin lesions' relations (e.g., paraneoplastic manifestations) to the Veteran's hematologic disorder (i.e., essential thrombocythemia. She also noted that while it had been reported in medical literature that thrombocythemia could cause paraneoplastic manifestations in organs such as the skin, the diagnoses of the Veteran's skin lesions and its connection as a paraneoplastic manifestation of his essential thrombocythemia were less than certain. The Board finds that the opinion of the July 2013 VHA examiner is more probative than the opinion of Dr. W. The July 2013 VHA examiner reviewed the Veteran's entire claims file and rendered an opinion that was supported by a detailed and complete rationale. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that she misstated any relevant fact. Thus, the Board finds this opinion to be the more probative evidence of record. In short, the preponderance of the evidence is against a finding that the cause of death is in anyway linked to a disease or injury in service, including the service-connected eczematoid dermatitis. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the appellant's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ K. J. Alibrando Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs