Citation Nr: 1534590 Decision Date: 08/13/15 Archive Date: 08/20/15 DOCKET NO. 11-14 918A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for epithelial exfoliation. 2. Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for trigeminal neuralgia. 3. Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD), to include memory loss. 4. Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for bipolar disorder. 5. Entitlement to service connection for PTSD, to include memory loss. 6. Entitlement to service connection for hearing loss. 7. Entitlement to service connection for myasthenia gravis. 8. Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: John F. Ketcherside, Attorney WITNESSES AT HEARING ON APPEAL Appellant and Dr. R.M. ATTORNEY FOR THE BOARD N. Kroes, Senior Counsel INTRODUCTION The Veteran served on active duty from January 1966 to November 1967. He passed away on July [redacted], 2009. The appellant claims as his surviving spouse and has been substituted as the claimant in this case. This matter is before the Board of Veterans' Appeals (Board) on appeal from February 2009, April 2009, and May 2011 decisions of the Nashville, Tennessee, Department of Veterans Affairs (VA) Regional Office (RO). In November 2012, the appellant testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims file. The Board notes that the issue of entitlement to service connection for the cause of the Veteran's death was not certified to the Board by the RO. This claim was denied by the RO in May 2011. In June 2011, the appellant submitted a VA Form 9 perfecting her appeal as to the other issues on the title page. The Board is also accepting this form as a timely notice of disagreement to the denial of service connection for the cause of the Veteran's death. While no statement of the case has been issued on this claim, nor has a substantive appeal been received, VA has treated the claim as if it was on appeal as testimony was taken on this issue in November 2012. As such, the Board will take jurisdiction of this issue. See Percy v. Shinseki, 23 Vet. App. 37 (2009). As the Board's finding in this decision is fully favorable as to the claim for service connection for the cause of the Veteran's death there is no prejudice to the appellant in addressing the merits of this issue. The appellant submitted additional evidence and in November 2014 waived Board consideration of that evidence in the first instance without consideration by the Agency of Original Jurisdiction (AOJ). See 38 C.F.R. § 20.1304 (2014). However, in June 2015, the appellant's attorney specifically indicated that AOJ review of a March 2015 medical opinion obtained by the Board regarding myasthenia gravis was not waived. As the Board is granting the claim for service connection for myasthenia gravis and the claim for service connection for the cause of the Veteran's death (due to myasthenia gravis), remand for AOJ consideration of this medical opinion is not necessary. FINDINGS OF FACT 1. The Veteran did not appeal the May 2004 rating decision that denied service connection for epithelial exfoliation, trigeminal neuralgia, PTSD, and bipolar disorder nor did he submit new and material evidence regarding those claims in the year after the decision was issued. 2. Additional evidence associated with the claims file since the May 2004 rating decision is cumulative or redundant of evidence previously of record, does not relate to an unestablished fact necessary to substantiate the claims for service connection for epithelial exfoliation, trigeminal neuralgia, and bipolar disorder, and does not raise a reasonable possibility of substantiating the claims. 3. Some of the new evidence received since the May 2004 rating decision relates to an unestablished fact necessary to substantiate the claim for entitlement to service connection for PTSD and raises a reasonable possibility of substantiating that claim. 4. The Veteran was diagnosed with PTSD by a VA psychiatrist based upon events he witnessed in the Republic of Vietnam. 5. The Veteran did not have hearing loss related to his military service. 6. Credible medical evidence reflects that the Veteran developed myasthenia gravis as a result of his exposure to Agent Orange while serving in Vietnam. 7. The Veteran died on July [redacted], 2009. A Delayed Report of Diagnosis - Death listed the immediate cause of death as acute morphine intoxication. 8. Medical evidence indicates that a disability of service origin, myasthenia gravis, caused the Veteran's death. CONCLUSIONS OF LAW 1. The May 2004 rating decision denying service connection for epithelial exfoliation, trigeminal neuralgia, PTSD, and bipolar disorder is final. 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2003). 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for epithelial exfoliation. 38 U.S.C.A. §§ 5107, 5108, 7105 (West 2014); 38 C.F.R. § 3.156 (2014). 3. New and material evidence has not been received to reopen the claim of entitlement to service connection for trigeminal neuralgia. 38 U.S.C.A. §§ 5107, 5108, 7105 (West 2014); 38 C.F.R. § 3.156 (2014). 4. New and material evidence has been received to reopen the claim of entitlement to service connection for PTSD. 38 U.S.C.A. §§ 5107, 5108, 7105 (West 2014); 38 C.F.R. § 3.156 (2014). 5. New and material evidence has not been received to reopen the claim of entitlement to service connection for bipolar disorder. 38 U.S.C.A. §§ 5107, 5108, 7105 (West 2014); 38 C.F.R. § 3.156 (2014). 6. The criteria for establishing service connection for PTSD have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2014). 7. The criteria for establishing service connection for hearing loss have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2014). 8. The criteria for establishing service connection for myasthenia gravis have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307 (2014). 9. With resolution of reasonable doubt in the appellant's favor, the criteria for establishing service connection for the cause of the Veteran's death have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.312 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. § 3.159 (2014). The VCAA applies to the instant claims. As the Board is reopening the claim for service connection for PTSD and granting the claims for service connection for PTSD, myasthenia gravis, and the cause of the Veteran's death, further discussion of VA's duties to notify and assist regarding these claims is not necessary. The duty to notify was satisfied in this case by a March 2009 letter. The claims were last readjudicated in May 2011. VA has also fulfilled its duty to assist. VA obtained the Veteran's service treatment records and identified post-service treatment records. No medical opinions were obtained for the claims to reopen previously denied claims for service connection for epithelial exfoliation, trigeminal neuralgia, and bipolar disorder. As the Board is not reopening those claims, medical opinions are not warranted. As discussed below, the evidence does not suggest that the Veteran had a hearing loss disability related to service; therefore, a medical opinion is not necessary before deciding that claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) (2014); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The record reflects that at the November 2012 hearing the undersigned explained the issues, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. Neither the appellant nor her attorney has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Given the above, no further action related to the duties to notify and assist is required in this case. Analysis Claims to Reopen A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of decision. 38 C.F.R. §§ 20.302, 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In this regard, it must be noted that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Prior to this appeal, the RO most recently denied the Veteran's claims of service connection for epithelial exfoliation, trigeminal neuralgia, PTSD, and bipolar disorder in a May 2004 rating decision. The Veteran was provided notice of this decision and his appellate right but did not appeal the decision or submit new and material evidence within one year of the decision. Therefore, the decision is final. See 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2003). Epithelial Exfoliation The evidence received since the May 2004 rating decision is not new and material to the claim for service connection for epithelial exfoliation. See 38 C.F.R. § 3.156 (2014). In denying the claim for service connection for epithelial exfoliation, the May 2004 decision found that a chronic, disabling condition manifested by epithelial exfoliation was not shown and there was no evidence relating such condition to the Veteran's military service. Service treatment records were of record at the time and showed a rash, identified as jock itch in September 1966; a circumscribed patch on the right ankle and buttocks, identified as tinea corporis in April 1967; and a pimple on the penis with rash in May 1967. The Veteran's November 1967 separation examination report showed a normal evaluation of the skin, other than a scar on the right lower quadrant. In connection with that examination, the Veteran denied having had any skin diseases. The Veteran also made statements in connection with the finally denied claim that he first had a skin disability in 1967, had no available treatment records, and had a loss of skin and nails. Since the May 2004 rating decision became final, the relevant evidence associated with the file includes the Veteran's claim and VA treatment records. In the Veteran's February 2009 claim form he indicated he had a skin disorder he believed was related to service. VA treatment records show that in May 2008 the Veteran had diffuse hyperpigmented pink macules over his entire body. The assessment was "?DRUG RASH." The Veteran was given medication and told to notify the clinician if the condition did not improve. In January 2009 it was noted that the Veteran's skin was warm and dry, with no rash, skin growths, or jaundice. In February 2009 it was noted that the Veteran had no skin problems. The evidence received since the May 2004 rating decision does not suggest that the Veteran had a chronic skin disorder or that such was related to service. As such, it is not new and material and the claim is not reopened. Trigeminal Neuralgia The evidence received since the May 2004 rating decision is not new and material to the claim for service connection for trigeminal neuralgia. See 38 C.F.R. § 3.156 (2014). In denying the claim for service connection for trigeminal neuralgia, the May 2004 decision found that the evidence did not reflect that the condition was present during service or related to the Veteran's period of service. Service treatment records were of record at the time and did not show any complaint, treatment, or diagnosis of trigeminal neuralgia. The Veteran's November 1967 separation examination report showed a normal evaluation of the face and a normal neurologic evaluation. In connection with that examination, the Veteran denied having had any neuritis. The Veteran also made statements in connection with the finally denied claim that his trigeminal neuralgia began in 1987. A VA treatment record from February 2004 reflected the Veteran's report of taking medication for trigeminal neuralgia from 1987 to 1994. Since the May 2004 rating decision became final, the relevant evidence associated with the file includes the Veteran's claim and private treatment records. In the Veteran's February 2009 claim form he indicated he was treated for trigeminal neuralgia from 1987 to 1998. Private treatment records from 2008 record the Veteran's report of occasional flare ups of right fascial pain since he developed trigeminal neuralgia in the 1980's and that his trigeminal neuralgia resolved spontaneously. The evidence received since the May 2004 rating decision does not suggest that the Veteran has trigeminal neuralgia related to service. In fact, the Veteran reported onset in 1987 (two decades after service), treatment into the 1990's, and then spontaneous resolution of the disability. As such, the evidence is not new and material and the claim is not reopened. PTSD The evidence received since the May 2004 rating decision includes evidence that is both new and material to the claim for service connection for PTSD. See 38 C.F.R. § 3.156 (2014). For example, in denying the claim for service connection for PTSD the May 2004 decision found that that the Veteran's claimed in-service stressor could not be verified. In December 2012 the appellant's attorney submitted a copy of an Army Commendation Medal awarded to the Veteran for heroism on 20 June 1967 in the Republic of Vietnam. This new evidence addresses the reason for the previous denial; that is, a verifiable in-service stressor. Accordingly, the claim for service connection for PTSD is reopened and will be considered on the merits. Bipolar Disorder The evidence received since the May 2004 rating decision is not new and material to the claim for service connection for bipolar disorder. See 38 C.F.R. § 3.156 (2014). In denying the claim for service connection for bipolar disorder, the May 2004 decision found that the evidence did not show a relationship between the condition and his military service. Service treatment records were of record at the time and showed no complaint, treatment, or diagnosis of bipolar disorder. The Veteran's November 1967 separation examination report showed a normal psychiatric evaluation. In connection with that examination, the Veteran denied having had any depression, excessive worry, or nervous trouble of any sort. The Veteran also made statements in connection with the finally denied claim that he had problems with alcohol, drugs, and attention deficit disorder beginning in 1967 and other mental health problems starting in the 1990's. November 2003 and January 2004 VA treatment records listed diagnoses of bipolar disorder. Since the May 2004 rating decision became final, the relevant evidence associated with the file includes the Veteran's claim and records from the Social Security Administration (SSA). In the Veteran's August 2008 claim form he indicated his bipolar disorder began in 1967. This is cumulative evidence as the Veteran previous reports of symptoms beginning in 1967 were considered in May 2004. The records from SSA indicate that the Veteran was disabled due to anxiety related disorders and affective/mood disorder. A disability examination report diagnosed PTSD and attention deficit hyperactivity disorder. No diagnosis of bipolar disorder was made. The evidence received since the May 2004 rating decision does not suggest that the Veteran has bipolar disorder that is related to his military service. As such, it is not new and material and the claim is not reopened. Claims for Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, such as organic diseases of the nervous system and myasthenia gravis, can be presumed related to service when a veteran has certain qualifying service and the chronic disease becomes manifest to a degree of 10 percent within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1131, 1133 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2014). In addition, with chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). PTSD Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). On July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the occurrence of the required in-service stressor. See 75 Fed. Reg. 39,843 (July 13, 2010), and 75 Fed. Reg. 41,092 (July 15, 2010) (correcting the effective and applicability dates from July 12, 2010 to July 13, 2010). The revisions apply to, among others, claims appealed before July 13, 2010, but not yet decided by the Board. This revision adds to the types of claims VA will accept through credible lay testimony alone, as being sufficient to establish occurrence of an in-service stressor without undertaking other development to verify the Veteran's account. The PTSD regulation, § 3.304(f), previously only authorized VA to accept statements from Veterans who served in combat, as denoted by combat-related awards or decorations or other evidence sufficient to establish participation in combat, as sufficient to accept the occurrence of the claimed in-service stressor. VA later amended its PTSD regulations to also accept the statements of Veterans who are former Prisoners-of-War and those with an in-service diagnosis of PTSD as sufficient to establish occurrence of an in-service stressor if they are consistent with the places, types, and circumstances of service. The amendment of 38 C.F.R. § 3.304(f) eliminates the requirement for corroborating evidence of the claimed in-service stressor if it is related to the Veteran's "fear of hostile military or terrorist activity." The new regulatory provision requires that: (1) A VA psychiatrist or psychologist, or contract equivalent, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD; (2) the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service; and (3) the Veteran's symptoms are related to the claimed stressor. In this case, the record reflects multiple diagnoses of PTSD. Notably, in January 2004, a VA psychiatrist diagnosed PTSD and noted as one of the stressful events that the Veteran saw burnt and dead bodies. The Veteran's military records reflect that he served in the Army as a water craft operator and deckhand, and that he was awarded the Army Commendation Medal for heroism on 20 June 1967 in the Republic of Vietnam. The Board finds that seeing burnt and dead bodies is consistent with the circumstances of the Veteran's service. As a VA psychiatrist diagnosed the Veteran with PTSD based on a stressor that is consistent with the circumstances of the Veteran's service, service connection for PTSD is warranted. Hearing Loss For the purpose of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2014). The threshold for normal hearing is from 0 to 20 decibels; higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). The appellant asserts that the Veteran had hearing loss as a result of his military service. Service treatment records do not show hearing loss disability during service, to include at separation. At separation the Veteran reported that he had not had hearing loss. During a July 2006 VA history and physical, the Veteran denied having hearing loss. In a February 2009 claim, the Veteran stated that he had hearing loss but did not indicate when the hearing loss began. As the Veteran was a water craft operator in the military and was awarded a medal for heroism, the Board finds that during the course of his service he was likely exposed to significant noise. However, this claim must fail as there is no evidence of a hearing loss disability for VA purposes or any indication that any hearing loss would have been related to his military service. As noted above, the Veteran denied hearing loss at separation and in July 2006. The only evidence in favor of the claim is the implication of the claim filed in February 2009, that the Veteran believed he had hearing loss related to his service. Unfortunately, without evidence of a current hearing loss disability the claim must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328 (1997). In addition, neither the medical evidence nor the Veteran's claim indicates that hearing loss had its onset during service. Given the above, entitlement to service connection for hearing loss is not warranted. Myasthenia Gravis The appellant asserts that the Veteran had myasthenia gravis as a result of his service, to include his exposure to herbicides. The Veteran served in Vietnam and his exposure to herbicides is presumed. 38 C.F.R. § 3.307(a)(6)(iii). In addition, multiple treatment records verify that the Veteran was diagnosed with myasthenia gravis shortly before his death. For example, a July 2008 private neurology consultation report shows an impression of myasthenia gravis. Thus, the remaining question is whether the Veteran's myasthenia gravis was related to his exposure to herbicides during service. The file contains multiple opinions from Dr. R.M., the Veteran's father-in-law and a physician who was Board-certified in internal medicine. In an undated letter, Dr. R.M. concluded that the Veteran's myasthenia gravis was as likely as not caused by exposure to Agent Orange and/or other herbicides and noxious gases that were prevalent during the Veteran's service in Vietnam. He explained that it is well documented in the medical literature that Agent Orange causes both autoimmune and neurologic dysfunctions, which are the nature of myasthenia gravis. In November 2012, Dr. R.M. testified that he had reviewed the Veteran's records as well as medical journals on Agent Orange and myasthenia gravis. Board Hearing Tr. at 16, 18. He noted that he had seen cases presented in seminars where young women with myasthenia gravis, supposedly from Agent Orange, did not live more than 18 months after the diagnosis, while the patients not exposed to Agent Orange survived longer. Board Hearing Tr. at 18-19. The latter group usually had chronic disease of the thymus gland and got a lot better with the removal of the thymus gland. Board Hearing Tr. at 19. According to Dr. R.M., the Veteran did not get better with removal of the thymus gland. Board Hearing Tr. at 19. The Board notes that the Veteran had a thymectomy for myasthenia gravis in July 2008 and passed away in July 2009. Doctor R.M. testified that he had no question at all that the Veteran's myasthenia gravis was the result of his exposure to Agent Orange. Board Hearing Tr. at 20. He explained that medical literature documented that there is a relationship between herbicide exposure and autoimmune or neurological disorders. Board Hearing Tr. at 20. In a March 2015, a VA physician opined that there was less than a 50 percent possibility that the Veteran's exposure to Agent Orange caused his myasthenia gravis symptoms. The examiner cited to a lack of literature documenting myasthenia gravis by Agent Orange by induction of autoimmune disorder, the period of time between exposure and diagnosis, and the timing of positive sero-conversions. The opinions offered by Dr. R.M. and the VA physician both appear to be based on the Veteran's history, medical expertise, and a review of literature. As such, they are both afforded high probative value. Two medical professionals have offered their reasoned opinions on this issue and have come to opposite conclusions. A key component of Veteran's disability benefits law is that the benefit of the doubt is awarded to the appellant. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In this case, the evidence is evenly balanced and the benefit of the doubt is for application. As such, service connection for myasthenia gravis is warranted. Service Connection for the Cause of Death The death of a Veteran will be considered as having been due to a service-connected disability when the evidence establishes that such a disability was either the principal or contributory cause of death. See 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. Initially the Board notes that the Veteran received an honorable discharge; therefore, dependency and indemnity compensation is available in this case. See 38 U.S.C.A. § 1310(b)(1). The appellant was recognized by VA as the Veteran's surviving spouse when she was allowed substitution in this appeal. As such, she is eligible for dependency and indemnity compensation. See 38 U.S.C.A. § 1310(a). As explained above, the Veteran developed myasthenia gravis as a result of his military service. The appellant argues that myasthenia gravis caused the Veteran's death. The Veteran died on July [redacted], 2009. The Veteran's original death certificate shows the cause of death as "Pending." A "Delayed Report of Diagnosis - Death," issued in November 2009, lists the immediate cause of death as acute morphine intoxication. The medical examiner noted that the complete cause of death could not be determined within 48 hours after death as he was awaiting toxicology. No underlying causes initiating events resulting in death were listed on either certificate. Both Dr. R.M. and a VA physician have determined that myasthenia gravis caused the Veteran's death. In an undated letter, Dr. R.M. noted that he was present at the Veteran's death and the Veteran declined rapidly and died of respiratory failure as myasthenia gravis patients do. Doctor R.M. noted that he was certain the Veteran died as a direct result of myasthenia gravis. He reasoned that it was clear that the disease was not controlled because of the many discussions regarding the Veteran's breathing status and his abnormal respiratory values. In a November 2010 statement, Dr. R.M. noted that it was unfortunate that the death certificate listed morphine intoxication as the cause of death. He reiterated his opinion that the cause of death was respiratory failure from myasthenia gravis. He explained that the Veteran suffered from severe respiratory distress that could only be relieved with the use of narcotics. He relayed that he spoke with the coroner and the body was cremated before blood results were back and the listed cause of death was only the result of the blood sample and did not explain the need for the morphine. In a March 2015 opinion, a VA physician noted that in this case there seemed no question that the Veteran suffered from and died as a corollary of myasthenia gravis. He noted that the use of narcotic agent may potentiate suppression of respiratory drive. Given the overwhelming evidence that myasthenia gravis caused the Veteran's death, and the finding in this decision that myasthenia gravis was caused by the Veteran's honorable service, service connection for the cause of the Veteran's death is warranted. (CONTINUED ON NEXT PAGE) ORDER New and material evidence having not been received, the claim of entitlement to service connection for epithelial exfoliation is not reopened, and the appeal is denied. New and material evidence having not been received, the claim of entitlement to service connection for trigeminal neuralgia is not reopened, and the appeal is denied. New and material evidence having been received the claim of entitlement to service connection for PTSD is reopened. New and material evidence having not been received, the claim of entitlement to service connection for bipolar disorder is not reopened, and the appeal is denied. Entitlement to service connection for PTSD is granted. Entitlement to service connection for hearing loss is denied. Entitlement to service connection for myasthenia gravis is granted. Entitlement to service connection for the cause of the Veteran's death is granted. ______________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs