Citation Nr: 1647644 Decision Date: 12/21/16 Archive Date: 12/30/16 DOCKET NO. 12-27 640 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Penelope E. Gronbeck, Attorney at Law WITNESS AT HEARINGS ON APPEAL The Appellant-Widow ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The Veteran served on active duty from September 1970 to August 1973. He died in August 2008. The appellant is his surviving spouse, so widow. She appealed to the Board of Veterans' Appeals (Board) from a January 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that, in relevant part, denied her claim of entitlement to service connection for the cause of his death. The appellant-widow had a videoconference hearing in March 2014. The undersigned Veterans Law Judge of the Board presided and a transcript of the hearing is of record. In September 2014, another hearing was requested. However, the appellant as mentioned already had been provided a hearing in March 2014, and claimants are only entitled to one hearing concerning a particular issue. See 38 C.F.R. § 20.700(a) (2015). Additional hearings are discretionary. The hearing in March 2014 was regarding this same cause-of-death claim. The appellant has not identified any reason why that hearing was inadequate or specified what additional evidence she would present during an additional hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010), citing 38 C.F.R. § 3.103(c)(2). Consequently, the required good cause has not been shown for permitting an additional hearing concerning this identical issue. In August 2014 the Board remanded the claim for further development, including especially for a medical opinion needed to assist in deciding the claim. There were differing opinions in the file concerning whether treatment (more specifically, prescribed medications) for service-connected disabilities had caused or contributed substantially or materially to the Veteran's death, so the Board requested supplemental medical comment on this determinative issue to try to resolve this conflict. Unfortunately, the additional medical opinion obtained on remand was not entirely responsive to the critical questions the Board had asked. Accordingly, the Board remanded the claim again in February 2016 for reparative action, which since has occurred. Satisfactory action was taken following that additional remand such that the case is now ready for the Board's review. See Stegall v. West, 11 Vet. App. 268 (1998) (Where the remand orders of the Board are not complied with, the Board itself errs as a matter of law when it fails to ensure compliance). But see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only "substantial" rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Also note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. Prior to the Veteran's death in August 2008, service connection had been established for depressive disorder and anxiety disorder rated 100-percent disabling; also for residuals of a right shoulder separation rated 50-percent disabling; erectile dysfunction with deformity rated 20-percent disabling; atrophy of the posterior right shoulder girdle muscle rated 10-percent disabling; and residuals of a right 5th metacarpal fracture rated 0-percent disabling, so noncompensable. 2. He died from a probable myocardial infarction (i.e., heart attack), with other significant conditions contributing to death being coronary artery disease with angina. 3. These disorders did not initially manifest during his military service, or within the year immediately after it concluded, and are otherwise unrelated to his service, including not caused or aggravated by his service-connected disabilities. 4. None of his service-connected disabilities caused or contributed substantially or materially to his death. 5. He did not die from VA treatment that was a result of carelessness, negligence, lack of proper skill, error in judgment, or some other incident of fault on the part of VA or as a result of an event that was not reasonably foreseeable. CONCLUSION OF LAW The criteria are not met for entitlement to service connection for the cause of the Veteran's death. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1151, 1310 (West 2015); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.312, 3.361 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION With respect to this cause-of-death claim being decided, VA has met all statutory and regulatory notice and duty to assist obligations, and it has not been contended otherwise, except as indicated below. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In cases involving a claim for Dependency and Indemnity Compensation (DIC), so including for service connection for cause of death, the notice mentioned must include: (1) a statement of the conditions, if any, for which the Veteran was service connected at the time of his death; (2) an explanation of the evidence and information required to substantiate the DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate the DIC claim based on a condition not yet service connected. See Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). The Appellant-Widow was provided this required notice. VA also fulfilled its duty to assist the Appellant-Widow by obtaining all potentially pertinent medical and other evidence, including the service treatment records (STRs) and other records concerning the diagnosis and treatment of the Veteran's ultimately terminal conditions. In DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008), the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) indicated that, while 38 U.S.C. § 5103A (a) does not always require VA to assist a claimant in obtaining a medical nexus opinion for a DIC claim, it does require VA to assist a claimant in obtaining such whenever necessary to substantiate the DIC claim. See also Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008) (holding that, in the context of a DIC claim, VA must also consider that 38 U.S.C. § 5103A (a) only excuses VA from making reasonable efforts to provide an opinion when no reasonable possibility exists that such assistance would aid in substantiating the claim). The appellant contended during her October 2012 hearing, before a local Decision Review Officer (DRO) at the RO, that the VA examiner who had rendered a medical opinion in June 2012 did not have enough information in front of him. However, that examiner had access to all valuable information in the Veteran's claims folder, as did the VA examiners who since have examined the file and provided supplemental comment. The Board consequently finds that the VA examination reports and other relevant evidence of record are collectively adequate to render a fair and impartial decision on this claim. Also, as for due process, the appellant appears to have intended to contend in October 2012 that VA had made a decision on her claim before she had had a chance to submit additional evidence. But since that time, she has had ample opportunity to submit all the evidence she wants or believes would be beneficial to her claim, including following her more recent March 2014 videoconference hearing before the Board. Moreover, her claim since has been readjudicated, and so the Board concludes that she has been afforded due process. Next considering whether this claim has substantive merit, in order to establish entitlement to service connection for cause of death, the evidence must show that a disability incurred in or aggravated by active military service, in the line of duty, was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). The issue involved will be determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the Veteran, including, particularly, autopsy reports. The service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312 (b). In order to be a contributory cause of death, it must be shown that there were "debilitating effects" due to a service-connected disability that made the Veteran "materially less capable" of resisting the effects of the fatal disease or that a service-connected disability had "material influence in accelerating death", thereby contributing substantially or materially to the cause of death. See Lathan v. Brown, 7 Vet. App. 359 (1995); 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)(3). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312 (c)(1). Establishing entitlement to service connection more generally requires having competent and credible (and therefore probative) evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a correlation ("nexus") between the disease or injury in service and the disability being presently claimed. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection alternatively may be awarded on a presumptive basis for certain chronic diseases listed in 38 C.F.R. § 3.309(a) that manifest to a degree of at least 10-percent disabling within 1 year of service separation. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed.Cir.2013). Arteriosclerosis is one such chronic disease. Evidence of continuity of symptomatology may be sufficient to invoke this presumption if a claimant demonstrates (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet.App. 488, 496-97(1997)); see 38 C.F.R. § 3.303(b). Service connection may be granted, as well, on a secondary basis for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Similarly, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the non-service-connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). In this latter instance, the non-service-connected disease or injury is said to have been aggravated by the service-connected disease or injury, but compensation is only payable for the amount of disability above and beyond that existing prior to the aggravation. 38 C.F.R. § 3.310(b). Still yet, when a Veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service connected. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361(a). For claims, as here, filed on or after October 1, 1997, pursuant to 38 U.S.C.A. § 1151, the Veteran must show that the VA treatment in question resulted in additional disability and, further, that the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of the disability was an event that was not reasonably foreseeable. 38 U.S.C.A. § 1151; see also VAOPGCPREC 40-97. Also compare and contrast 38 C.F.R. § 3.358 versus § 3.361, discussing the pleading-and-proof requirements for claims filed before or after October 1, 1997. In determining whether additional disability exists, the Veteran's physical condition immediately prior to the beginning of the hospital care, medical or surgical treatment, or other incident in which the claimed disease or injury was sustained (i.e., medical examination, training and rehabilitation services, or work therapy), is compared to his condition after such treatment, examination or program has stopped. 38 C.F.R. § 3.361(b). Provided that additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the Veteran's additional disability. 38 C.F.R. § 3.361(c)(1). Furthermore, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment or other instance of fault proximately caused the additional disability, it must be shown either that VA failed to exercise the degree of care expected by a reasonable treatment provider, or furnished the medical treatment at issue without the Veteran's informed consent. 38 C.F.R. § 3.361 (d)(1). Proximate cause may also be established where the Veteran's additional disability was an event not reasonably foreseeable - to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider the type of risk that a reasonable health care provider would have disclosed as part of the procedures for informed consent (in accordance with 38 C.F.R. § 17.32 (2015)). See 38 C.F.R. § 3.361(d)(2). The U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC) rather recently clarified that the standard is not actual foreseeability or possible foreseeability, but that the test is driven wholly by how a "reasonable health care provider" would behave if asked to perform a certain procedure on a Veteran with the same characteristics as the Veteran in a given case. See Schertz v. Shinseki, 26 Vet. App. 362 (2013). The Veteran's STRs are entirely unremarkable for reference to heart and blocked arteries or issues, and both were described as normal during his military discharge examination in June 1973. The appellant-widow contended in her October 2012 hearing testimony that a doctor in a clinic overseas had found the Veteran to have an irregular heartbeat (arrhythmia), but this is not otherwise indicated or confirmed by the record on appeal. Moreover, her contention is undermined by the fact that, in January 1994, the Veteran claimed entitlement to pension for heart disease, indicating that it had started in 1992 (so, if true, long after the conclusion of his service), and that there had been no in-service treatment. There was a VA medical opinion in April 2004 indicating that the preponderance of the scientific medical evidence did not support that depressive disorder causes or aggravates coronary artery disease. The examiner indicated that there are well-known, multiple-risk factors for development or aggravation of coronary artery disease, and that depression is not one of them. The Veteran died on August [redacted], 2008. His death certificate lists "probable myocardial infarction" (i.e., a heart attack) as the condition that caused his death, and coronary artery disease, angina, as contributing. The appellant-widow first alleged that the Veteran's service-connected disabilities in general caused or contributed substantially or materially to that terminal event. Specifically, in a May 2010 statement, she claimed that his service-connected major depressive disorder caused him to take too much medication the night of his death, which in turn led to his fatal myocardial infarction. However, her contentions were more focused beginning approximately during her October 2012 hearing before a local DRO at the RO. She began alleging more specifically that medications prescribed by VA physicians, in particular, albeit including for service-connected disabilities, played a substantial or material role in his death. The claims file resultantly was sent in June 2012 for a VA medical nexus opinion regarding the cause of the Veteran's death. The examiner opined that it was less likely than not that the Veteran's use of medications to treat any of his service-connected conditions, including the depressive disorder, anxiety disorder, right shoulder separation, erectile dysfunction, and right 5th finger metacarpal fracture disability, either had caused or contributed to his death due to probable myocardial infarction. This commenting examiner reasoned that the medications used by the Veteran were not directly or indirectly linked to the myocardial infarction. In response, however, the appellant-widow submitted a June 2013 statement from the Veteran's primary care physician, T H, M.D. in support of the claim. Dr. H stated that he had treated the Veteran since 1995. The Veteran had coronary artery disease and vasospastic angina, along with a past myocardial infarction. But Dr. H then stated that, according to the appellant, the Veteran had started a group of new medications on August 20, 2008, many of which "had potential side effects that could have aggravated his existing cardiac disease". Additionally, this commenting physician stated that the medications produced a potential for drug-drug interactions that also could have had a significant adverse effect on the existing heart condition. The appellant told Dr. H that these new medications included Trazodone, Seroquel (quetiapine), Ritalin (methylphenidate), Remeron (mirtazapine), Effexor (venlafaxine), and Wellbutrin (bupropion). He then went on to list the various warnings associated with the medications with regards to heart conditions. He further stated that it was quite possible that drug-drug interactions may have had an adverse effect on the Veteran. Those reactions could include serotonin syndrome, respiratory depression, or an irregular heart rhythm. He emphasized that the Veteran had been started on 6 new medications by VA doctors and then died suddenly 7 days later. In response to the now conflicting medical evidence of record, the RO sent the claims file back to the June 2012 examiner for an addendum opinion, which was provided in August 2013. This examiner again concluded that it was less likely than not that the Veteran's use of VA-prescribed medications to treat his service-connected conditions either had caused or contributed to his death due to probable myocardial infarction. The examiner's rationale again repeated his opinion that none of the medications used by the Veteran were "directly or indirectly" linked to a myocardial infarction. He added this time, however, that the Veteran's known heart conditions of the past, including heart disease and a prior heart attack, had placed him at a high risk for sudden death, which was not caused by medication use. In response to that supplemental VA opinion, and following the hearing testimony the appellant had provided to the Board in March 2014, the appellant submitted a second statement from Dr. H in June 2014. The opinion is mostly a reiteration of his previous one. In it, he stated, "I strongly believe that the addition of [the] potent medications more likely than not contributed substantially or materially to [the Veteran's] premature death. Starting a known cardiac patient on multiple medications that have significant cardiac warnings is not appropriate and more likely than not combined to cause his death". Review of VA treatment records reveals that, contrary to the appellant's allegations, the Veteran was not prescribed Trazodone, Seroquel, Ritalin, Remeron, Effexor , and Wellbutrin on August 20, 2008. The psychiatric treatment record from that date lists these medications (by their generic names) as "past meds" for him. An exhaustive medications list confirms that, while he was prescribed these medications (except for Ritalin/methylphenidate, which is not contained on the list), this occurred variously in the years prior to 2008. While this in turn lessens the probative value of Dr. H 's original opinion, which was based upon the erroneous assumption that all of these medications were prescribed on August 20, 2008, shortly before the Veteran's death on August [redacted], 2008, so just a week later, there still remained the possibility, as competently attested to by Dr. H, that the Veteran's use of medications with known heart risks was inappropriate. In August 2014, the Board found that, as such, the VA opinions provided to that date were inadequate, as they did not sufficiently address this contention beyond a conclusory statement. Accordingly, the Board remanded the claim to obtain additional comment on this determinative issue, and on the entitlement standard of 38 U.S.C.A. § 1151 and 38 C.F.R. § 3 361, since the medications purportedly were prescribed by the Veteran's VA doctors during the course of his VA evaluations and treatment. In August 2014, a VA examiner reviewed the conflicting medical evidence and provided the following opinion. Careful review of the available medical record documents that the Veteran with a long history of ischemic heart disease/status post myocardial infarction and with a long history of nicotine abuse had a sudden unobserved death diagnosed as probable myocardial infarction. The Veteran had been followed by his private physician, Dr. H, for his multiple medical problems and an opinion by Dr. H regarding the Veteran's death was reviewed. The Veteran was also followed by a VA psychiatrist for his significant mental health issues. At the time of his death, he was on the following psychiatric medications as noted on August 20, 2008: lorazepam, citalopram, and olanzapine. The preponderance of the scientific medical evidence would not support the contention that the psychiatric medications contributed to the death of a patient who had known significant ischemic cardiac disease in part related to his extensive smoking history. Causal nexus of psychiatric medications causing the Veteran's death is not supported. The Board again remanded the claim in February 2016 for a supplementary medical opinion considering all medications the Veteran had been prescribed by VA over the years, including trazodone, mirtazapine, quetiapine, venlafaxine, and bupropion. In April 2016, a VA physician reviewed the claims record and opined that it was less likely than not that any of the medications used by the Veteran is linked directly or indirectly to his myocardial infarction or any other cause of his death. The physician noted that the Veteran had significant heart disease and a prior myocardial infarction. He stated that a history of heart attack and prior myocardial infarction placed the Veteran at high risk for sudden death caused by heart disease. This commenter explained that heart disease is not caused by medications used to treat other conditions. He indicated that a medical nexus with prescribed medications is not established. He stated that this opinion was based on sound medical judgment and was not subject to change with time. He also indicated that it was less likely as not that the Veteran's death was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA in furnishing hospital care or medical treatment. Regarding the latter, this VA examiner's rationale was that there was no documented medical evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA during treatment and management of the Veteran's medical conditions leading to his death. This VA examiner stated that Dr. H's contention that certain of the Veteran's prescribed medications were inappropriate (contraindicated) for a person with known heart issues to use by themselves or in combination is an opinion with no basis of support in medical documents reviewed. This VA examiner indicated that it was less likely than not that the Veteran's death was the result of any claimed VA failure to exercise the degree of care that would be expected of a reasonable health care provider. The rationale was that there is no documented medical evidence of VA failing to exercise the degree of care that would be expected of a reasonable health care provider during treatment and management of the Veteran's medical conditions leading to his death. This VA examiner also indicated that the proximate cause of the Veteran's death was not related to an event that was not reasonably foreseeable, and that informed consent was obtained for all invasive procedures as required per hospital policies. Based on this collective body of evidence, the Board finds that service connection is not warranted for the cause of the Veteran's death, either under traditional cause-of-death law and regulations or 38 U.S.C.A. § 1151 and 38 C.F.R. § 3.361. The preponderance of the competent and credible evidence shows the Veteran died from a myocardial infarction, with coronary artery disease contributing. These ultimately terminal conditions did not initially manifest during his service or to a degree of at least 10-percent disabling within 1 year of his separation from service and were not caused or aggravated by his service-connected disabilities. The STRs are grossly unremarkable, either for relevant subjective complaint or objective clinical finding, including diagnosis, and the ultimately terminal conditions were not first shown until many years (indeed decades) post service. The appellant testified in October 2012 that the Veteran had served in Vietnam and was there in about March 1972. If this were true, it would qualify his death as presumptively service connected based on the presumption of service connection for ischemic heart disease given to Veterans who set foot in Vietnam during the Vietnam Era, based on presumed herbicide exposure. See 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309 (2015). However, the preponderance of the evidence indicates that the Veteran did not have any service in Vietnam; his service records do not show it. His DD Form 214 and other service personnel records (SPRs) indicate that his foreign service was in Europe - in Germany to be specific - and contain no suggestion of service in Vietnam, meaning on the landmass or inner waterways (brown water not blue water service). See Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008); VAOPGCPREC 27-97. There is no other satisfactory evidence of service in Vietnam of record. Moreover, there was a VA medical opinion in April 2004 probatively indicating that the Veteran's coronary artery disease was not caused or aggravated by his service-connected depression. More recently, there have been medical opinions probatively indicating the Veteran's myocardial infarction and coronary artery disease were not caused or aggravated by medications for service-connected disabilities, with rationale explaining that such medications were not directly or indirectly linked to them. These opinions were based on a review of evidence in the claims folder and in consideration of medication taken for the service-connected disabilities and whether they caused or aggravated fatal disease, and, as such, they are deemed most probative. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for determining probative value of medical opinions include their thoroughness and detail, whether they discussed why contrary opinions were not persuasive, and the opinion-writer's access to relevant records). The evidence also shows the Veteran did not die from VA treatment that was a result of carelessness, negligence, lack of proper skill, error in judgment, or some other incident of fault on the part of VA, or because of an event that was not reasonably foreseeable. This matter has been carefully considered by VA examiners, who have essentially indicated as much, based on the fact that there is no support in the record for this notion. It is clear that the Veteran was not started on multiple medications all at once prior to his death, and so the foundation for Dr. H's opinions concerning causation is incorrect, severely limiting the probative value of his opinions. See Reonal v. Brown, 5 Vet. App. 458 (1993) (discussing how the probative value of a medical opinion may be undermined by mistaken reliance on an inaccurate factual premise or predicate). Also, there is no support for the proposition that any medication prescribed by VA was in any way responsible for the Veteran's death, as attested to by the VA physician who opined this in April 2016. That physician reviewed the claims folder, noting important information it contained, and rendered probative negative medical opinions importantly with supporting reasons, after reviewing all relevant evidence. Accordingly, that opinion is considered quite probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). In this Neives-Rodriguez decision, the Court held that most of the probative value of an opinion comes from the discussion of its underlying reasoning, so a medical opinion should contain a conclusion and a reference to supporting data with a "reasoned medical explanation connecting the two." Neives-Rodriguez, at 301. The Board has considered the contrary opinions by Dr. H, but finds they are entitled to less weight and deference, under Prejean and Reonal v. Brown, 5 Vet. App. 458 (1993). Dr. H relied on erroneous information provided by the appellant in rendering his medical opinions, including importantly as to when medications were prescribed by VA, and does not appear to have reviewed relevant records. And while it is true that a commenting doctor's independent review of the file is not determinative of the probative value of his/her opinion, including if relying on a history that has been self-recounted by the Veteran and/or his widow, this is significant and reason to undermine the probative value of the opinion if, as mentioned, it relies on misinformation or does not account for relevant facts. See Coburn v. Nicholson, 19 Vet. App. 427 (2006); Kowalski v. Nicholson, 19 Vet. App. 171 (2005). It is equally worth noting that a VA physician has indicated that there is no support for Dr. H's report that medications prescribed by VA caused the Veteran's death, noting that none of the medications prescribed by VA are directly or indirectly linked to myocardial infarction or any other cause of the Veteran's death. Speculation on the part of Dr. H, including to the effect that medications prescribed by VA could have had a significant adverse effect on his heart condition, is given less probative weight in light of the standard of proof that is required - an at least as likely as not standard. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board also sees the appellant has made a number of medical contentions, and they have been considered. However, since she is a layperson and the medical matters at issue are medically complex and require medical expertise to competently opine about, her opinions on such medical matters, including as to causation, do not have probative weight. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Also, contentions she has made as to the competence of health care providers who have evaluated the Veteran are of no probative value, as she lacks competence, as a layperson, to opine on this also. Conversely, the examinations, especially when considered collectively, included consideration of the Veteran's relevant medical history and set forth findings enabling the Board to make a fully-informed decision on this claim regarding the cause of his death. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate, and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Indeed, even when this (competency of examiner) is challenged, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159 (a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). Furthermore, the competence of VA health care providers assigned to a task is presumed for completion of that task. The Board remanded this claim to cure deficiencies in the opinions to date. The opinion since obtained is clearly unfavorable to the claim. The Board regrets that it resultantly is unable to render a decision that is favorable to the appellant. Additionally, the Board certainly is very grateful for the Veteran's approximately 3 years of honorable service to his country, including his willingness to accept difficult jobs and the personal interest and skills he displayed in the maintenance field, as reflected by an April 1973 letter of commendation he received. Approval of this appeal, however, is not shown to be warranted. ORDER This claim of entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs