Citation Nr: 1801707 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 14-13 476 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for the cause of the Veteran's death. 2. Entitlement to Dependency and Indemnity Compensation (DIC) benefits under 38 U.S.C. § 1318. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Jiggetts, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1968 to November 1979. The Veteran died in April 2007. The Veteran's surviving spouse is the Appellant herein. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin, which denied the Appellant's claims. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Appellant if further action is required. REMAND The Board finds that additional development is warranted in this case before a decision may be rendered. The Veteran's death certificate states the immediate cause of death was cerebrovascular accident (CVA); the underlying cause of death was arteriosclerotic cardiovascular disease (ASCVD); and, that other significant conditions contributing to death but not resulting in the underlying cause were: chronic renal failure (CRF), hepatic insufficiency; hypertension (HTN); and congestive heart failure (CHF). Service treatment records reflect that in June 1969, the Veteran complained of stomach cramps, chills, and fever; and was determined to have an "undiagnosed disease manifested by fever, jaundice, positive blood cultures, and anemia of an unknown etiology." In November 1970, the Veteran again complained of abdominal pain and was diagnosed with "elevated bilirubin, etiology unknown, untreated, probable cholecystitis." At issue is whether the Veteran's cause of death is a result of the conditions that manifested in military service, or whether his death otherwise resulted from service, including any disease, injury, or event therein. The Appellant claims that the Veteran's cause of death is a result of the conditions the Veteran manifested in military service. In support of her position, in a September 2012 Statement of Accredited Representative, the Appellant references medical literature, citing to an article in the Journal of the Society of Laparoendoscopic Surgeons and the US Library of National Medicine National Institutes of Health which indicates that: [A]cute cholecystitis may cause a clinical picture similar to that of cardiac ischemia with a syndrome of abdominal fullness, nausea, diaphoresis, chest pain, as well as angina pectoris, arrhythmias, or non-specific ST-T wave changes on the electrocardiogram. In a patient with known coronary artery disease who present with acute cholecystitis and epigastric or chest pain or questionable electrocardiogram, the diagnosis of coronary ischemia had to be promptly ruled out with further testing, including stress testing and a cardiac catheterization if needed, before proceeding with cholecystectomy; however, surgeons must keep in mind undue delay in treatment may result in both cardiac and septic complications. In a February 2014 VA examination, the examiner states the Veteran's cause of death is not a result of the conditions that manifested during service, finding that none of the conditions found in the service treatment records, and in particular records of treatment in June 1969, are primary or contributory causes of the Veteran's death. However, the examiner did not address the medical literature referenced by the Appellant, which appears to suggest there may be a connection between cholecystitis such as the Veteran experienced in service and later cardiac and septic disorders. The examiner further failed to address the Veteran's November 1970 complaints of abdominal pain and diagnosis of "elevated bilirubin, etiology unknown, untreated, probable cholecystitis." In light of the above, the Board has determined that an additional medical opinion is needed to determine whether there is a nexus between the Veteran's cause of death and his service. This opinion must specifically address the medical literature referenced by the Appellant and must consider all relevant evidence of record, to include the November 1970 complaints of abdominal pain and diagnosis of "elevated bilirubin, etiology unknown, untreated, probable cholecystitis." Finally, the Board notes that the issue of entitlement to DIC benefits under 38 U.S.C. § 1318 is inextricably intertwined with the claim of entitlement to service connection for the cause of the Veteran's death. The cause of death claim could therefore directly impact the claim for DIC benefits under 38 U.S.C. § 1318. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, on remand the AOJ must first consider the cause of death claim before it may consider the claim of entitlement to DIC benefits under 38 U.S.C. § 1318. Accordingly, the case is REMANDED for the following action: 1. Request that the Appellant submit a copy of the medical literature from the Journal of the Society of Laparoendoscopic Surgeons and the US Library of National Medicine National Institutes of Health referenced above, or if she is unable to provide a copy, request that she provide the full citation for the article so that the AOJ may obtain the article for consideration by the VA examiner. 2. Refer the claims file and a copy of this Remand to a qualified VA medical professional, who must offer a well-reasoned opinion regarding the following question: Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's cause of death is attributable to any of his medical conditions noted in service, or is otherwise related to his military service. In reaching this conclusion, the qualified VA medical professional must specifically address each of the conditions listed in the Veteran's death certificate (cerebrovascular accident, arteriosclerotic cardiovascular disease, chronic renal failure, hepatic insufficiency, hypertension, and congestive heart failure), and determine whether any of these conditions, or pre-cursors for these conditions, were diagnosed, treated, or otherwise noted in service. The examiner must specifically address the medical literature submitted by Appellant that suggests a link between the Veteran's cause(s) of death and the medical conditions noted in service. The examiner must also specifically discuss the June 1969 and November 1970 service treatment records referenced above, wherein the Veteran was treated for abdominal pains and diagnosed with jaundice, anemia, and "probable cholecystitis." 3. After completing the above, readjudicate the claims. If the decision is adverse to the Appellant, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claims to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ CAROLINE B. FLEMING Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).