Citation Nr: 18145882 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-38 732 DATE: October 30, 2018 REMANDED Entitlement to service connection for the cause of the Veteran’s death is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1964 to March 1992. He died in April 2015. The appellant is his surviving spouse. This matter is on appeal from a June 2015 rating decision. Entitlement to service connection for the cause of the Veteran’s death is remanded. The appellant seeks service connection for the cause of the Veteran’s death. In support of this claim, the appellant’s representative submitted a private medical opinion opining that it was at least as likely as not that immunosuppressive medications the Veteran was required to take to treat his service-connected renal insufficiency with hypertension, status post renal transplant, were “proximate to his death.” The Veteran passed away in April 2015. An April 2015 death certificate identifies the immediate causes of his death as cardiac arrest, anemia, and coagulopathy. Prior to death, the Veteran was service connected for the following disabilities : bilateral pes planus; status post right total knee replacement due to shell fragment wound residuals; bronchial asthma with hay fever; renal insufficiency with hypertension, status post renal transplant; diabetes mellitus, type 2; residual shell fragment wounds to right foot, right elbow, and right wrist; gout; residual fracture left fifth metatarsal; residual scar at the site of renal transplant; and ventral hernia associated with renal insufficiency with hypertension, status post renal transplant. The Veteran served on active duty from February 1964 to March 1992. A November 1991 service medical record reported that the Veteran had carried a diagnosis of hypertension for ten years and renal insufficiency for six years. A February 1992 report of medical examination reported the Veteran’s kidneys and hypertension as defects. An August 1994 rating decision granted entitlement to service connection for renal insufficiency with hypertension as the Veteran had been diagnosed in service with hypertension and hypertensive nephropathy and had been under treatment since 1979. In February 2010, the Veteran underwent a kidney transplant. To prevent rejection of the transplanted kidney, immunosuppression was started preoperatively with Myfortic, while Myfortic and Prograf were prescribed postoperatively. In June 2012, the Veteran submitted a statement in which he reported that his hypertension medications had increased due to the anti-rejection medications he was taking for his transplanted kidney, which were Prograf, Myfortic, and Prednisone. He reported that the side effects of the anti-rejection medications decreased his body’s ability to protect itself against illness, infections, dizziness, tremor, diarrhea, nausea, increased blood pressure, weakness, drowsiness, and osteoporosis. The Veteran was afforded a VA examination for kidney conditions in August 2013. The Veteran reported taking several medications for his transplant that caused fatigue and depressed his immune system. The examiner reported these medications as Prograf, Myfortic, and Prednisone. A November 2013 private medical record includes the following hand-written note from the treating physician: “[The Veteran] is on immune suppression medications due to his kidney transplant. He should be considered immunosuppressed.” In support of her claim, the appellant provided a February 2018 independent medical review and private medical opinion. According to the February 2018 independent medical review compiled by Dr. I.H.N., the Veteran was admitted to the Heart of Florida Regional Medical Center in April 2015. During that hospital admission, he developed gastrointestinal bleeding, severe anemia, and coagulopathy. He had an endoscopy, which showed blood in the stomach and intestine. The Veteran was then intubated and later that day, he expired. According to Dr. I.H.N., “[i]t is my opinion within a reasonable degree of medical certainty based upon review of the medical records that [the Veteran] died from severe gastrointestinal bleeding, which led to a cardiac arrest. Moreover, Dr. I.H.N. opined that it is as likely as not that “the immunosuppressive medications, specifically prednisone and mycophenolate [also known as Myfortic], which [the Veteran] was required to take to support his service connected renal transplant, was proximate to his death.” The Board notes that the Veteran had been taking immune suppression medications following his kidney transplant in February 2010 and that the effects of those medications depressed the Veteran’s immune system. However, the appellant did not submit any medical records related to the Veteran’s treatment at the time of his death, including those reviewed by Dr. I.H.N. to compile his independent medical review. Without these records, it is not possible for the Board to assess either the accuracy of the factual account of the Veteran’s cause of death or the soundness of the opinion and rationale provided by Dr. I.H.N. In view of the foregoing, the Board finds that a remand for a medical opinion to assess whether there is any relationship between the Veteran’s cause of death and his military service is necessary. The matter is REMANDED for the following action: 1. Contact the appellant and request that she either submits, or provides VA sufficient information and authorization to obtain, any private treatment records from the Heart of Florida Regional Medical Center, the facility at which the Veteran was receiving treatment at the time he died, as well as any other pertinent records. 2. To expedite this case, the appellant’s representative (and/or the appellant), should be asked to obtain these records herself and inform the RO/AMC that all appropriate records have been submitted, to ensure that all pertinent records have been submitted in a timely manner so that the VA may adjudicate this case quickly. 3. The claims file should be sent to an appropriate VA examiner to provide an opinion on the cause of the Veteran’s death. The examiner is requested to review the claims folder, to include this remand, and provide the following opinion: Is it at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran’s cause of death was etiologically related to service, to include the effects of medications required to treat service-connected disabilities. In rendering the requested opinion, the examiner should specifically address and discuss Dr. I.H.N.’s independent medical review and private medical opinion. 4. The report should include the complete rationale for all opinion(s) expressed. 5. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 6. If an opinion cannot be rendered without resorting to speculation, the examiner should explain why it would be speculative to respond. 7. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the appellant’s claim should be readjudicated based on the entirety of the evidence. 8. If the claim remains denied, the appellant and her representative should be issued a supplemental statement of the case, and an appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate review, if in order. The appellant has the right to submit additional evidence and argument on the matter 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. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Moore, Associate Counsel