Citation Nr: 18149354 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 14-07 292 DATE: November 9, 2018 REMANDED Service connection for residuals of frostbite of the feet is remanded. Service connection for residuals of frostbite of the hands is remanded. Service connection for cause of the Veteran’s death is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1964 to October 1967. The Veteran died in February 2015, and the appellant is his surviving spouse. In June 2015, her motion for substitution was granted by the RO. The case is on appeal from May 2013 (frostbite issues) and May 2015 (cause of death issue) rating decisions. In a September 2015 decision, the Board reopened the previously denied claims of service connection for residuals of frostbite in the hands and feet, and denied an initial disability in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). At that time, the Board also remanded the frostbite claims and a hearing loss claim for further development. Since that time, the appellant has also perfected an appeal of the cause of death issue. In a May 2017 rating decision, the RO granted service connection for hearing loss. Thus, that issue is no longer on appeal. In April 2018, the appellant testified at a Board hearing. The record was held open to submit additional evidence, which was thereafter submitted. 1. Service connection for residuals of frostbit of the feet is remanded. 2. Service connection for residuals of frostbite of the hands is remanded. The appellant testified at the April 2018 Board hearing that the Veteran always complained about his hands and feet being so cold and numb. She recalled the Veteran’s long-standing peripheral neuropathy symptoms which the Veteran attributed to frostbite he experienced during service. These statements indicate at least a possibility that the Veteran’s peripheral neuropathy symptoms are related to service. Thus, an opinion on direct service connection should be obtained. The record also reasonably raises a theory of secondary service connection. A July 1995 VA mental health examination report notes diagnosis under Axis I of alcohol dependence and history of alcohol abuse, history of alcoholic hepatitis and jaundice in the 70s, recurrent alcoholism, peripheral neuropathy, and abnormal liver. Further, a January 1998 hospital record indicates that the Veteran attributed these symptoms to Lithium, a medication used to treat his service-connected PTSD and anxiety. This evidence at least indicates a possible relationship between the Veteran’s reported symptoms affecting the extremities and his service-connected PTSD, via medication use or a secondary alcohol use disorder. Because service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury, 38 C.F.R. § 3.310, the medical opinion should also address this theory. Although the Veteran primarily asserted the theory of frostbite residuals, there may be other causes of his observable symptoms that are medically complex in nature. Thus, the claim may be broader and include neuropathy. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 3. Service connection for cause of the Veteran’s death is remanded. During his lifetime, the Veteran was service connected for acquired psychiatric disorders (PTSD and anxiety), hearing loss, tinnitus, and a traumatic brain injury (TBI). His claims for service connection for peripheral neuropathy in the hands and feet are now pending. His death certificate lists lung cancer, malignant plural effusion, liver cirrhosis, and emphysema as causes of death. Atrial fibrillation was listed as a contributing cause of death. At the April 2018 Board hearing, the appellant testified that the Veteran started drinking alcohol because he could not sleep due to anxiety. The Veteran had a long history of treatment for alcohol abuse and dependence, in the 1970s, only a few years after service and in the 1990s. Liver cirrhosis, a listed cause of death, is well-known to be caused by excessive alcohol use. Because the Veteran’s alcohol use may have been a secondary disorder to service-connected PTSD and anxiety, a medical opinion as to whether the Veteran’s PTSD or anxiety caused of contributed to death is warranted. Notably, primary alcohol use disorders are not service connectable. See 38 C.F.R. § 3.301. Further, the appellant should be given an opportunity provide, or to identify so that VA can obtain, private medical records from Canada, Elmwood Mental Hospital, and any other non-VA medical providers who may have relevant treatment records that have not yet been obtained. The matters are REMANDED for the following action: 1. Contact the appellant so that she may provide private treatment records, or enable VA to obtain private treatment records, including from Canada, and Elmwood Mental Hospital. 2. Thereafter, forward the claims file to an examiner to determine the etiology of the Veteran’s symptoms affecting the four extremities, and the Veteran’s cause of death. Specifically, after reviewing the entire claims file, the examiner should opine as to whether: (A) It is at least as likely as not that the Veteran had a disorder affecting his four extremities, such as residuals of frostbite and/or peripheral neuropathy that had their onset during, or are otherwise related to, reported frostbite during service? (B) It is at least as likely as not that the Veteran had a disorder affecting the four extremities, such as peripheral neuropathy, that were caused or aggravated by his service-connected PTSD and anxiety? Consideration should be given as to whether this was due to medication to treat the psychiatric condition (such as Lithium) and/or whether there was a secondary alcohol use disorder. Any primary alcohol use disorder is to be excluded. (C) It is at least as likely as not that the Veteran’s PTSD and anxiety was a principal or contributory cause of the Veteran’s death (contributed substantially and/or materially, or when combined with another disability)? Consideration should be given to the theory of an alcohol use disorder secondary to the PTSD/anxiety that in turn led to cirrhosis of the liver. (Continued on the next page)   A complete rationale should be provided for any opinion rendered. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. George