Citation Nr: 18155681 Decision Date: 12/06/18 Archive Date: 12/04/18 DOCKET NO. 17-44 267 DATE: December 6, 2018 ORDER Entitlement to an initial 30 percent rating for service-connected Meniere’s syndrome with vertigo is granted. Entitlement to an initial compensable disability rating for service-connected sinusitis with sinus headaches is denied. REMANDED Entitlement to dependency and indemnity compensation (DIC) based on service connection for the cause of the Veteran’s death is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s Meniere’s syndrome was productive of non-compensable hearing impairment, tinnitus, and more than occasional dizziness; the competent and probative evidence does not establish that the Veteran had attacks of vertigo and cerebellar gait one to four times a month. 2. Throughout the appeal period, the Veteran’s sinusitis did not manifest three or more non-incapacitating episodes characterized by headaches, pain, and purulent discharge or crusting; there were no incapacitating episodes requiring prolonged antibiotic treatment. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent disability rating, but no higher, for service-connected Meniere’s syndrome, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, 4.87, Diagnostic Codes 6204, 6205, 6260. 2. The criteria for an initial compensable disability rating for service-connected sinusitis with sinus headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Code 6514. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1951 to March 1953, to include service during the Korea Conflict era. The Veteran died in January 2016 and the Appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that assigned initial noncompensable disability evaluations for awards of service connection for Meniere’s syndrome and sinusitis, as well as a June 2016 rating decision that denied the Appellant’s claim of entitlement to service connection for the cause of the Veteran’s death. The Board acknowledges that the Appellant submitted a VA Rapid Appeals Modernization Program (RAMP) opt-in election form in May 2018. However, as the Veteran’s appeal of the claims herein had already been activated at the Board, they are not eligible for the RAMP program. Neither the Appellant nor her representative has raised any issues with the duty to notify or duty to assist. By way of history, the Veteran was awarded service connection for chronic otitis media of the right ear and a residuals of a left eardrum perforation in July 1953 and September 1993, respectively. In the years following, the Veteran sought entitlement to service connection for various disabilities as both directly related to service and as secondary to his service connected ear disabilities, including hearing loss, tinnitus, Meniere’s syndrome/vertigo, and sinusitis. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.310. While hearing loss and tinnitus were awarded in rating decisions dated May 2001 and September 2003, respectively, the Veteran’s claims for Meniere’s syndrome and sinusitis continued to be denied by both the RO and the Board. As noted above, however, and after several remands by the United States Court of Appeals for Veterans Claims (Court), service connection for Meniere’s syndrome and sinusitis were eventually awarded to the Veteran in an August 2015 Board decision. In a subsequent rating decision by the RO in September 2015, a noncompensable (zero percent) rating was assigned for both disabilities, effective October 10, 2001 – the date of receipt of the Veteran’s original service connection claims. Following the Veteran’s death, and after substitution as the claimant, the Appellant submitted a notice of disagreement in September 2016, asserting that the severity of the Veteran’s Meniere’s syndrome and sinusitis disabilities warranted compensable evaluations during for the entire period on appeal. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 1. Entitlement to an initial compensable disability rating for service-connected Meniere’s syndrome. The Veteran’s service-connected Meniere’s syndrome prior to his death was evaluated at zero percent disabling. Under Diagnostic Code 6205, Meniere’s syndrome manifesting hearing impairment with vertigo less than once a month, with or without tinnitus, is rated 30 percent disabling. Meniere’s syndrome manifesting hearing impairment with attacks of vertigo and cerebellar gait occurring from one to four times a month, with or without tinnitus is rated 60 percent disabling. Meniere’s syndrome manifesting hearing impairment with attacks of vertigo and cerebellar gait occurring more than once weekly, with or without tinnitus, is rated 100 percent disabling. 38 C.F.R. § 4.87. Of particular importance to this matter, a Note to Diagnostic Code 6205 provides that Meniere’s syndrome is to be rated either under these criteria or by separately rating vertigo (as a peripheral vestibular disorder under Diagnostic Code 6204), hearing impairment, and tinnitus, whichever method results in a higher overall rating. Under Diagnostic Code 6204 for peripheral vestibular disorders, dizziness and occasional staggering warrants a 30 percent rating, and occasional dizziness warrants a 10 percent rating. Objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this code, and hearing impairment or suppuration is separately rated and combined. 38 C.F.R. § 4.87, Diagnostic Code 6204. As the record reflects that the Veteran was service-connected for hearing loss and tinnitus secondary to service-connected chronic otitis media, the Bard will also address whether higher ratings are warranted for hearing loss and tinnitus under Diagnostic Codes 6100 and 6260, respectively. The Note to Diagnostic Code 6205 also provides that a rating for hearing impairment, tinnitus, or vertigo is not to be combined with a rating under Diagnostic Code 6205. 38 C.F.R. § 4.87. Turning to the evidence, the Veteran was admitted to hospital after a dizzy spell and fall in February 1999. The treating physician noted that, although the Veteran’s symptoms sounded consistent with vertigo, “there could be a component of cardiovascular compromise either from arrhythmia or decreased cardiac output,” but that he had “no murmur to suggest aortic stenosis” and the Veteran did not report significant symptoms regarding his ischemic heart disease at that time. The physician finally stated that with chronic tinnitus and episodes of vertigo, Meniere’s syndrome “becomes a possibility.” July and August 2000 hospital treatment reports note the Veteran undergoing a percutaneous transluminal coronary angioplasty (PTCA) after a complaint of chest pains and near syncope. A two-year history of chronic dizziness and syncopal episodes were indicated. The Board notes that in the same paragraph of the portion of the August 2000 report that pertained to his history of dizziness also discusses the Veteran’s right carotid blockage with possible neurogenic orthostatic hypertension, which the Board finds suggestive that the Veteran’s dizziness was suspected as cardiac-related. The report also notes that a pacemaker was placed during the PTCA. Additional hospital admissions in November 2000 and January 2001 for continued chest pain are absent accompanying complaints of dizziness or syncopal episodes, and a February 2001 follow-up examination report notes that his syncopal episodes had ceased since his pacemaker was implanted. However, an August 2001 VA cardiology treatment record notes the Veteran reporting that he would sometimes get dizzy and feel like he was going to pass out. A VA ear disease examination was afforded to the Veteran in December 2000. The examination report notes the Veteran reporting that he had vertigo for which he uses a wheelchair due to losses of balance, but that he blamed this purported vertigo on his “neck problems.” Vertigo, however, was not officially diagnosed by the examiner. A December 2002 statement from the Veteran’s private physician notes “decreased hearing, pain in ears, ringing in the ears and vertigo for a prolonged period of time,” and that “[c]onstant ringing in the ears and recurrent vertigo are symptoms of inner ear disease” dating back to the Veteran’s military service. In response to the Veteran’s representative asserting that the Veteran’s in-service otitis media actually represented the onset of Meniere’s syndrome, an additional VA ear disease examination was afforded in August 2003. Upon interview and examination, it was noted that the Veteran and his spouse were poor historians, often giving vague answers or having no recollection of certain details of the Veteran’s medical history. The Veteran did, however, report that he used to fall backwards and hit his head until his pacemaker was implanted, but that he may have fallen the previous month. The examiner opined, regarding a diagnosis of Meniere’s syndrome, that while it is true Meniere’s is a disorder characterized by recurrent prostrating vertigo, sensory hearing loss, tinnitus, and a feeling of fullness in the ear associated with generalized dilation of the membranous labyrinth, the reverse is not true – such symptoms do not themselves cause Meniere’s, as the Veteran’s representative had argued. He continued that the cause of Meniere’s is unknown and may have been misdiagnosed in this Veteran’s case. Additional VA treatment records dated in the years following the August 2003 examination and until the Veteran’s eventual death continue to note him reporting symptoms of occasional dizziness, vertigo, and lightheadedness, particularly when he stands. A May 2008 VA treatment record notes the Veteran explaining the use of assistive devices was because he would fall “all the time” due to the weakness of his muscles. The assessment at the time was that his dizziness was due to polypharmacy, as the Veteran was taking 40 different medications at the time. A January 2011 treatment note indicating a fall after dizziness was assessed as possibly related to prescribed Finasteride or his diabetes-related diet. Finally, VA audiological examinations were also afforded to the Veteran that are relevant to the Veteran’s Meniere’s syndrome appeal. In May 1991 and December 2000, puretone testing revealed thresholds, at worst, of 24 decibels in the right ear and 32 decibels in the left ear. Speech recognition was, at worst, 92 percent in the right ear and 88 percent in the left ear. The May 1999 examiner noted that the Veteran presented with complaints of dizziness and falling; however, the examiner was unable to determine when the etiology of these symptoms based on the Veteran’s difficulty in answering questions. A September 2000 private audiological report was not in significant conflict with the above VA examinations, indicating puretone thresholds of 25 decibels in the right ear and 32 decibels in the left, and speech recognition at 92 percent, bilaterally. A January 2002 VA audiology consultation showed no significant change in the Veteran’s hearing loss since the 1999 and 2000 VA examinations, with hearing acuity in the right ear noted as within normal limits through 3000Hz and sloping to mild hearing loss at 4000Hz to 6000Hz. Hearing acuity in the left ear was within normal limits through 1000Hz, sloping to a mild to moderate hearing loss at higher frequencies. Speech recognition was noted as “good.” Based on the foregoing, the Board finds that the evidence is in favor of an initial 30 percent rating for the Veteran’s service-connected Meniere’s syndrome. As an initial matter, the Board notes that the evidence is in conflict as to whether the Veteran had an actual diagnosis of Meniere’s syndrome or even true vertigo during the appeal. As previously indicated, however, a Note to Diagnostic Code 6205 provides that Meniere’s syndrome may be rated by separately rating hearing impairment, tinnitus, and dizziness (as a peripheral vestibular disorder) under their appropriate diagnostic codes, whichever method results in a higher overall rating. 38 C.F.R. § 4.87. In that regard, the Board finds of particular significance the private medical report of Dr. A.A., who opined that, while it was not unreasonable to label the Veteran’s various conditions involving his ears, dizziness, hearing loss, and tinnitus as Meniere’s syndrome, it “does more justice to [the Veteran’s] complicated medical profile to not assign a name or syndrome, but to simply understand that [he] suffers from chronic otitis, hearing loss, tinnitus, chronic sinusitis, and vertigo.” Here, service connection was already separately established for bilateral hearing loss since July 2000, with a noncompensable evaluation has been assigned. The results of audiological testing during the appeal period indicated that the severity of the Veteran’s hearing loss did not warrant a compensable rating, with test results revealing no more than Level I hearing impairment in the right ear and Level II hearing impairment in the left ear. See 38 C.F.R. § 4.85. Additionally, at the time of the Veteran’s death, service connection for tinnitus had been in effect since October 28, 1993 and evaluated at the maximum available schedular rating of 10 percent. See 38 C.F.R. § 4.87, Diagnostic Code 6260. Thus, while the evidence may be may be in conflict as to whether the Veteran had true vertigo, the Board finds that a separate compensable rating is warranted for the Veteran’s dizziness under Diagnostic Code 6204 for a peripheral vestibular disorder. Pursuant to the Note to Diagnostic Code 6204, objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned. In this case, the medical evidence shows that, despite conflicting etiological opinions which included polypharmacy and his various cardiac disorders, the Veteran nonetheless had objective findings of dizziness and imbalance throughout his appeal period, with the Veteran reporting dizziness “all the time” and periodic falling such that he took to using an assistive device on a constant basis. Accordingly, the Board finds it more appropriate to award an initial 30 percent rating pursuant to Diagnostic Code 6204 for peripheral vestibular disorders. Evaluating the Veteran’s hearing loss, tinnitus, and findings of dizziness separately is more favorable to the Appellant and would result in a higher overall rating. As explained above, the Veteran’s hearing loss was noncompensably disabling, his tinnitus was 10 percent disabling, and the record reflects that he did experience more than occasional dizziness (with falling) of an unconfirmed etiology warranting the maximum 30 percent rating for that disorder. The Board notes that service-connection was also in effect for is chronic otitis media, rated as 10 percent disabling during the entire appeal period. For the next higher, 60 percent rating to be assigned under Diagnostic Code 6205, there would need to be a showing of vertigo with cerebellar gait occurring at least once a month. It is noted that a cerebellar gait is a staggering ataxic gait (unsteady, uncoordinated walk, with a wide base and the feet thrown out), sometimes with a tendency to fall to one side, indicative of cerebellar lesions. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 747 (30th ed. 2003). As noted above, the record is in conflict as to finding of true vertigo. A cerebellar gait is not shown. While the record may reflect the Veteran’s abnormal gait, he suffered from a variety of disabilities which cause him to take to using a wheelchair due to “weakness,” including, but not limited to, arthritis, peripheral neuropathy, and a hip fracture. A cerebellar gait is simply not documented or supported by the record. Thus, a higher 60 percent rating is not warranted under Diagnostic Code 6205. 38 C.F.R. §4.87. Therefore, for the reasons and bases expressed above, the Veteran’s service-connected Meniere’s syndrome should be initially evaluated pursuant to separate ratings for hearing loss (0 percent), tinnitus (10 percent) and peripheral vestibular disorder-related dizziness (30 percent). 2. Entitlement to an initial compensable disability rating for service-connected sinusitis. During the period on appeal, the Veteran’s sinusitis was rated as noncompensable. Service connection was awarded just prior to his death, in September 2015, and the Appellant contends that he should have been assigned a compensable initial rating because of a history of antibiotic medication. Upon review of the evidence, the Board finds that a compensable rating is not warranted. Under the General Rating Formula for Sinusitis (Diagnostic Codes 6510 through 6514), a noncompensable rating is assigned for sinusitis that is detected by x-ray only. 38 C.F.R. § 4.97. A 10 percent evaluation is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment; or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment; or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis; or near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, Diagnostic Code 6514. The Note following this section provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. Also relevant to this appeal is Diagnostic Code 6502, which contemplates traumatic deviation of the nasal septum. Diagnostic Code 6502 provides for a 10 percent disability rating when there is a 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side of the nose. 38 C.F.R. § 4.97. Turning to the evidence, during a VA ear disease examination in December 2000, the Veteran reported sinus trouble since his military service and that he used nasal preparation drops for “stuffy sinuses.” The Board notes that while the Veteran also reported use of antibiotic injections one to three times per year, this appears to relate to chronic ear infections rather than sinus infections. Physical examination of the Veteran’s nose was normal. A VA treatment record dated February 2001 notes “nasal stuffiness controlled with present medicines.” The Board notes that a contemporaneous medication list indicates only nasal spray prescribed for the Veteran’s sinuses. May 2001 treatment for week-long coughing notes sinus drainage and some sinus headache. While Amoxicillin, an antibiotic, was initial prescribed, it appears to have been subsequently crossed out by the attending physician. The Board notes that Amoxicillin is a Penicillin-based antibiotic, and that the record reflects the Veteran was allergic to Penicillin. An alternative antibiotic was prescribed instead, along with Sudafed. A December 2002 VA ear, nose, and throat (ENT) consultation noted chronic sinusitis with marginal relief with medication. A medication listing notes only Guaifenesin, an expectorant, prescribed to treat his symptoms. The final impression was a deviated nasal septum without evidence of obstructive sinusitis. At an additional ear disease examination in August 2003, the Veteran reported nasal spray for his sinuses and antibiotics for his ears. He specifically stated that he did not recall taking antibiotics for his sinuses. The examiner noted that the Veteran’s medical records noted only one complaint of sinus headaches that did not appear to be a recurring problem, however the Veteran did report frontal headaches “most of the time.” Physical examination revealed a 50 percent obstruction of his left nares, with nontender sinuses. X-rays of the sinuses were normal without any evidence of sinusitis or nasal fractures. A December 2005 private treatment record notes the Veteran reporting left moderate facial fullness and pain above the eyes and severe left nasal congestion. The Veteran reported being treated with antibiotics “most of his adult life.” A nasal examination showed a deviated septum with 100 percent obstruction and mild mucosal congestion on the right side, but no polyps or any purulent discharge. A January 2006 follow-up notes that he had completed an antibiotic course and was continuing with a prescribed nasal steroid. While he continued to report severe congestion on the left side, he had near complete resolution of facial fullness and pain. An April 2008 VA treatment record notes the Veteran reporting sinus drainage and congestion. Physical examination revealed clear drainage and non-tender palpation. Loratadine, an antihistamine, was prescribed. At a VA respiratory examination in October 2008, X-rays indicated clouding of the right maxillary sinus. The Veteran was noted as being prescribed nasal spray as needed for his sinuses. He reported that he was “always incapacitated,” but also reported no purulent discharge or headaches. He did note occasional sinus pain and that he needed antibiotics “several times a year”. Physical examination indicated nontender sinuses and unobstructed nasal passages. A June 2011 telephone call encounter notes the Veteran’s daughter reporting congestion, headaches, and a “greenish” drainage from his sinuses. A Z-pak (Zithromax), which contains the antibiotic Azithromycin, was prescribed. Additional treatment records the following month noted that this treatment had ended. However, after March and May 2012 treatment for additional complaints of sinus pain and congestion, active medication records once again listed Azithromycin in July 2012. His left deviated septum was also noted. Finally, a VA sinusitis examination was afforded in October 2013. While diagnostic testing revealed inflamed right paranasal sinuses, the examiner indicated that there were no findings, signs, or symptoms attributable to his sinusitis at that time, including and headaches, pain or tenderness, or purulent discharge. The Veteran also reported that there were no incapacitating episodes of sinusitis requiring antibiotics during the previous 12 months, nor were there any non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge. The examiner ultimately described the baseline level of severity of the Veteran’s sinusitis as “[i]ntermittent sinus infections requiring antibiotics.” Based on the foregoing, the Board finds that a compensable rating for the Veteran’s sinusitis is not warranted during the period on appeal. Again, to warrant a higher disability rating for sinusitis the evidence would have to support that the Veteran has either (1) two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or (2) three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 38 C.F.R. § 4.97, Diagnostic Code 6514. The Board finds that the evidence supports neither. Despite the Veteran’s statement during his October 2008 VA respiratory examination that he was “always incapacitated,” the Board interprets this statement to pertain to the Veteran’s overall disability picture at the time, rather than his sinusitis specifically. Moreover, there is no indication in the record that the Veteran’s antibiotic treatments throughout the appeal period were both prolonged and accompanied by physician-prescribed bedrest (the criteria for an “incapacitating episode”). See 38 C.F.R. § 4.97, Diagnostic Code 6514, Note. As to non-incapacitating episodes of sinusitis, the Board notes that the criteria for compensable ratings are stated in the conjunctive, which means that all three conditions must be met – headaches, pain, and crusting or purulent discharge – to warrant a rating of 10 percent or greater. See e.g., Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (finding that the use of the conjunctive “and” in the criteria for a 40 percent rating for diabetes – “insulin, restricted diet, and regulation of activities” – meant that entitlement to that rating required all three criteria to be met.) Here, while the Veteran had many episodes of sinusitis that manifested symptoms of headaches, pain and pressure, or occasional purulent discharge, the evidence does not reflect that the Veteran experienced these symptoms at a frequency to satisfy the criteria for a higher rating. Id. The Board has considered whether a separate or higher rating is available under another Diagnostic Code but has found none. While the record confirms that the Veteran had a deviated nasal septum that was 100 percent obstructed on the left side, no physician or medical examiner opined as to its etiological relationship to the Veteran’s sinusitis. More importantly, there was no indication that it was traumatic in nature to warrant a rating at all under Diagnostic Code 6502. Id. X-rays of the Veteran’s sinuses revealed no nasal fractures. The Board is sympathetic to the lay statements of the Appellant and the Veteran prior to his death that his sinusitis was worse than initially evaluated and those statements have been considered. Both are competent to report symptoms because this requires only personal knowledge as it comes through their senses. Layno v. Brown, 6 Vet. App. 465 (1994). However, identification of the specific nature and extent of the Veteran’s disability according to the appropriate diagnostic code has been provided by the medical personnel who examined him during the appeal period and rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which his sinusitis was evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability rating. Neither the Appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. REASONS FOR REMAND While the Board sincerely regrets further delay, remand is necessary to obtain a VA medical opinion as to the etiology of the Veteran’s 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 disability was either the primary or contributory cause of death. 38 C.F.R. § 3.312. As noted above, the Veteran died in January 2016. The immediate cause of death listed on the Veteran’s death certificate was sudden cardiac death due to congestive heart failure and coronary artery disease with unstable angina. Other significant contributing conditions listed are severe chronic obstructive pulmonary disease (COPD), moderate to severe pulmonary hypertension, diabetes, Alzheimer’s dementia, chronic dysphagia, chronic anemia, obstructive sleep apnea, osteoarthritis, hypothyroidism and deep venous thrombosis. At the time of his death, service connection was in effect for major depressive disorder, chronic otitis media with scar on right ear drum, residuals of a left eardrum perforation, tinnitus, bilateral hearing loss, Meniere’s syndrome, and sinusitis. In its June 2016 rating decision denying the Appellant’s claim, the RO determined that the Veteran’s service treatment records were negative for treatment or diagnosis for any of the conditions resulting in his death, and that the evidence did not establish that any of the Veteran’s service-connected disabilities caused or contributed to the cause of his death. It is the Appellant’s contention, however, that the medication the Veteran was prescribed for his service-connected major depressive disorder – Amitriptyline, Carbamazepine, Sertraline, and Mirtazapine – contributed to his death. Specifically, in her substantive appeal, the Appellant referenced several medical articles that suggest that these medications can increase the risk of cardiac instability and sudden cardiac-related death. While the Board does not find the evidence currently of record to be dispositive for this appeal, the Board cannot say that there is no reasonable possibility that obtaining a VA medical opinion would aid in substantiating the appellant’s claim. Thus, the Board finds that the Appellant’s claim should be remanded to obtain a VA medical opinion addressing the etiology of the cause of the Veteran’s death. The matter is therefore REMANDED for the following actions: 1. Ask the Appellant to identify any remaining outstanding treatment records relevant to her claim. All identified VA records should be added to the claims file. All other properly identified records should also be obtained if the necessary authorization to obtain the records is provided by the Appellant. If any records are not available, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Appellant of the unavailability of the records. 2. After the above is completed, send the claims file to a physician with appropriate medical expertise for a VA medical opinion regarding the etiology of the cause of the Veteran’s death. The claims folder should be reviewed by the physician. After review of the evidence, the physician should address the following: Whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran’s service-connected disabilities contributed materially or substantially to cause his death. The physician should specifically address the Appellant’s arguments in her August 2017 VA Form 9 that the medication prescribed to the Veteran to treat his major depressive disorder caused cardiac instability and ultimately his cardiac-related death. The medical treatise evidence submitted should be discussed. A rationale for the requested opinion should be provided as the Board is precluded from making any medical findings, and should include citation to evidence in the record, known medical principles, and/or any medical treatise evidence. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Scarduzio, Associate Counsel