Citation Nr: 18157655 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 14-10 258 DATE: December 13, 2018 ORDER Entitlement to service connection for the Veteran’s cause of death is denied. FINDING OF FACT 1. The Veteran served during peacetime. 2. The Veteran died in January 2011, and his un-amended death certificate listed his cause of death as respiratory failure due to idiopathic pulmonary fibrosis. 3. At the time of his death, the Veteran was receiving compensation for the following service-connected disabilities: post-traumatic stress disorder (PTSD), hearing loss, tinnitus, and the residuals of squamous cell carcinoma, to include hypothyroidism, osteomyelitis, loss of an ear, facial scar, multiple superficial scars, and vertigo 4. In October 2015, the Veteran’s death certificate was amended to include PTSD, gastroesophageal reflux disease (GERD), loss of his ear, facial scar, hearing impairment, labyrinthitis osteopathy, and tinnitus and as contributing to his death. 5. The Veteran’s service-connected disabilities, to include PTSD, hearing loss, tinnitus, and the residuals of squamous cell carcinoma, to include hypothyroidism, osteomyelitis, loss of an ear, facial scar, multiple superficial scars and vertigo, are not etiologically related to idiopathy pulmonary fibrosis and did not contribute substantially or materially to the Veteran’s death. CONCLUSION OF LAW The criteria for service connection for the Veteran’s cause death have not been met. 38 U.S.C. §§ 1131, 1310, 1318 (2012); 38 C.F.R. §§ 3.22, 3.303, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from July 1963 to October 1967. Entitlement to Service Connection for the Veteran’s Cause of Death Appellant, who is the Veteran’s surviving spouse, contends that she is entitled to service connection for the Veteran’s cause of death. The Veteran died in January 2011, and his un-amended death certificate identifies respiratory failure due to idiopathic pulmonary fibrosis as the immediate cause of his death. The Veteran’s death certificate was amended in October 2015 to state that the Veteran died due to or as a consequence of PTSD, GERD, loss of his ear, facial scar, hearing impairment, labyrinthitis osteopathy, and tinnitus. The question here is whether any of the Veteran’s service-connected disabilities are principal or contributory causes of the Veteran’s death. To establish service connection for the cause of death, the evidence must show that a disability that was incurred in or aggravated by service—or which was proximately due to or the result of a service-connected condition—was either a principal or contributory cause of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(a). For a service-connected disability to be the principal cause of death, it must singularly or jointly with some other condition be the immediate or underlying cause of death, or be etiologically related thereto. 38 C.F.R. § 3.312(b). For a service-connected disability to be a contributory cause of death, it must be shown that it contributed substantially or materially, that it combined to cause death, or aided or lent assistance to the production of death. Id. § 3.312(c). The Appellant makes three arguments to associate the Veteran’s idiopathic pulmonary fibrosis with his service-connected disabilities: that it is due to exposure to asbestos while the Veteran served on the U.S.S. Stormes, due to GERD that was aggravated beyond its natural progression by PTSD, and due to oxygen toxicity from hyperbaric chamber treatments for the Veteran’s squamous cell carcinoma. A. Exposure to Asbestos In a November 2017 Statement in Support of Claim, the Appellant contends that the Veteran’s idiopathic pulmonary fibrosis was due to his exposure to asbestos while serving aboard the U.S.S. Stormes. The Board solicited an expert medical opinion through the Veterans Health Administration to address this contention. Notably, in a July 2018 letter, Dr. R.T., who is board-certified in Pulmonary and Critical Care Medicine, concluded that the Veteran’s idiopathic pulmonary fibrosis was less likely than not due to the Veteran’s exposure to asbestos. Dr. R.T. noted that there was no evidence of asbestos bodies in a CT scan of the Veteran’s lungs or in his transbronchial lung biopsy. Accordingly, a diagnosis of asbestosis was not indicated. Dr. R.T. also references a body of medical literature finding no causal association between asbestos exposure and idiopathic pulmonary fibrosis. Dr. R.T.’s opinion is highly probative. It is based on a review of the Veteran’s claim file, consultation of medical literature, and provides a rationale for the opinion reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-02 (2008). Dr. R.T.’s letter is more probative than the material submitted by the Appellant. The Board concludes that the Mayo Clinic internet article on pulmonary fibrosis is not probative. In his July 2018 letter, Dr. R.T. noted that the article addressed many forms of pulmonary fibrosis and was not limited to idiopathic pulmonary fibrosis. The article also constitutes generic evidence that does not address the specific factual circumstances of the Veteran’s case or the issue before the Board. The Appellant also submitted a September 2014 press release noting research by Dr. C.R., et al. with findings consistent with the hypothesis that idiopathic pulmonary fibrosis is likely caused by exposure to asbestos. This article is also entitled to little probative weight. Dr. R.T. noted that the Appellant submitted a press release and abstract for a paper presented at a scientific meeting. He concluded that the press release does not show that the Veteran’s idiopathic pulmonary fibrosis was more likely than not due to asbestos exposure. Contrary to the Appellant’s contention, the article does not demonstrate that there is a causal relationship between asbestos exposure and idiopathic pulmonary fibrosis. Dr. R.T. found the peer-reviewed paper submitted at the meeting, and quoted the researches admitting “that ‘this relationship cannot establish causation, and may be entirely coincidental.’” Further, Dr. R.T. notes that this single paper is contrary to a body of medical literature finding no causal link between asbestos exposure and idiopathic pulmonary fibrosis causes. See Monzingo v. Shinseki, 26 Vet. App. 105, 106-07 (2012) (noting examiners are presumed to be up-to-date on medical knowledge and current medical studies). In a November 2010 letter, Dr. D.S., who treated the Veteran, opined that idiopathic pulmonary fibrosis was due to the Veteran’s exposure to asbestos while serving aboard the U.S.S. Stormes. Dr. D.S.’s opinion is, however, conclusory and does not include any rationale for the opinion reached. The 2018 VHA opinion far more comprehensive and fact specific. Accordingly, the November 2010 letter is afforded no probative value. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding “a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor’s opinion”). B. GERD Secondary to the Veteran’s Service-Connected PTSD and Depression In a November 2017 Statement in Support of Claim, the Appellant contends that the Veteran’s service-connected PTSD and depression are etiologically related to GERD, which in turn, is etiologically related to the Veteran’s idiopathic pulmonary fibrosis. The probative weight of the evidence of record does not support the Appellant’s contention. In a July 2018 VHA opinion, Dr. R.T. concluded that it was less likely than not that GERD caused the Veteran’s idiopathic pulmonary fibrosis. Dr. R.T. noted that GERD has long been found in patients with idiopathic pulmonary fibrosis, and cited medical literature showing GERD is observed in approximately 90 percent of idiopathic pulmonary fibrosis patients. However, according to Dr. R.T., the data does not show an etiological, or causal, association between GERD and idiopathic pulmonary fibrosis. See Monzingo, 26 Vet. App. at 106-07. They are simply comorbid conditions. Dr. R.T.’s letter is highly probative. Dr. R.T. provided adequate rationales for his opinion and based it on a thorough review of the Veteran’s claim file and pertinent medical literature. See Nieves-Rodriguez, 22 Vet. App. at 301-02. In a June 2012 letter, Dr. D.S., concluded that the “it is possible” that the Veteran’s PTSD and depression contributed to the development of GERD. Dr. D.S. reasoned that the GERD is a “well-known direct cause/contributing element to the type of pulmonary fibrosis” that caused the Veteran’s respiratory failure. Dr. D.S. opinion is of limited probative value. First, first the opinion is stated in equivocal terms, “it is possible,” that is too speculative to support a grant of the claim on appeal. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (2014). Second, Dr. R.T.’s July 2018 letter notes that the medical literature shows GERD is observed in a high percentage of patients with idiopathic pulmonary fibrosis, but the data does not show a causal association between GERD and idiopathic pulmonary fibrosis. Dr. D.S. makes no reference to any data or published literature to support his contention that such an association is well-known. Thus, the Board affords more probative weight to Dr. R.T.’s July 2018 letter than Dr. D.S.’s June 2012 letter. The Appellant also relies on a June 2012 letter from Dr. S.S., who treated the Veteran starting in January 2001. Dr. S.S. noted the Veteran’s diagnoses for PTSD, depression and stress, and opined that the Veteran first suffered from GERD and developed idiopathic pulmonary fibrosis as a result of the severe GERD. Dr. S.S. stated that the Veteran’s service-connected PTSD made the Veteran’s GERD worse. Dr. S.S.’s letter is of little probative value. Dr. S.S.’s opinion is conclusory and the June 2012 letter does not contain his rationales for his opinion that GERD caused idiopathic pulmonary fibrosis or his opinion that PTSD worsened the Veteran’s GERD. See Stefl, 21 Vet. App at 125. Dr. R.T.’s July 2018 letter is entitled to more probative weight than Dr. S.S.’s June 2012 letter. Whereas Dr. S.S. provide no rationales and cites no medical literature to support his conclusion, Dr. R.T. reviewed the Veteran’s claim file, included rationales, and relied on medical literature in concluding that the Veteran’s GERD is less likely than not etiologically related to idiopathic pulmonary fibrosis. In reaching this conclusion, the Board notes that Dr. R.T. did not address whether the Veteran’s PTSD aggravated his GERD. This does not weaken the probative weight of Dr. R.T.’s July 2018 letter. The issue of whether the Veteran’s service-connected PTSD aggravated his GERD does not impact the outcome of the Appellant’s claim for service connection for the Veteran’s cause of death because Dr. R.T. stated that it was less likely than not that there is an etiological association between GERD and idiopathic pulmonary fibrosis. Even if the Veteran’s PTSD aggravated his GERD, GERD did not cause idiopathic pulmonary fibrosis, and, therefore, PTSD could not have contributed substantially or materially to the Veteran’s death, combined to cause death, or aided or lent assistance to the production of death. C. Oxygen Toxicity In a November 2017 Statement in Support of Claim, Appellant contends that hyperbaric oxygen therapy sessions caused his idiopathic pulmonary fibrosis. In support of her contention, the Appellant submitted two letters from Dr. E.M.C. An April 12, 2001 letter described the Veteran as an excellent candidate for hyperbaric oxygen treatments. Dr. E.M.C. described the continued impact of radiation treatment on pulmonary function and observed that hyperbaric oxygen therapy would increase the Veteran’s oxygen gradient, promote angiogenesis, and increase vascular density in the irradiated tissue. Dr. E.M.C. recommended 20 treatments at 2.5 ATA for 90 minutes each prior to reconstructive surgery and 10 treatments at 2.5 ATA for 90 minutes each after reconstructive surgery. In a June 2001 letter, Dr. E.M.C. noted that the Veteran completed the recommended course of hyperbaric oxygen treatments between April 2001 and June 2001. Dr. E.M.C. recommended ten additional sessions following osseointegrated implants to afford him the best opportunity for healing and to reduce the risk of developing osteoradionecrosis. Dr. E.M.C.’s April 2001 and June 2001 letters are not probative. The letters document a specific course of treatment that pre-dated the Veteran’s death by nearly ten years. They do not discuss idiopathic pulmonary fibrosis as a risk-factor for the treatments, and they do not address whether the Veteran’s cause of death, idiopathic pulmonary fibrosis, was as likely as not due to the course of hyperbaric oxygen treatments from April 2001 to June 2001. The Appellant also submitted a portion of an article on pulmonary toxicity. According to the article, oxygen toxicity is caused by exposure to oxygen at partial pressures greater than those to which the body is normally exposed and occurs with hyperbaric oxygen therapy. The article is not probative. It is generic in application and suggests guidelines on the partial pressure of oxygen in a variety of settings and does not address any etiological association between idiopathic pulmonary fibrosis and the Veteran’s hyperbaric chamber therapy sessions between April 2001 and June 2001. In his July 2018 VHA opinion, Dr. R.T. concludes that the Veteran’s idiopathic pulmonary fibrosis was less likely than not etiologically related to oxygen toxicity from hyperbaric oxygen treatments. Dr. R.T. noted that oxygen toxicity is observed with high oxygen levels for prolonged periods of time and has the potential to cause pulmonary toxicity. Pulmonary toxicity would have presented as mild substernal chest discomfort, which could progress to chest pain on deep inspiration, cough, chest tightness, and shortness of breath. Dr. R.T. reasoned that none of the Veteran’s treatment records document respiratory symptoms consistent with oxygen toxicity or pulmonary toxicity. Dr. R.T. also noted that according to medical literature, current applications of hyperbaric oxygen therapy do not cause pulmonary symptoms or clinically significant pulmonary functional deficits. He also noted that there is no medical literature supporting a causal link between hyperbaric oxygen therapy and idiopathic pulmonary fibrosis, and he has not seen such a link in his clinical experience. Dr. R.T.’s July 2018 letter is highly probative. It is based on a review of the Veteran’s claim file and provides a clear rationale that is based on medical literature and Dr. R.T.’s clinical experience. See Nieves-Rodriguez, 22 Vet. App. at 301-02. In reaching its conclusions, the Board notes Appellant’s opinion that the Veteran’s cause of death is related to his exposure to asbestos, GERD aggravated beyond its natural progression by the Veteran’s service-connected PSTD and depression, and/or oxygen toxicity due to hyperbaric oxygen therapy. She is not, however, competent to provide nexus opinions in this case. This issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body as well as the interpretation of complicated diagnostic medical testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). There is no indication in the record that the Appellant has the requisite knowledge, training, or experience to render a competent opinion on whether there is an etiological relationship between the Veteran’s cause of death and his active service or his service-connected disabilities. In light of the foregoing, the Board concludes that the weight of probative evidence is against the Appellant’s claim. Thus, the benefit-of-the-doubt doctrine does not apply, see 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53, and service connection for the Veteran’s cause of death must be denied. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Douglas M. Humphrey, Associate Counsel