Citation Nr: 18159731 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 10-29 111 DATE: December 19, 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 service from November 1965 to November 1967. He subsequently passed away in July 1983. The appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2009 rating decision, which continued the denial of service connection for the cause of the Veteran’s death. The appellant testified before the undersigned Veterans Law Judge (VLJ) in August 2011. A copy of the transcript has been reviewed and associated with the claims file. This matter was before the Board in January 2013, at which time it was reopened and remanded for additional evidentiary development. This matter was again before the Board in September 2015, at which time it was again remanded for additional evidentiary development. Entitlement to service connection for the cause of the Veteran's death is remanded. The Veteran passed away in July 1983. The cause of death was listed as respiratory/cardiovascular arrest due to hemorrhagic pancreatitis. No autopsy was performed. The Veteran service-connected disabilities included fracture of the right ankle with recurrent neuroma and osteomyelitis, pulmonary embolus and thrombophlebitis of the right lower extremity, right orchectomy, gunshot wound to the right thigh with damage to muscle group XIV, and post-operative left inguinal hernia. In the Board’s September 2015 remand instructions, it requested a medical opinion by an endocrinologist to determine whether the Veteran’s diabetes caused or contributed to his hemorrhagic pancreatitis. Although a medical opinion was obtained in February 2016, this opinion was not rendered by an endocrinologist as requested by Board in its September 2015 remand. Accordingly, a medical opinion by an endocrinologist should be obtain on remand. Furthermore, the Veteran had service in Vietnam and conceded exposure to Agent Orange. However, an opinion has not been obtained as to whether the Veteran’s cause of death, respiratory/cardiovascular arrest due to hemorrhagic pancreatitis, was directly related to his Agent Orange exposure. Furthermore, the Veteran’s DD Form 214 indicates that the Veteran had service at Camp Lejeune. Pursuant to 38 C.F.R. § 3.307, a Veteran is presumed to have been exposed to contaminants in the water supply if he served 30 days (consecutive or nonconsecutive) at Camp Lejeune during the period of the Veteran’s service. Accordingly, the Board finds that the RO should obtain confirmation that the Veteran served 30 days at Camp Lejeune and obtain a medical opinion to determine if his cause of death was directly related to his exposure to Agent Orange and/or contaminants in the water supply at Camp Lejeune on remand. Lastly, a medical opinion was obtained by a cardiologist in May 2018. Although the examiner found that the Veteran did not have ischemic heart disease at the time of his death, he did confirm his recurrent pulmonary emboli, which was the result of a venous thrombus. The Veteran underwent multiple surgeries in service and post-service due to gunshot wounds in service. He was subsequently service-connected for recurrent neuroma and osteomyelitis, pulmonary embolus, and thrombophlebitis of the right lower extremity due to complications from his gunshot wounds and related surgeries. However, a medical opinion has not been obtained regarding whether the Veteran’s service-connected disabilities and related surgeries contributed substantially or materially to the Veteran’s death. Accordingly, the Board finds that an addendum opinion by the May 2018 cardiologist is warranted on remand to determine whether the Veteran’s service-connected disabilities caused and/or contributed to his death. The matter is REMANDED for the following actions: 1. The RO should provide information and/or documents regarding whether the Veteran had 30 days (consecutive or nonconsecutive) of service at Camp Lejeune. See 38 C.F.R. § 3.307(a)(7)(iii). 2. After completion of #1, arrange to have the Veteran’s claims file reviewed by a qualified examiner to determine whether the Veteran’s cause of death was directly related to his conceded Agent Orange exposure and/or exposure to contaminated water supply at Camp Lejeune. The examiner should opine as to whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s cause of death (respiratory/cardiovascular arrest due to hemorrhagic pancreatitis) was causally related to his active service, to include conceded exposure to Agent Orange and/or exposure to contaminates in the water supply at Camp Lejeune. The examiner must provide a comprehensive rationale for each opinion provided. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 3. Forward the claims file to an endocrinologist for an opinion regarding whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran’s diabetes mellitus, type II, caused and/or contributed in any way to the Veteran’s acute hemorrhagic pancreatitis. The examiner must provide a comprehensive rationale for each opinion provided. The examiner should discuss the article submitted in August 2011 regarding inflammation of the pancreas and diabetes. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 4. Forward the claims file, including a copy of this remand, to the May 2018 cardiologist for an addendum opinion. If the May 2018 cardiologist is not available the file should be forwarded to another appropriate clinician for an opinion. The claims file, including this remand, must be reviewed by the examiner and such review should be noted in the examination report. The examiner should provide an opinion as to whether or not it is at least as likely as not (a probability of at least 50 percent) that the Veteran’s service-connected disabilities, including fracture of the right ankle with recurrent neuroma and osteomyelitis, pulmonary embolus and thrombophlebitis of the right lower extremity, right orchectomy, gunshot wound to the right thigh with damage to muscle group XIV, and post-operative left inguinal hernia and/or any related operations, contributed substantially or materially to his death. The examiner must provide a comprehensive rationale for each opinion provided. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Hurley, Associate Counsel