Citation Nr: 20007079 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 14-17 625 DATE: January 28, 2020 ORDER Entitlement to service connection for a liver condition is denied. Entitlement to service connection for abdominal pain, to include gall bladder condition is denied. Entitlement to service connection for headaches is granted. Entitlement to service connection for an acquired psychiatric disorder, to include depression, post-traumatic stress disorder (PTSD) and anxiety is granted. Entitlement to a rating in excess of 40 percent for bilateral hearing loss is denied. Entitlement to survivors’ pension benefits is denied. REMANDED Entitlement to service connection for the cause of death of the Veteran is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that liver condition began during active service or was otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that abdominal pain disability began during active service or was otherwise related to an in-service injury or disease. 3. Resolving reasonable doubt in the Appellant’s favor, an acquired psychiatric disorder was at least as likely as not caused by or aggravated by the Veteran’s service-connected hearing loss and tinnitus. 4. The preponderance of the evidence supports finding that headaches were at least as likely as not related to the Veteran’s service-connected tinnitus and acquired psychiatric disorder. 5. The Veteran’s bilateral hearing loss manifested by average pure tone air conduction thresholds at 1000, 2000, 3000, and 4000 Hertz (Hz) of no worse than 63.75 decibels in the right ear and 61.25 decibels in the left ear, and speech recognition ability of no worse than 54 percent in the ears bilaterally. 6. The Veteran did not have active duty service during a period of war as recognized by VA. CONCLUSIONS OF LAW 1. The criteria for service connection for a liver condition have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.10. 2. The criteria for service connection for abdominal pain disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.10. 3. The criteria for service connection for a headache disability have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 4. The criteria for service connection for an acquired psychiatric condition have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 5. The criteria for a disability rating in excess of 40 percent for bilateral hearing loss were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.85, Diagnostic Code (DC) 6100. 6. The criteria for entitlement to survivor’s pension benefits have not been met. 38 U.S.C. §§ 101, 1503, 1521, 1541, 5312; 38 C.F.R. §§ 3.1, 3.2, 3.3, 3.23, 3.50, 3.271, 3.272, 3.274. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1957 to March 1958. He died in June 2017. Thereafter, the Agency of Original Jurisdiction (AOJ) recognized the appellant, the Veteran’s surviving spouse, as the substitute claimant. See 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. As such, she has been substituted for the appellant for purposes of processing the claim to completion. These matters come before the Board of Veterans’ Appeals (Board) on appeal from April 2012 and November 2017 decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to service connection for PTSD and depression have been broadened to encompass entitlement to service connection for an acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to show a service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection is also warranted for disabilities that are proximately due to or aggravated by service-connected disease or injury. 38 C.F.R. § 3.310. To establish service connection on a secondary basis, the record must reflect sufficient evidence to show: (1) that a current disability exists and (2) the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. 1. Entitlement to service connection for a liver condition The appellant contends that the Veteran had a liver condition caused by or aggravated by service. The question for the Board is whether the Veteran had a disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a diagnosis of a liver condition, the preponderance of the evidence is against finding that it began during active service, or was otherwise related to an in-service injury, event, or disease. Concerning element (1), a diagnosis, Social Security Administration ( SSA ) records reflect the Veteran had elevated liver function tests compatible with obstructive jaundice in August 1983. However, the criteria for element (2) have not been met as there is no evidence of an in-service liver condition diagnosis. While the Appellant may be competent to report that the Veteran had symptoms related to a liver condition that he stated began in service, these reports are largely not credible due to internal inconsistency and inconsistency with other evidence in the record. Specifically, a close review of the service treatment records (STRs) revealed the Veteran sought treatment in August 1957 for anorexia, malaise and right subcostal pain. On examination, the physician noted the Veteran had a tender liver palp, 2cm below the right costal margin and was tender in nature. However, repeated liver function tests were normal. The impression at the hospital was that he had asthma as he gave a history of hospitalization for asthma 1 ½ years prior with similar symptoms. Upon enlistment, there was no indication of liver or intestinal trouble. There was no mention of a liver condition on the medical board separation report. Therefore, the criteria for element (2) have not been met. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Additionally, there is also no indication that his liver condition was caused or aggravated by a service-connected condition, to include his service-connected hearing loss or tinnitus, nor has the Appellant contended so. The Board reiterates that the preponderance of the evidence weighs against finding that his liver condition was caused or aggravated by his military service directly or on a secondary basis. There is no benefit of the doubt to be resolved. Accordingly, the appeal is denied. 2. Entitlement to service connection for abdominal pain, to include gall bladder bile and GERD The Appellant contends that the Veteran had abdominal pain disability that was caused or aggravated by military service. The question for the Board is whether the Veteran had a disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a diagnosis of a condition that caused abdominal pain, the preponderance of the evidence is against finding that it began during active service, or was otherwise related to an in-service injury, event, or disease. Concerning element (1), a diagnosis, SSA records reflect the Veteran had a history of contracted gallbladder with a thickened wall. It was felt that it was consistent with cholecystitis. They did not find definite, dilated intrahepatic ducts, but the common duct was mildly dilated. He underwent surgery, which revealed a one centimeter in diameter common duct with stone. He underwent a cholecystectomy with common duct exploration. However, the common duct stone was found to be high in the biliary tree; despite multiple attempts at removal, it would not move. Therefore, a choledochoduodenostomy was performed in a side-to-side fashion. He did well and was discharged within two weeks. Accordingly, the criteria for element (1) have been met. However, the criteria for element (2), the criteria have not been met as there is no evidence of an in-service liver condition diagnosis. While the Appellant may be competent to report that the Veteran complained of abdominal pain beginning in service, these reports are largely not credible due to internal inconsistency and inconsistency with other evidence in the record. STRs indicate that the Veteran complained of abdominal pain in the form of a tender palp over his liver, as discussed above, but there is no indication of pain due to his gallbladder or any other gastrointestinal condition in-service. Rather, his pain was associated with his chronic asthma. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). There is also no indication that his abdominal pain was caused or aggravated by a service-connected condition, to include his service-connected hearing loss or tinnitus, nor has the Appellant contended so. The Board reiterates that the preponderance of the evidence weighs against finding that the Veteran’s abdominal pain disability was caused or aggravated by his military service directly or on a secondary basis. Accordingly, the appeal is denied. 3. Entitlement to service connection for an acquired psychiatric condition The Appellant contends that the Veteran acquired a psychiatric condition on a secondary basis due to his service-connected hearing loss and tinnitus as well as headaches. The question before the Board is whether the acquired a psychiatric condition proximately due to or aggravated by a service-connected condition. With respect to the first element of service connection, a diagnosis, the record is silent for a diagnosis of PTSD. Service connection cannot be granted absent a current diagnosis of disability. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). However, a private psychiatrist completed a disability benefits questionnaire (DBQ) in April 2016, as well as numerous post-service treatment records, indicates that he has a current diagnosis of depressive disorder with depressed features. Therefore, element (1) has been met. Turning to the second element, whether there is medical evidence establishing a link from his psychiatric disorder to a service-connected condition, the criteria has also been met. In May 2019, a private psychiatrist noted she conducted a psychiatric evaluation of the Veteran in April 2016 where he reported experiencing a number of psychiatric symptoms including auditory hallucinations, chronic sleep impairment, difficulty establishing and maintaining relationships, difficulty adapting to stressful circumstances including work, disturbance of motivation and mood, near continuous panic and depression affecting his ability to function effectively, mild memory loss, impairment of short and long-term memory, neglect of personal hygiene and intermittent inability to perform activities of daily living. The Veteran also reported having trouble communicating and avoiding others because he did not like to ask others to repeat themselves and is irritable. He stated he did not leave the house because he could not stand crowds. He reported having significant stress and anxiety during his military service which progressed over the years and led to self-medicating. He also reported his hearing loss and tinnitus caused significant frustration because he was unable to hear others and work. The psychiatrist reviewed the Veteran’s STRs, January 1986 medical records where the Veteran reported having a nervous breakdown in 1970, a March 1986 psychiatric evaluation where he diagnosed with major depression, SSA records, a private DBQ related to his hearing loss and tinnitus making it impossible for him to keep a job because he was unable to hear instructions at work and recurrent tinnitus that required him to stop what he is doing to reorient himself as well as written lay statements from the Veteran’s widow and daughter in law. The psychiatrist noted there are medical journal articles that discussed the emergence of mental health symptoms within active duty servicemen generally, literature on the connection between depressive disorder and tinnitus, literature on how people with hearing loss are more inclined to experience depression, and literature on how mood disorders lead to occupational dysfunction and poor work-related quality of life. The psychiatrist ultimately opined that the Veteran’s unspecified depressive disorder more likely than not began in military service, continued uninterrupted and was aggravated by his tinnitus and hearing loss. The examiner noted records show an onset of mental issues in service as confirmed by the Veteran. His wife, now widow or the Appellant, stated he had mental issues as long as she had known him. His mental issues continued and worsened [post-service] due to life stressors. Given the Veteran’s poor coping ability, his mental [condition] became disabling. He had a history of self-medicating his depressive disorder, but his mental issues continued after his remission from substance abuse; therefore, confirming it is secondary in nature. The examiner stated that there were many issues contributing to his mental health disorder, and she could not separate how much each was contributing due to substantial overlap. The psychiatrist concluded that her depressive disorder prevented him from maintaining substantially gainful employment since he last worked in the 1980s. Upon reviewing the totality of the evidence considering the governing authority, the Board finds that the claim must be afforded the benefit of the doubt; the claim for service connection for an acquired psychiatric disorder secondary to service-connected hearing loss and tinnitus is granted. While the medical opinion did not solely attribute his acquired psychiatric condition to his service-connected hearing loss and tinnitus, the examiner stated that she was unable to separate the causes of his disorder, from military and non-military factors. VA law mandates that when it is not possible to separate the effects of a service-connected disability and a nonservice-connected disability, reasonable doubt must be resolved in the appellant’s favor and the symptoms in question attributed to the service-connected disability. There is no other opinion to the contrary. As such, the Board assigns great weight to the medical opinion and will attribute all current psychiatric symptoms and impairment as due to service-connected acquired psychiatric disorder. See Mittleider v. West, 11 Vet. App. 181 (1998); see also Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (noting that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant’s case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). Accordingly, the criteria for element (2) have been met. In sum, the Board finds that that the record confirms a diagnosis of depression. The May 2019 private psychiatrist opinion, in part, links the diagnosis of depression to his service connected hearing loss and tinnitus. The evidence establishes the diagnosis and nexus elements to at least equipoise. When reasonable doubt is resolved in the Veteran’s favor, the Board finds that the Veteran’s acquired psychiatric disorder is related to his service-connected hearing loss and tinnitus. Accordingly, service connection for an acquired psychiatric disorder is warranted. 4. Entitlement to service connection for headaches The Appellant contends that the Veteran’s acquired headaches were secondary to his service-connected tinnitus. Alternatively, she asserts that the headaches are directly caused by service. The question before the Board is whether his headaches were proximately due to or aggravated by a service connection condition, to include tinnitus. With respect to the first element of service connection, a diagnosis, a May 2016 private Disability Benefits Questionnaire (DBQ) reflects the Veteran had a diagnosis of tension headaches. SSA records reflect a diagnosis of right sided tingling to sharp stabbing headaches, occurring above right eye to the back of head, every day in May 1978.Therefore, the Board finds that the criteria for element (1) have been met. Turning to the second element, whether there is medical evidence establishing a link from his psychiatric disorder to a service-connected condition, a May 2016 DBQ reflects the Veteran reported his headaches began in service and that they increased in both severity and frequency over the years. The headaches manifested in constant head pain, pulsating or throbbing head pain, pain on both sides of his head with nausea, sensitivity to light and sound, changes in vision (such as scatoma, flashes of light, tunnel vision), and dizziness with loss of balance. He complained that his headaches occurred daily, and never fully subsided. He stated that they originated at the temples. He stated that he would miss several days of work and required frequent unscheduled breaks throughout the day due to his headaches. Dr. H.S., a private physician, opined that his non-migraine headache pain occurred more frequently than once per month and that they were very frequent prostrating and prolonged attacks. Most importantly, he opined that the headaches were caused by his service-connected tinnitus along with his depressive disorder. The examiner reasoned that the Veteran was diagnosed with tinnitus at a January 2012 VA examination where it reflected that tinnitus impacted his daily life, including the ability to work to the point where he had to stop what he was doing to re-orient himself then continue activities due to tinnitus. He reported that when his tinnitus flared up it brought on a headache. Dr. H.S. explained that it is known that damage to the auditory system resulting in tinnitus can also cause headaches, citing to an enclosed treatise entitled psychological and audiological correlates of perceived tinnitus severity. He also opined that another contributing factor to the headaches is depressive disorder. The examiner reviewed the April 2016 DBQ where a private psychiatrist noted medical research states that patients with mental health conditions are more likely to develop headaches because pain and mood are regulated by the same part of the brain.Dr. H.S. explained further that because the Veteran was constantly straining to hear, [his hearing loss] aggravated his headaches, causing him to often isolate himself and avoid social interaction, which contributed to and worsened his depressive disorder; thus, increasing the number of headaches. Dr. H.S. also noted that when he spoke to the Veteran in May 2016, he reported he was having a headache. Dr. H.S. stated he had to repeat himself several times because the Veteran was having trouble hearing and understanding him. He reported his headaches occurred daily and never fully subsided with pain of 8/10 in severity where he had to lie in a dark room to try to get the headache to subside. Upon reviewing the totality of the evidence considering the governing authority, the Board finds that the claimant must be afforded the benefit of the doubt; the claim for service connection for headaches secondary to service-connected tinnitus is granted. The medical opinion clearly attributes his headaches to his service-connected tinnitus and acquired psychiatric disorder. There is no other medical opinion of record that suggests otherwise. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (noting that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant’s case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). Therefore, the opinion is assigned great weight and the criteria for element (2) have been met. Notably, STRs reflect several complaints of headaches with accompanied dizziness and blacking out while in service in January 1958. This was attributed to chronic asthma and was the basis for his medical discharge from active service. This evidence suggests his headaches were associated with a pre-existing condition, not caused or aggravated by military service. Yet, STRs also note that was some question that something other than asthma was going on in the Veteran that caused his symptoms of bilateral frontal headaches, dizziness and blackouts; a separate disease process. Since service connection has already been granted on a secondary basis; it is not necessary to assess whether the condition was directly related to service. In sum, the Board finds that that the record confirmed a diagnosis of headaches and a May 2016 private opinion links the headaches to his service connected tinnitus and acquired psychiatric disorder. Therefore, the preponderance of the evidence supports a favorable determination that his headaches are related to his service-connected tinnitus and acquired psychiatric disorder. Accordingly, service connection is granted. Increased Rating 5. Entitlement to a rating in excess of 40 percent for bilateral hearing loss Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where, as here, entitlement to service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each piece of evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran’s hearing loss disability is rated under diagnostic code 6100. 38 C.F.R. §§ 4.85, 4.86, DC 6100. Pursuant to this diagnostic code, hearing impairment evaluations are derived by a mechanical application of the ratings schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmen v. Principi, 3 Vet. App. 345, 349 (1992). The ratings schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in both ears. See 38 C.F.R. § 4.85. The Appellant is seeking an increased rating for the Veteran’s service-connected bilateral hearing loss disability. Throughout the appellate period, the Appellant cited difficulties with communication as the primary symptom relating to hearing loss. In a March 2019 written statement, the Appellant reported the Veteran isolated himself because of his hearing problems. He did not want to socialize or interact because he could not hear and did not want to keep asking people to repeat themselves. He stopped going to church and only would go to a restaurant across the street. He also interacted with a few friends because they all had hearing problems. In an April 2019 written statement, the Veterans’ daughter in law also reported difficulties with him engaging in conversation because he could not hear what everyone was saying. The Appellant and the Veteran’s daughter-in-law are competent to describe the personally observable symptoms relating to the Veteran’s difficulties with hearing. However, there is no evidence that either possesses the medical knowledge or training to report the severity of his hearing loss in the clinical terms contemplated by the rating criteria for this disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Hearing loss ratings are determined by the mechanical application for the regulations to clinical results. As such, the more probative evidence for evaluating the severity of the Veteran’s hearing loss is the competent clinical evidence and audiological examination results that appear in the record. To evaluate the severity of his hearing loss, he was afforded a VA examination in January 2012 at which he reported trouble hearing conversations and having been told that he spoke too loudly. An audiological evaluation resulted in the following hearing thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 40 40 65 75 75 LEFT 40 40 65 70 70 Average pure tone threshold was 63.75 in the right ear and 61.25 in the left ear. Speech recognition was tested using the Maryland CNC word list, and the score was 54 percent discrimination in the ears bilaterally. The VA examiner noted that the use of speech discrimination score is appropriate for the Veteran. The examiner diagnosed the Veteran with sensorineural hearing loss in the frequency range of 500 to 4,000 Hz in both ears and with sensorineural hearing loss in the frequency range of 6,000 Hz or higher in both ears. Under Table VI, the findings translate to Level VII hearing acuity in both ears. 38 C.F.R. § 4.85, Table VI. Applying these findings to Table VII, DC 6100, this equates to a 40 percent rating. There are no additional medical records that reflect audiological findings or clinical testing that would warrant a disability rating in excess of 40 percent subsequently. The Board in no way discounts the difficulties that the Veteran experienced as a result of his service-connected hearing loss disability. Again, however, disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hence, the Board must base its determination on the results of the pertinent and valid VA audiology studies. In other words, the Board is bound by law to apply VA’s rating schedule based on the Veteran’s audiometry results. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In this case, as explained above, the numeric designations do not correlate to a rating in excess of 40 percent. As such, the preponderance of the evidence is against the Veteran’s claim for a schedular higher rating. Consequently, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107(b). Survivors Pension Benefits 6. Whether the Veteran has qualifying wartime service for purposes of entitlement to nonservice-connected pension benefits The Appellant asserts that she is entitled to survivor pension benefits. Basic entitlement to VA nonservice-connected death pension benefits exists if: (i) the veteran had qualifying service (a veteran who served during wartime); or (ii) the veteran was, at time of death, receiving or entitled to receive compensation or retired pay for a service-connected disability based on service during a period of war; and (iii) the surviving spouse meets the net worth requirements of 38 C.F.R. § 3.274 and has an annual income not in excess of the applicable maximum annual pension rate specified in 38 C.F.R. § 3.23. 38 U.S.C. § 1541; 38 C.F.R. § 3.3(b)(4). VA presently recognizes the following, in relevant part, as periods of war: the Korean conflict is defined by VA as the period from June 27, 1950, through January 31, 1955, inclusive. 38 U.S.C. § 101(9); 38 C.F.R. § 3.2(e). The Vietnam era is defined as the period beginning on February 28, 1961, and ending on May 7, 1975, inclusive for veterans who served in Vietnam; otherwise, the Vietnam era began August 5, 1964. 38 U.S.C. § 101(29); 38 C.F.R. § 3.2(f). The Persian Gulf War era is defined as the period beginning on August 2, 1990, through such date to be prescribed by Presidential proclamation or law. 38 U.S.C. § 101(33); 38 C.F.R. § 3.2(i). In this case, the Veteran’s DD Form 214 and military personnel records reflect that he served in July 1957 to March 1958. The Appellant does not contend to additional periods of service. Unfortunately, such service does not coincide with a period of war, as defined by VA regulation. 38 C.F.R. § 3.2. Therefore, the Veteran’s service during this period does not make the appellant eligible to receive survivor pension benefits. Because the Veteran did not have the requisite period of wartime service, the Board need not discuss the other element of a survivor’s pension benefit. In summary, the Board is sympathetic to the Appellant’s claim and has carefully reviewed the claims file. The record reflects that the Veteran served his country honorably. The nature of the Veteran’s service does not meet the statutory criteria of “wartime service” for purposes of entitlement to nonservice connected survivor pension benefits. Without the requisite qualifying service, she is not eligible for VA nonservice-connected pension benefits. Therefore, the Board must deny the claim. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for the cause of death of the Veteran is remanded. The Board cannot make a fully-informed decision on the issue of service conenction for the cause of death of the Veteran because no VA examiner has opined whether his service conencted acquired psychaitric disorder caused non-service connected hypertension, which ulimately caused heart disease and the death of the Veteran. See Daves v. Nicholson, 21 Vet. App. 46, 50-51 (2007). For service connection to be granted for the cause of a Veteran’s death, the Appellant must show either 1) the cause of death is or should be service conncted or that a service conncted disability caused the Veteran’s death. In cases where the Appellant is arguing that the cause of death should be service connected, the Board must conduct a regular servie connction analysis for each cause of death. In other words, the Board must determine whether each condition, or cause of death, was caused or aggravated by service or a service connected disaiblity. In June 2019, Dr. M.B., opined it was as likely as not that the Veteran’s depression contirbuted materially and substantially to his non-service conencted hypertension, and his non-service conencted hypertension contributed materially and substantially to his coronary artery disease and other heart problems which led to his death. Unfortuantely, this opinion is inadequate for adjudication purposes. There is an obvious missing link in the opinion; hypertension is not a service-connected disability. Therefore, the Board needs a medical opinion to assess whether whether the Veteran’s hypertension was caused by or aggravated by service directly, or if it was secondary to his service connected acquired psychiatric disorder, depression. In other words, the sole question that remains is whether the Veteran’s hypertension should have been service connected at his time of death. Without such opinion, the Board is unable to adjudiate the claim. On remand, the RO must obtain a VA opinion as to whether the Veteran’s hypertension was caused or aggravated by his service conencted depression. 2. Entitlement to a TDIU is remanded. Finally, because a decision on the whether the Veteran’s hypertention should have been serivce conencted at the time of the Veteran’s death has been remanded, and could significantly impact a decision on TDIU, the Board finds the issues are inextricably intertwined. A remand of the claims for TDIU is required. The matters are REMANDED for the following action: 1. Obtain a VA opinion by an appropriate clinician to determine the nature and etiology of any heart condition, to include hypertension and coronary artery disease. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. The examiner must also opine whether the Veteran’s heart conditions, to include hypertension and coronary artery disease, was at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability, to include his service connected acquired psychiatric disorder, depression. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.