Citation Nr: 21003022 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 18-44 928 DATE: January 19, 2021 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for a heart condition, to include as secondary to hypertension, is granted. Entitlement to service connection for a lung condition, to include sarcoidosis, is granted. Entitlement to accrued benefits and reimbursement of last sickness and burial expenses in excess of $7,730 is denied. REMANDED Entitlement to service connection for blindness is remanded. Entitlement to service connection for a skin condition, to include as secondary to a lung condition, to include sarcoidosis is remanded. Entitlement to service connection for a stomach condition, to include as secondary to a lung condition, to include sarcoidosis is remanded. Entitlement to service connection for arthritis and joint pain, to include as secondary to a lung condition, to include sarcoidosis is remanded. Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for a kidney (renal) condition, to include glomerulonephritis, is remanded. Entitlement to service connection for diabetes mellitus type II is remanded. Entitlement to service connection for the cause of the Veteran’s death is remanded. FINDINGS OF FACT 1. Resolving any reasonable doubt in favor of the Veteran, the Veteran’s hypertension has been causally linked to his military service. 2. Resolving any reasonable doubt in favor of the Veteran, the Veteran’s heart condition has been causally linked to his hypertension. 3. Resolving any reasonable doubt in favor of the Veteran, the Veteran’s sarcoidosis has been causally linked to his military service. 4. At the time of his death in February 2012, the Veteran was due and unpaid an amount of $8,720.49 of compensation benefits. 5. The appellant provided documentation indicating that she paid burial expenses for the Veteran in the amount of $7,730; there is no indication from the evidence that any additional amounts of burial expenses were actually paid for by the appellant. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a heart condition, to include as secondary to hypertension have been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for a lung condition, to include sarcoidosis have been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for award of accrued benefits in excess of $3,331 are not met. 38 U.S.C. §§ 503, 1503, 1521, 5112, 5121, 5312, 7104; 38 C.F.R. §§ 3.2, 3.3, 3.23, 3.260, 3.261, 3.262, 3.272, 3.500, 3.1000. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1983 to June 1986. He died in August 2017. The appellant is the Veteran’s sister. In July 2018, the appellant was recognized as the substitute claimant. See VA Memo, July 2018. The service connection claims will thus be addressed on a substitution basis, rather than an accrued benefits basis. The matters are before the Board of Veterans’ Appeals (Board) on appeal from the October 2015 and December 2018 rating decisions and a January 2019 administrative decisions. The October 2015 rating decision denied, in part, service connection for a heart condition, diabetes mellitus type 2, a kidney condition, diabetes, a low back condition, sarcoidosis, a lung condition, hypertension, a skin condition, glomerulonephritis, arthritis/joint pain, blindness, and a stomach condition. The December 2018 rating decision denied service-connected cause of death. The January 2019 administrative decision denied service-connected burial benefits. The March 2019 statement of the case (SOC) denied entitlement to accrued benefits in excess of $7,730 for all reasonable expense’s incident to the last illness and burial of a beneficiary veteran. In April 2019, the Veteran filed a timely substantive appeal noting that an award for non-service connected burial allowance should not have been granted since the appellants claim for service-connection for cause of death was pending. The appellant testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in August 2020. Service Connection Generally, to establish service connection a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009). In each case where a Veteran is seeking service connection for any disability due consideration shall be given to the places, types, and circumstances of such Veteran’s service as shown by such Veteran’s service record, the official history of each organization in which such Veteran served, such Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for hypertension 2. Entitlement to service connection for a heart condition, to include as secondary to hypertension Prior to the Veteran’ s death he asserted that his hypertension and heart condition was causally related to his military service. See Correspondence, December 2015; Notice of Disagreement (NOD), September 2017. A review of the Veteran’s service treatment records reflect that the Veteran had elevated blood pressure reading throughout his military service. See STR-Medical, May 2015. In December 2008, the Veteran was seen for palpitations and chest pain. See Medical Treatment Record-Non-Government, December 2015 at p.44 of 142. The examination report reflects that the Veteran had been treated for tachycardia with a blood pressure medication, but had recently ran out which triggered the palpitations. Id. The Veteran was diagnosed with atrial flutter and an additional blood pressure medication was prescribed. Id. A consultation report reflects that the Veteran’s blood pressure was 119/106. Id. at p.56 of 142. A diagnosis of hypertension was noted. Id. at p.53 of 142. A May 2010 exercise myocardial perfusion imaging report reflects that the Veteran’s blood pressure response to exercise was hypertensive with a peak blood pressure of 200/90 and resting blood pressure of 140/44 with no meds. Medical Treatment Record-Non-Government, December 2015 at p.22 of 36. In April 2020, a private medical opinion from neuro-radiologist Dr. C.B. was added to the Veteran’s claims file. Dr. C.B. noted that the Veteran’s blood pressure was elevated during service. See Correspondence, December 2015 at p.21 of 30. Dr. C.B. stated that based on the evidence of record, the Veteran had hypertension during service and post service. Id. Additionally, Dr. C.B. opined that the Veteran’s current cardiac problems were due to his military service. Id. at p.22 of 30. Further, Dr. C.B. noted that the Veteran’s records “do not support another more plausible etiology for his past cardiac pathology HTN with atrial enlargement cardiomegalia…to explain his problems other than his service time and post service time experiences with HTN.” Id. The Board finds that Dr. C.B.’s opinion is adequately supported by the medical and lay evidence of record. As the Veteran’s hypertension has been causally linked to his military service, resolving any reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for hypertension and therefore, is granted. Additionally, as the Veteran’s heart condition has been causally linked to his hypertension, resolving any reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for a heart condition secondary to hypertension is warranted and therefore, is granted. 3. Entitlement to service connection for a lung condition, to include sarcoidosis Prior to the Veteran’s death, he asserted that his sarcoidosis was causally related to his military service. See Correspondence, December 2015; NOD, September 2017. Specifically, the Veteran asserted that he was presented with symptoms of sarcoidosis during his military service but was misdiagnosed. See Correspondence at p.4 of 18. Additionally, the Veteran reported that he was frequently exposed to chemicals, metals, and substances during his work in motor pools. See VA 21-8940, June 2015. A review of the evidence of record reflects that the Veteran’s military occupation was an equipment records and parts specialist. See Military Personnel Record, September 2015 at p.78 of 46. He was diagnosed with sarcoidosis in July 2010. See Medical Treatment Record-Non-Government, December 2015 at p.13 of 29. In the April 2020 opinion, Dr. C.B. asserted that the Veteran worked in a motor pool during his entire term of service, which resulted in him breathing in hazardous fumes. See Correspondence. at p.11 of 30. Dr. C.B. further asserted that the Veteran had medical visits for symptoms consistent with sarcoid during his service, and the lag time between the symptoms and the manifestation of sarcoidosis is consistent with known medical principles and the natural history of the disease. Id. at p.10, 12 of 30. Dr. C.B. opined, “considering every possible sound medical etiology/principle, to at least the 90% level of probability that his sarcoid problems are due to his experiences that he had during military service and this hastened his demise.” Id. at p.11 of 30. In support of his conclusion, Dr. C.B. provided an excerpt from a medical article which stated, “it is possible that trichloroethylene could promote activation of CD4+ T cells through increasing serum levels of hyaluronate (HA), the ligand for…it is also found in the bronchoalveolar lavage fluid in patients with idiopathic sarcoidosis.” Id. The Board notes that there is no evidence reflecting that the Veteran’s bronchoalveolar lavage fluid was tested for hazardous substances. However, the Board finds that Dr. C.B.’s opinion is adequately supported by the medical and lay evidence of record. As the Veteran’s sarcoidosis has been causally linked to his military service, and resolving any reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for sarcoidosis and therefore, is granted. 4. Entitlement to accrued benefits and reimbursement of last sickness and burial expenses in excess of $7,730 The appellant asserts that an award in excess of $7,730 is warranted for accrued benefits. The Board notes that in June 2018, the appellant submitted an application for reimbursement from accrued amounts due a deceased beneficiary. See VA 21-601, June 2018. As such, the issue has been recharacterized to reflect reimbursement of last sickness and burial expenses. Accrued benefits may be paid to reimburse a person who bore the expenses of the last sickness and burial of a payee. 38 U.S.C. § 5121(a)(5); 38 C.F.R. § 3.1000 (a)(5). Payments to persons who bore the expense of last sickness or burial shall be limited to the amount necessary to reimburse such persons for the expenses of last sickness and/or burial. 38 C.F.R. § 3.1003(a). The maximum amount of the benefits owed to the Veteran at the time of his death, was $8,720.49. In an October 2018 administrative decision, the appellant was awarded $7,730 in accrued benefits because the appellant provided evidence that she paid the Veteran’s last expenses in the amount of $7,730. The appellant has not submitted any evidence of additional expenses related to the Veteran’s last sickness or burial. Accordingly, the claim seeking accrued benefits in excess of this amount is denied. REASONS FOR REMAND 1. Entitlement to service connection for blindness (including light perception only) Prior to the Veteran’s passing he asserted that his blindness had its onset during military service. See NOD, December 2015. A review of the evidence of record reveals that on the Veteran’s 1983 enlistment examination report his distant vision was recorded as 20/400 bilaterally, with correction to 20/20. See STR-Medical, May 2015 at p.57 of 75. His near vision was recorded as 20/100 bilaterally, with correction to 20/40 in the right eye and 20/30 in the left eye. Id. The Veteran was issued an E2 vision profile. Id. The Veteran’s 1986 separation examination report revealed bilateral distant and near vision of 20/200, with correction to 20/20. Id. at p.14 of 75. In November 2007, the Veteran had right eye surgery for visually significant cataract. See Medical Treatment Record-Non-Government Facility, June 2019 at p.99 of 103. In January 2014, the Veteran was hospitalized due to blunt trauma to the left side of his face. Id. at p.75 of 103. Upon examination, the Veteran was found to have severe left eye trauma associated with rupture and no light perception vision. Id. The Veteran was diagnosed with ruptured left ocular globe with extensive left periorbital soft tissue swelling; left lamina papyracea fracture with entrapment of the posterior aspect of the left medial rectus muscle. Id. at p.83 of 103. The Board notes that eye conditions, including diabetic retinopathy, may be secondary to type II diabetes mellitus. As the claim for service connection for type II diabetes mellitus has been remand, the claims are inextricably intertwined, and the claim for service connection for blindness must be deferred on remand. 2. Entitlement to service connection for a skin condition, to include as secondary to lung condition, to include sarcoidosis Prior the Veteran’s passing, he asserted that he had a skin condition which was causally related to his military service. See NOD, December 2015. A review of the evidence of record reflects that the Veteran reported and was treated for a rash on his arm and hands after being in the field. See STR at p.28 of 75. The Veteran was diagnosed with contact dermatitis. Id. The Veteran also asserted that his skin condition was secondary to his lung condition, to include sarcoidosis. As no opinion has been obtained regarding whether the Veteran’s claimed skin condition is proximately due to or aggravated beyond its natural progress by his service-connected lung condition, the Board finds that a remand is necessary in order to obtain an opinion. 3. Entitlement to service connection for a stomach condition, to include as secondary to a lung condition, to include sarcoidosis Prior the Veteran’s passing he asserted that he had a stomach condition which was causally related to his military service. See NOD, December 2015. A review of the evidence of record reflects that the Veteran reported and was treated for diarrhea. See STR-Medical, May 2015 at p.33 of 75. The Veteran also asserted that his stomach condition was secondary to his lung condition, to include sarcoidosis. As no opinion has been obtained regarding whether the Veteran’s claimed stomach condition is proximately due to or aggravated beyond its natural progress by his service-connected lung condition, the Board finds that a remand is necessary in order to obtain an opinion. 4. Entitlement to service connection for arthritis and joint pain, to include as secondary to a lung condition, to include sarcoidosis Prior to the Veteran’s passing he asserted that he his arthritis/joint pain was due to has sarcoidosis. As the Veteran was granted service connection for a lung condition, to include sarcoidosis in this decision, and no opinion has been obtained regarding whether the Veteran’s claimed arthritis and joint pain is proximately due to or aggravated beyond its natural progress by his service-connected lung condition, the Board finds that a remand is necessary in order to obtain an opinion. 5. Entitlement to service connection for a low back condition The Veteran originally filed a claimed for service connection for a back condition in July 1986. In September 1986, the Veteran was afforded a VA back examination. The Veteran reported that his onset of chronic lower back pain occurred February 1985. See VA Examination, September 1986. A VA radiologic report reflects that spina bifida occulta of S1 and fusion defects of the transverse process of L1 were noted. Id. at p.10 of 16. The examiner noted that there was no objective ortho abnormal physical findings in the lower back. The claim for service connection was denied in the March 1987 rating decision based on the determination that spina bifida occulta was a constitutional or developmental abnormality. In May 2015, however, the Veteran’s STRs were added to his claims file. See 38 C.F.R. § 3.156(c). A March 1985 examination report reflects that the Veteran reported having low back pain for three months without trauma but with increased urination and frequency. See STR at p.27 of 75. Upon examination, there was no increase in pain with direct pressure, straight over bending, or heel and toe work. Id. The Veteran was diagnosed with probable muscle strain. A March 1985 radiographic report reflects that the Veteran reported having low back pain for four months with no history of injury. See STR-Medical, May 2015 at p.7 of 8. Occult spina bifida at S1 was noted. Id. An April 1985 urology consultation report notes that the Veteran had 4 month history of low back pain thought to be secondary to prostatitis. See STR-Medical at p.44 of 75. A July 1985 preliminary kidney-ureter-bladder (KUB) x-ray of the abdomen revealed incidental spina bifida at the S1 level. See STR-Medical at p.3 of 8. An August 1985 renal radiographic report reflects a notation of “occult spina bifida S1-not clinically signif.” Id. at p.6 of 8. An October 1985 standing lateral spine radiographic report reflects a provisional diagnosis of low back pain. Id. at p.5 of 8. An undated examination report notes that the Veteran was seen for a follow-up low back pain. See STR at p.17 of 75. The Veteran’s profile was renewed, and a bone scan ordered. Id. Another undated examination report notes that the bone scan was normal. Id. at p.20 of 75. An October 1985 consultation report reflects that the Veteran had low back pain for 10 months without history of trauma, with pain gradually increasing and becoming worse over time. Id. a p.40 of 75. The examiner noted that the pain was at the L5-S1, midline without radiation and increased with bending forward and standing for prolong periods of time and decreased with stretching trunk extensors. Id. The Veteran was diagnosed with mechanical low bac pain. Id. at p.42 of 75. November 1985 physical therapy reports reflect that the Veteran reported pain in the L5 area of the spine which increases with exercise. Id. at p.23, 24 of 75. A January 1986 consultation report reflects a normal limited bone scan. Id. at p.39 of 75. During the Veteran’s May 1986 separation examination, he reported having lower back pain. Id. at p.13 of 75. The examiner noted that the Veteran follow up with orthopedic treatment for his lower back pain. Id. at p.13, 15 of 75. In June 2015, the Veteran submitted a request to reopen his claim for service connection for a back condition. See VA 21-526EZ, June 2015. The October 2015 rating decision denied service connection for any back condition to include back injury, low back condition, low back strain, lumbar sprain, lumbar strain and lower lumbar because the Veteran did not attend a scheduled VA examination and did not show good caused for the failure. In a December 2015 correspondence, the Veteran provided a list of inservice complaints and treatment for low back pain from March 1985 to August 1986. See Correspondence, December 2015. In January 2016, the Veteran was afforded a VA back examination. The Veteran was diagnosed with mild degenerative disc disease at L4-L5, L5-S1. See C&P Exam, January 2016 at p.1 of 7. The Veteran reported that in 1985, he fell and injured his back, sought medical attention, and was treated with TENS unit and massage. Id. The examiner opined that the Veteran’s claimed condition was less likely than not a result of his service-related activity and more likely than not the result of his 17 years working in a factor. See C&P Exam, January 2016 at p.2 of 2. The Board notes that the examiner did not address the Veteran’s in-service complaints of and treatment for lower back pain in the areas in which the Veteran was currently shown to have degenerative disc disease, the in-service diagnosis of spina bifida, the in-service notation of lower back pain secondary to prostatitis, and report of lower back pain upon separation. In April 2020, a private medical opinion from neuro-radiologist Dr. C.B., was added to the Veteran’s claims file. Dr. C.B. noted that the Veteran was previously denied based on a diagnosis of spina bifida; however, the Veteran had no back issues prior to service and clearly had low back problems in service. See Correspondence, April 2020 at p.12 of 30. Dr. C.B. noted that the Veteran’s history of chronic low back pain in service meets the VA’s criteria for chronic illness and it was his opinion that the Veteran had a “chronic low back degenerative process” since service. Id. at p.16 of 30. Dr. C.B. further opined, “considering every possible sound medical etiology/principle…that his current low back pain and DDD spine problems are due to his auto accident.” The Board notes that the Veteran’s service treatment records do not reflect that the Veteran sustained back injuries from an auto accident. Moreover, the examiner did not address the Veteran’s actual complaints and treatment in service in support of his opinion of direct service connection. Furthermore, the examiner did not address whether spina bifida was aggravated by military service, resulting in in-service complaints. For the above reasons, the Board finds that a remand is necessary in order to obtain an adequate medical opinion addressing aggravation of pre-service spina bifida and direct service connection. 6. Entitlement to service connection for a kidney condition, to include glomerulonephritis The evidence of record reflects that the Veteran was diagnosed with a kidney condition post-service. Prior to the Veteran’s passing, he asserted that his kidney condition had its onset in service. See Correspondence, December 2015 at p.9 of 18. An April 1985 consultation report reflects that the Veteran was provisionally diagnosed with chronic prostatitis. See STR at p.44 of 75. An examination revealed possible urethral stricture, prostatitis like symptoms which were unresponsive to antibiotic therapy. Id. Renal/urethral disease was considered the cause of the Veteran’s condition. Id. An August 1985 urologic examination reflects that the Veteran’s ureters were seen to be fusing. Id. at p.47 of 75. No opinion has been obtained regarding the nature and etiology of the Veteran’s post-service kidney condition. Therefore, the Board finds that a remand is necessary. 7. Entitlement to service connection for diabetes mellitus type II The evidence of record reflects that the Veteran was diagnosed with diabetes mellitus type II post-service. Prior to the Veteran’s passing, he asserted that his diabetes had its onset in service. See Correspondence, December 2015 at p.13 of 18. A 1983 military entrance and 1986 separation examination reports reflect the Veteran’s urinalysis was negative for albumin and sugar. See STR at p.56 of 75. A November 1984 lab report reflects that the Veteran’s glucose was 117. Id. at p.68 of 75. No opinion has been obtained regarding the nature and etiology of the Veteran’s diabetes mellitus type II. Therefore, the Board finds that a remand is necessary. 8. Entitlement to service connection for cause of death The Veteran passed away on August 31, 2017. His immediate cause of death was cardiac failure due to or a consequence of septic shock and bacterial peritonitis. In October 2019, the AOJ issued a statement of the case (SOC) denying service connection as an accrued benefit for a heart condition, hypertension, lung condition to include sarcoidosis, diabetes mellitus type II, back condition, kidney condition, skin condition, stomach condition, and blindness. In April 2020, the appellant submitted a private medical opinion from Dr. C.B., who opined that the Veteran’s sarcoidosis and cardiac problems were causally related to his military service, and his back condition had its onset in service. See Correspondence, April 2020. Additionally, Dr. C.B. opined that the Veteran’s “demise was hastened due to sarcoidosis, spine induced weight gain, which caused his longstanding heart dysfunction.” Id. During the August 2020 Board hearing, the appellant’s representative testified that the Veteran’s sarcoidosis, heart problems, and back condition had its onset during service, as evidenced by the Veteran’s service treatment records. As this decision has awarded service connection for a heart condition, the Board finds that a remand is necessary in order to obtain a medical opinion as to whether the Veteran’s heart condition caused or contributed substantially or materially to cause the Veteran’s death. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion on the nature and etiology of any diagnosed skin condition. The entire claims file, and a copy of this REMAND, must be reviewed by the examiner. The examiner must clearly state whether the Veteran had a diagnosed skin condition during his lifetime. If not, this must be explained in full. For each diagnosed skin condition, the examiner must opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s skin condition is attributable to service, or is proximately due to or aggravated beyond its natural progress by his service-connected lung condition, to include sarcoidosis. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. Obtain a VA medical opinion on the nature and etiology of any diagnosed stomach condition. The entire claims file, and a copy of this REMAND, must be reviewed by the examiner. The examiner must clearly state whether the Veteran had a diagnosed gastrointestinal condition during his lifetime. If not, this must be explained in full. The examiner must opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s stomach condition is attributable to service, or is proximately due to or aggravated beyond its natural progress by his service-connected lung condition, to include sarcoidosis. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Obtain a VA medical opinion on the nature and etiology of any diagnosed arthritis and joint pain condition. The entire claims file, and a copy of this REMAND, must be reviewed by the examiner. The examiner must opine as to whether it is as likely as not that the Veteran’s arthritis and joint pain condition is at least as likely as not (a 50 percent or greater probability) proximately due to or aggravated beyond its natural progress by his service-connected lung condition, to include sarcoidosis. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Obtain a VA medical opinion on the nature and etiology of any diagnosed back condition. The entire claims file, and a copy of this REMAND, must be reviewed by the examiner. The examiner must opine as to the following: (a.) Whether any diagnosed back condition (i.e., spina bifida) is a congenital defect or a disease. (b.) If the examiner determines that the diagnosed back condition constitutes a congenital defect, the examiner must render an opinion as to whether the Veteran experienced a superimposed disease or injury during service that caused additional disability to the congenital defect. (c.) If the examiner determines that the diagnosed back condition is a congenital disease, the examiner must render an opinion as to whether there is clear and unmistakable evidence that it was not aggravated beyond the normal progression during service. “Clear and unmistakable evidence” includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. (d.) If the Veteran’s diagnosed back condition is not a congenital defect or disease, the examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that his diagnosed back condition was incurred in or related to active duty service. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Obtain a VA medical opinion on the nature and etiology of any diagnosed kidney condition, to include glomerulonephritis. The entire claims file, and a copy of this REMAND, must be reviewed by the examiner. The examiner must opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s kidney condition, to include glomerulonephritis, had its onset during or as a result of his active service. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. Obtain a VA medical opinion on the nature and etiology of the Veteran’s diabetes mellitus type II. The entire claims file, and a copy of this REMAND, must be reviewed by the examiner. The examiner must opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s diabetes mellitus type II had its onset during or as a result of his military service. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. After all available records and/or responses have been associated with the claims file, arrange to have an appropriate VA physician comprehensively review the record and provide an opinion addressing the relationship, if any, between the Veteran’s now service-connected heart condition and his death. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to, and be reviewed by, the designated physician, and the opinion must include discussion of the Veteran’s documented medical history and all lay assertions, to include those advanced by the appellant. Following a review of all the relevant evidence and considering accepted medical principles, the reviewing physician must provide an opinion, consistent with sound medical principles, as to whether it is at least as likely as not (a 50 percent or greater probability) that the service-connected heart condition caused or contributed substantially or materially to cause the Veteran’s death. In addressing the above, the physician must consider and discuss all in- and post-service medical and other objective evidence, as well as all lay assertions. If lay assertions in any regard are discounted, the examiner must clearly so state, and explain why. A complete, clearly-stated rationale for all conclusions reached must be provided. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Camille NeSmith, Associate Counsel 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.