Citation Nr: 21004796 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 13-31 814 DATE: January 28, 2021 ORDER Entitlement to service connection for the Veteran's cause of death is denied. FINDINGS OF FACT 1. The Veteran’s death certificate indicated that his cause of death was metastatic pancreatic cancer with other significant conditions contributing to death including cerebrovascular accident (CVA), hypertension (HTN), and deep vein thrombosis (DVT). 2. The preponderance of the evidence is against a finding that the Veteran’s metastatic pancreatic cancer with other significant conditions contributing to death including CVA, HTN, and DVT were related to his active duty service or that his service-connected posttraumatic stress disorder (PTSD) materially or substantially contributed to his cause of death. CONCLUSION OF LAW The criteria for entitlement to service connection for the Veteran's cause of death have not been met. 38 U.S.C. §§ 1110, 1310, 1312; 38 C.F.R. §§ 3.5, 3.303, 3.307, 3.309, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from June 1965 to June 1967. The Veteran died in December 2011 and the Appellant is his surviving spouse. This matter returns to the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision issued by the Department of Veterans’ Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. By way of background, the Board remanded this matter in October 2018 and July 2020 for additional development. As will be discussed in more detail below, the Board finds substantial compliance with the July 2020 remand directives has been met. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding when a remand is issued, the Veteran is entitled, as a matter of law, the right to compliance with the remanded order). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Entitlement to service connection for the Veteran's cause of death is denied. The Appellant contends that the Veteran’s death was caused by his service-connected PTSD. The Board finds service connection for cause of death is not warranted. Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty, or for the aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To established service connection for cause of the Veteran’s death, the evidence must show that a service-connected disability was either the principal or a contributory cause of death. A disability will be considered the principal cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. A disability will be considered a contributory cause of death when it contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death. Id. It is not sufficient to show that it casually shared in producing death, but rather, it must be shown that there was a causal connection. Id. To be a contributory cause of death, it must be shown that there were “debilitating effects” due to a service-connected disability that made the Veteran “materially less capable” of resisting the effects of the fatal disease or that a service-connected disability had “material influence in accelerating death,” thereby contributing substantially or materially to the cause of death. See Lathan v. Brown, 7 Vet. App. 359 (1995); 38 C.F.R. § 3.312. The Veteran’s cause of death was listed on his death certificate as metastatic pancreatic cancer with other significant conditions contributing to death including CVA, HTN, and DVT. At the time of his death, the Veteran was service connected for PTSD. Of note, the RO denied accrued service connection for pancreatic cancer, HTN, and pulmonary embolism in an unappealed December 2019 rating decision. Veterans who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. 38 U.S.C. § 1116; 38 C.F.R. § 3.307. If a Veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval or air service and has contracted an enumerated disease to a degree of 10 percent or more at any time after service, the Veteran is entitled to a presumption of service connection even though there is no record of such disease during service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(e). Certain chronic diseases, including tumors, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty, or for the aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In the event a Veteran has at least one service-connected disability, he or she may be entitled to benefits based on a secondary service connection. In order to establish a secondary service connection, the Veteran must show: (1) a current disability that is not already service-connected; (2) at least one service-connected disability; and, (3) evidence that the non-service-connected disability is either proximately due to or aggravated beyond its natural progression by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 444 (1995). When service connection cannot be established on a presumptive or secondary basis, the Court has held that the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (1994). The elements of direct service connection are: “(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 or injury incurred or aggravated during service,” also known as the nexus element. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Turning to the relevant evidence of record, the Veteran’s service treatment records, including his entrance and separation examinations, lacked any reference to diagnosis, treatment, symptoms, or complaints related to metastatic pancreatic cancer, CVA, HTN, or DVT. See June 1965 entrance examination. During service, treatment records reference a right calf wound including debridement of a fragment wound with delayed closure. See April 1966 STR. Of note, at separation the Veteran’s blood pressure was 136 over 64. See May 1967 separation examination. Post-separation, the Veteran was diagnosed with HTN around 1984. See November 2003 VA treatment records. His treatment records since then continued to reflect treatment for HTN. See June 1999 VA treatment records. The Veteran was granted service connection for PTSD effective July 31, 2009. See April 2010 rating decision. In July 2011, the Veteran experienced CVA with residual left-sided weakness resulting from right branches of the middle cerebral artery, occlusion, HTN, congestive heart failure with diastolic dysfunction, dyslipidemia, and colon polyps. See November 2011 VA treatment records. Prior to the CVA, the Veteran had stopped taking his aspirin for at least a week. See August 2011 VA treatment records. In September 2011, the Veteran sought medical treatment following complaints of shortness of breath as a result of which he was admitted to the hospital. Id. Imaging revealed no acute disease in the chest x-rays but found bilateral pulmonary embolisms. Id. A lower extremity ultrasound was completed revealing bilateral extensive DVT. Id. Also found was a right thigh mass that was noted to be a soft-tissue mass concerning for sarcoma following a right lower extremity CT scan. Id. An abdominal CT scan was completed showing metastatic lesions in the liver and ill-defined lesions in the pancreas with metastatic lesion in the bones. Id. An MRI of the right knee was done showing a mass. Id. Liver biopsy was performed to determine pathology, the results of which indicated indeterminate pancreatic adenocarcinoma. Id. During an oncology consultation, the Veteran was noted to have likely metastatic pancreatic cancer with lets to the liver and bone and possible bilateral adrenals. Id. In October 2011, a chest CT revealed nonocclusive bilateral defects in the pulmonary arteries concerning for pulmonary embolism with no definitive evidence of metastatic disease within the thorax. See October 2011 VA treatment records. A pancreatic mass was found consistent with the reported diagnosis of pancreatic cancer with innumerable scattered lesions throughout the liver concerning for metastatic disease. Id. In November 2011, during an oncology appointment, the Veteran was informed of his likely metastatic pancreatic cancer with metastases to the liver, bone, and possible bilateral adrenal glands. See November 2011 VA treatment records. The provider noted that liver biopsy confirmed poorly differentiated adenocarcinoma with laboratory results suggesting pancreatic adenocarcinoma. Id. Treatment options and life expectancy were discussed during this appointment. Id. A VA opinion was obtained in September 2016 to determine whether the Veteran’s PTSD materially or substantially contributed to his death. The provider opined that it is less likely as not that the Veteran’s service-connected PTSD materially or substantially contributed to his death. See September 2016 VA opinion. She opined that it is less likely as not that the Veteran’s service-connected PTSD caused debilitating effects and general impairment that would render the Veteran less capable of resisting the effects of the noted cause of death. Id. She reasoned there was no connection noted between medical providers and conditions related to death by medical providers in the record, there is no current literature to suggest such a connection, and there is no mention of PTSD impacting his medical care in the months before his death. Id. She explained that while PTSD often co-occurs with physical conditions, existing research has not determined that PTSD causes poor health. Id. Thus, a causal connection between the two does not exist. Id. Further, there is no literature to suggest a causal connection or increased risk between PTSD and cancer. Id. Additionally, the provider reasoned that while the Veteran was seen for mental health treatment in 2009, in the year preceding death, he was not seen for any mental health treatment noted in his medical records. Id. Specifically, during procedure recovery in 2009, the Veteran was evaluated given his PTSD history and acute delirium. Upon evaluation, it was noted that, “While his PTSD may be contributing to the presentation, delirium appears to be the most pressing problem at this time.” Id. He was evaluated again after resolution of delirium with no noted exacerbation of PTSD and planned follow-up with his regular mental health provider. Id. The Board finds the September 2016 VA opinion included consideration of the Veteran’s medical history and set forth all pertinent findings, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). When considered together and with the entire evidence of record, the Board finds the opinion adequate for adjudication of the service connection claim for cause of death because it is based upon an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). The Board finds the September 2016 VA opinion to be highly probative regarding whether PTSD substantially or materially contributed to the Veteran’s cause of death, including pancreatic cancer and contributing factors of CVA, HTN, and DVT. The opinion provided competent, credible, and probative evidence that the Veteran’s service-connected PTSD did not substantially or materially contribute to the Veteran’s cause of death or contributing factors to cause of death. The provider explained that the Veteran had not been treated for his PTSD in the year before his death. Further, the records from 2009 referencing PTSD surrounded an incident of delirium which resolved with no noted exacerbation of his PTSD. Most importantly, however, was the provider’s explanation that there was no reference in the Veteran’s treatment records indicating PTSD was interfering with or impacting his medical care and that there is no causal connection between PTSD’s physical symptoms and poor health, which the Board finds highly probative. Thus, service connection is not warranted for cause of death because the evidence fails to establish that the Veteran’s PTSD substantially or materially contributed to his pancreatic cancer, DVT, HTN, or CVA. The Board notes that if the cause of death was not service connected, as in this case, the Board must consider whether the cause of death could have been service connected. As previously mentioned, the RO denied service connection for pancreatic cancer and HTN in a December 2019 rating decision from which the Appellant did not appeal. Pancreatic Cancer Specifically relating to pancreatic cancer, the September 2016 VA psychologist opined that while PTSD often co-occurs with physical conditions, existing research has not determined that PTSD causes poor health. Id. Thus, a causal connection between the two does not exist and there is no literature to suggest a causal connection or increased risk between PTSD and cancer. Id. In February 2018, another VA opinion was obtained wherein the provider opined that it is less likely than not the Veteran’s metastatic pancreatic cancer was related to his period of active service to include as due to in-service herbicide agent exposure. See February 2018 BVA letter. He reasoned based upon review of available medical records, that the Veteran had numerous risk factors for pancreatic cancer including smoking, alcohol abuse, obesity, and race. Id. Present data does not support exposure to herbicide being causative agent for the development of pancreatic cancer. Id. At the outset, the Board notes while herbicide agent exposure has previously been conceded, pancreatic cancer is not a condition for which the presumptions relating to herbicide exposure apply under 38 C.F.R. §§ 3.307, 3.309(e). Additionally, though tumors fall under the presumptions relating to chronic conditions, the Veteran’s pancreatic cancer was diagnosed in 2011, decades after service and decades outside the required manifestation period for the chronic condition presumptions to apply. 38 C.F.R. §§ 3.307, 3.309(e). The Board finds the September 2016 and February 2018 VA examinations include consideration of the Veteran’s medical history and set forth all pertinent findings, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). When considered together and with the entire evidence of record, the Board finds the opinions adequate for adjudication of the service connection claim for cause of death because they are based upon an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). The Board finds the September 2016 VA opinion to be highly probative because it provided competent and credible evidence that the Veteran’s service-connected PTSD cause Veteran’s cause of death of pancreatic cancer. The Board finds highly probative the provider’s opinion that while PTSD manifests in physical symptoms, there is no causal relationship between PTSD and cancer nor is there literature to suggest such. While the examiner did not specifically address whether PTSD aggravated his pancreatic cancer, the Board finds the record lacks any contentions of aggravation. Thus, the evidence of record does not support a finding of service connection for pancreatic cancer on a secondary basis. Regarding direct service connection, it is undisputed that the Veteran had a diagnosis of pancreatic cancer. As previously mentioned, VA has conceded the Veteran’s herbicide agent exposure. There is no competent or credible evidence of record, however, that the Veteran’s pancreatic cancer was due to or proximately caused by any other aspect of active duty service including herbicide agent exposure. To this point, the Board finds the February 2018 VA opinion to be highly probative. The provider competently and credibly reasoned that the Veteran had numerous risk factors for pancreatic cancer including smoking, alcohol abuse, obesity, and race. Further, the provider explained that present data does not support exposure to herbicide agents causes pancreatic cancer. Thus, the Board finds a nexus to service, including herbicide agent exposure, for the Veteran’s pancreatic cancer cannot be established. To the extent that the Appellant, as a lay person, opines that the Veteran’s death was related to his PTSD or by service including herbicide agent exposure, the Board ultimately finds the medical opinions of the September 2016 and February 2018 VA examiners to be more probative based on the examiners’ detailed rational and their medical training, expertise, and credentials. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, service connection for cause of death as it relates to pancreatic cancer is not warranted. HTN Specifically relating to HTN, the February 2018 provider opined that it is less likely than not that the Veteran’s HTN had its onset in service or is otherwise related to service, to include as due to herbicide agent exposure. See February 2018 BVA letter. Based upon review of the Veteran’s medical records, he was at risk for HTN due to his age, obesity, and race. Id. While the pathogenesis of primary HTN is poorly understood, it is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and renal structure and function. Id. The National Academy of Sciences Institute of Medicine study indicates limited or suggestive evidence of an association between herbicide exposure and HTN. Id. Upon review of the study, however, the provider noted that emphasis should be placed on “limited or suggestive” evidence of association between herbicide exposure and HTN. Id. Association is not causation and there is no case control study of definitive causative association of herbicide exposure causing HTN. Id. The provider also opined that it was less likely than not that the Veteran’s HTN was caused or aggravated beyond its natural progression by his service-connected PTSD. Id. He noted the Veteran’s risk factors for HTN included age, obesity, and race. Id. The provider found based upon a review of the available medical records that his PTSD was reasonably well managed. Id. There was no evidence of hospitalizations for PTSD and the Veteran appears to have had a productive life as he worked for 25 years in quality control at a nuclear power plant. Id. His HTN was reasonably well managed with medications. Id. The examiner was unable to comment on the medical treatise referenced by the Veteran’s representative suggesting a link between PTSD and the risk of HTN and therefore was unable to comment. Id. In May 2019, a VA provider opined that it was less likely as not that PTSD caused or aggravated the Veteran’s HTN. See March 2019 VA opinion. She reasoned that although mental health conditions can temporarily aggravate cardiovascular conditions, such as HTN, said conditions do not permanently aggravate or cause cardiovascular conditions such as HTN. Id. Another VA opinion was obtained in June 2019 wherein the provider opined that the Veteran’s HTN was less likely than not caused or aggravated by his PTSD. See June 2019 VA opinion. The examiner again noted that medical treatment records are absent documentation of a causal relationship between the service-connected PTSD and HTN. Id. This is consistent with the research literature in which it is noted that mental health diagnoses, including PTSD, and medical conditions are often comorbid; however, a causal link between PTSD and physical ailments, including HTN, has not been established by research evidence. Id. Therefore, based on the evidence of record, the provider found that it is less likely than not that the Veteran’s service-connected PTSD contributed to his HTN which was recorded as an “other significant condition” on his death certificate. Id. A July 2020 opinion again found it was less likely than not the Veteran’s PTSD caused or aggravated his HNT. The provider specifically addressed an article submitted to the record discussing PTSD and HTN. See July 2020 VA opinion. The provider explained that the article speaks in generalized terms about possible neurobiological mechanisms of PTSD and theories of relationships between PTSD and cardiovascular conditions. Id. It discusses theories of how there could be a relationship; however, the studies are retrospective, and the data cannot be used to establish causative relationships. Id. The provider explained that retrospective studies can suggest directions for further research. Id. The article itself is by no means a “nexus” between HTN and PTSD. Id. The article states that the evidence indicates there is a link between PTSD and the risk of HTN but internally references a previous study finding no strong association or consistent evidence for a causal association. Id. The provider stated that examination of the available blood pressures in the Veteran’s treatment records revealed overall adequate control of his HTN for his age over a 14-year period from 1998 through 2011. Id. Thus, the provider found this indicated insufficient evidence of aggravation beyond natural progression. Id. Additionally, the provider found that the Veteran’s average systolic reading actually improved over the time leading up to his death. Id. Therefore, the provider opined it is less likely as not the Veteran’s PTSD resulted in aggravation of his HTN beyond its natural progress. Id. Regarding causation, the provider relied upon the previous VA opinions and stated that there is insufficient evidence of a causal relationship between the two conditions according to the overwhelming majority of the medical community. Id. Again, noting that an association is not causation and that HTN is so common in the populace that it will be found to be associated with many things. Id. The Board finds the February 2018, May 2019, June 2019, and July 2020 VA opinions include consideration of the Veteran’s medical history and set forth all pertinent findings, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). When considered together and with the entire evidence of record, the Board finds the opinions adequate for adjudication of the Veteran’s service connection claim because they are based upon an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). At the outset, the Board draws attention to 38 C.F.R. § 3.309 which specifically excludes HTN as a condition for which the presumptions related to herbicide agent exposure apply. Thus, service connection could not be granted for this condition based on herbicide agent exposure presumptions. Hypertension is a condition for which the presumptions relating to chronic conditions applies; however, the Veteran was not diagnosed with HTN until at least 1984, over a decade following service. Additionally, the Board notes the Veteran’s service treatment records and separation examination included normal blood pressure readings. Thus, the Veteran’s HTN was not diagnosed within the required manifestation period for chronic condition presumptions to apply. Regarding secondary service connection, as previously mentioned, the Veteran was service connected for PTSD and carried a diagnosis of HTN. The question for the Board is whether the Veteran’s PTSD caused or aggravated his HTN. On this point, the Board finds the July 2020 VA opinion to be most probative. The provider specifically reviewed and addressed the Appellant’s medical article submitted in support of her claim. The provider explained that the article recognizes theories of relationships between PTSD and HTN, but a causative relationship has not been found. Regarding aggravation, the same examiner noted that the Veteran displayed overall adequate control of his HTN for his age over a 14-year timespan. Further, his average systolic reading actually improved over time leading up to his death. These findings are highly probative and corroborated and supported by the multiple VA opinions obtained on the matter. In fact, this matter has been addressed multiple times by VA providers, all of which offered negative opinions regarding causation and aggravation. That is, the February 2018, May 2019, June 2019, and July 2020 VA providers offered resounding negative causal and aggravation opinions. While the Appellant contends that the Veteran’s PTSD led to his HTN which contributed to his death, she is not competent to offer an opinion regarding the nexus of the Veteran’s HTN. In fact, the competent and credible medical evidence of record as noted above found no causation or aggravation relationship between the Veteran’s PTSD and HTN; therefore, the Board finds this evidence to be more probative on the matter. The record lacks any competent and credible medical opinion finding a causation or aggravation relationship between the Veteran’s PTSD and HTN. Thus, in reliance upon the competent medical evidence of record, the Board finds the preponderance of the evidence is against awarding service connection for HTN secondary to PTSD. The Veteran’s STRs lack any reference to, diagnosis of, or treatment of HTN during service and a normal blood pressure was noted upon separation. The Veteran’s condition was not diagnosed until more than a decade after service. The February 2018 VA provider noted numerous risk factors that the Veteran had regarding HTN including age, obesity, and race. The Board finds this to be highly probative. Further, while HTN is explicitly listed as a condition for which the presumptions relating to herbicide agent exposure do not apply, the February 2018 VA provider noted that there is no evidence of a causative relationship between herbicide agent exposure and HTN. He recognized medical studies suggesting evidence of an association but explained said studies did not amount to a causative relationship. Thus, service connection on a direct basis for HTN is not warranted as a nexus to service has not been established. CVA and DVT Specifically relating to CVA and DVT, the record lacks any support that either condition was caused or incurred during service or is otherwise related to service or service-connected PTSD. Additionally, the Appellant, nor her representative have contended that said conditions are related to service. The February 2018 provider opined that it is less likely than not the Veteran’s CVA was related to his period of active service, to include as due to in-service herbicide agent exposure. See February 2018 BVA letter. He reasoned based upon review of available medical records, that the Veteran had numerous risk factors for CVA including smoking, hypertension, and hyperlipidemia. Id. Further, 2011 screening noted that the patient stopped taking aspirin about a month prior to his CVA, discontinuation of which predisposes to CVA. Id. The Board finds this opinion to be highly probative because it is based upon the Veteran’s medical history and provides rationale in support thereof. The Board notes the treatment record referenced indicated the Veteran stopped aspirin use for only a week prior to his CVA rather than the month noted by the examiner. Regardless, however, the Board finds the examiner’s opinion highly probative in consideration of the Veteran’s multiple noted risk factors for CVA. The Veteran’s STRs lack any reference to diagnosis, treatment, or symptoms related to CVA and the condition did not manifest until decades following separation. Thus, service connection on a direct basis is not warranted. Additionally, CVA is not a condition subject to the presumptions relating to herbicide agent exposure nor chronic conditions. The February 2018 provider considered the Veteran’s herbicide agent exposure in rendering his negative nexus opinion. It has not been contended nor does the record suggest that the Veteran’s PTSD was caused or aggravated by his CVA. The February 2018 VA provider also opined that it is less likely than not the Veteran’s DVT had its onset in service, or is otherwise related to service, to include as due to herbicide agent exposure. He reasoned that STRs document in May 1967, the Veteran reported cramps in his legs, and the examiner noted boils on his thigh and a fragment wound of his right calf. Although he had sustained injury in service, there is no evidence of DVT until September 2011. He opined that it is highly likely that the DVT is related to the underlying malignancy and highly unlikely that injury in the 1960s would cause DVT in 2011. The Board finds this opinion to be highly probative because it is based upon the medical evidence of record and provides the rationale in support thereof. Service connection is not warranted on a direct basis. Additionally, it has not been contended nor does the record indicate that the Veteran’s PTSD caused his DVT. Further, DVT was diagnosed decades following separation and is not entitled to application of any presumptions. Based on the aforementioned and upon review of the record, the Board finds that a preponderance of the evidence is against the Appellant’s claim that the Veteran’s service-connected PTSD substantially or materially contributed to his cause of death or that the noted cause of death or contributing causes of death are entitled to service connection. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.C. Allen, 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.