Citation Nr: 21062624
Decision Date: 10/08/21	Archive Date: 10/08/21

DOCKET NO. 17-36 793
DATE: October 8, 2021

ISSUE

Entitlement to service connection for the cause of Veteran's death. 

ORDER

Entitlement to service connection for the cause of Veteran's death is denied.

FINDINGS OF FACT

1. The Veteran's duties placed him in the Republic of Vietnam, and exposure to herbicide agents has been conceded.

2. The Veteran passed away in January 2016. The death certificate shows the immediate cause of death as brain cancer.

3. At the time of his death the Veteran's brain cancer was diagnosed as anaplastic astrocytoma, which is not a presumptive condition based on herbicide exposure. 

4. The preponderance of the evidence is against a finding that the Veteran had a diagnosis of prostate cancer. 

5. At the time of his death the Veteran was service connected for coronary artery disease (CAD). 

6. The competent and credible, therefore most probative, evidence does not establish to an as likely as not degree that the Veteran's death was the result of a disease of service origin, to include his service-connected CAD. 

CONCLUSION OF LAW

The criteria are not met for entitlement to service connection for the cause of the Veteran's death. 38 U.S.C. §§ 1110, 1310, 1313, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.312

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty in the United States Army from December 1965 to December 1967, with service in Vietnam. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).

The record shows that the Veteran passed away on January 27, 2016. The appellant is his surviving spouse. The record reflects that through a March 2017 determination letter, the RO granted the appellant's request to be substituted in the place of the Veteran. We will proceed accordingly.

The Board remanded this issue in July 2020 for further development. When the Board last addressed the appeal, there was included a remand of the issues of entitlement to service connection for astrocytoma grade three glioma, the propriety of the rating reduction for the service-connected coronary artery disease (CAD) from 30 percent to 10 percent and an increased disability rating in excess of 10 percent for CAD. The matters were remanded for additional development and the issuance of a statement of the case (SOC). Following the remand, the appellant's claims for service connection for astrocytoma grade three glioma and an increased disability rating in excess of 10 percent for CAD were denied. The RO also reduced the Veteran's rating for CAD from 30 percent to 10 percent effective March 1, 2016. An SOC was issued in September 2020. An appeal was not perfected as to these issues. As such, the matters are not before the Board and will not be addressed herein.

Upon review of the Veteran's claim file, the Board finds that there has been substantial compliance with the Board's July 2020 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Therefore, the Board will proceed to the merits of the issue on appeal.

Legal Criteria for Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, 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 or injury incurred or aggravated during service-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d).

Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include malignant tumors, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For malignant tumors, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3).

Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3.

In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54.

Service Connection Based on the Presumption of Herbicide Agent Exposure

Service connection can also be established based on herbicide agent exposure. 38 C.F.R. § 3.307(a)(6). For the purposes of determining herbicide agent exposure, a veteran who served in qualifying locations is presumed to have been exposed to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(iii). If the veteran is presumed to have been exposed to herbicides, the veteran is entitled to a presumption of service connection for certain disorders. See 38 C.F.R. § 3.309(e). This presumption is specifically limited to those diseases listed. Id.

A veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 9, 1962 and May 7, 1975 is presumed to have been exposed to an herbicide agent if a listed chronic disease manifests to a degree of 10 percent disabling or more, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a). The presumption is rebuttable. 38 C.F.R. § 3.307(d). Additionally, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases are presumed to be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of the disease during service. See 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e).

In the Agent Orange Act of 1991, Congress created statutory presumptions of service connection for certain diseases caused by exposure to herbicides, and it also established a process for VA to add additional medical conditions to the list of presumptions. The diseases associated with herbicide exposure for purposes of the presumption currently include ischemic heart disease. 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309(e); see 78 Fed. Reg. 54763 (Sept. 6, 2013).

Previously, VA presumed that a veteran who served in Vietnam during the Vietnam era (January 9, 1962, to May 7, 1975) was exposed to herbicide agents if they: Served on land within the Republic of Vietnam (i.e., had "boots on the ground"), or had "brown water" service. See Haas v. Peake, 525 F.3d 1168, 1192-93 (Fed. Cir. 2008). There is no regulatory requirement as to how long the veteran was in Vietnam; even a few hours of service in country is sufficient to establish the presumption of exposure. 38 C.F.R. § 3.307(a)(6)(iii). "Brown water" service includes service aboard a ship that: 1) served on the inland waterways of Vietnam; 2) went ashore while his or her ship was operating in Vietnam's close coastal waters; or 3) docked in Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii).

Where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection for disability due to exposure to herbicides with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1041 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure.

Service Connection for Cause of Death

Service connection for the cause of a Veteran's death is warranted if a service-connected disability either caused or contributed substantially or materially to the cause of the Veteran's death. 38 C.F.R. § 3.312(a). To establish service connection for the cause of a Veteran's death, competent evidence must link the fatal disease to a period of military service or an already service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. §§ 3.303, 3.312; Ruiz v. Gober, 10 Vet. App. 352 (1997).

In order to establish service connection for the cause of a Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. A service-connected disability will be considered as the principal, or primary, 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 C.F.R. § 3.312(b).

Contributory cause of death is inherently one not related to the principal cause. In order to constitute the contributory cause of death it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. 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. 38 C.F.R. § 3.312(c)(1); Lathan v. Brown, 7 Vet. App. 359 (1995); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994).

Medical evidence is required to establish a causal connection between service or a disability of service origin and the Veteran's death. See Van Slack v. Brown, 5 Vet. App. 499, 502 (1993).

Entitlement to service connection for the cause of Veteran's death.

The Veteran's certificate of death shows that he died in January 2016. Prior to his death, the Veteran was service- connected for coronary artery disease status post- myocardial infraction. The death certificate recorded the Veteran's primary cause of death as brain cancer. No secondary or contributing causes were listed.

The appellant has contended that the Veteran's should have been service- connected for his brain cancer because the Veteran was exposed to herbicide agents during active service in Vietnam. She has also contended that the Veteran's medical records show that he suffered from prostate cancer, which she argues is also due to his exposure to herbicide agents, and therefore he should be service- connected for that disease for cause of death. 

For the reasons provided below, the Board finds that neither service connection for brain cancer nor prostate cancer is warranted on a direct basis, and there is no path for service connection via a presumed basis.

Brain Cancer

Presumptive Service Connection for Brain Cancer

As an initial matter the Board notes that the Veteran's military personnel records reflect that the Veteran has verified service in the Republic of Vietnam. Thus, in the instant case, he was so called "boots on ground," and therefore, exposure to herbicide agents has been conceded.

With regard to the Veteran's brain cancer, the Board acknowledges that the cancers of B-cell leukemia and soft-tissue sarcoma, are included on the list of disabilities that are entitled to presumptive service connection based on herbicide exposure, effective as of August 31, 2010.

Private treatment records reflect that a brain CT scan was performed on the Veteran in October 2015 which revealed a "hyperdense mass" for which the examiner considered would include an etiology of glioma and lymphoma. A follow up brain biopsy was completed in October 2015 and the diagnosis was anaplastic astrocytoma (AA).

A VA medical opinion was completed in September 2020. At that time after reviewing the case file the examiner reiterated the Veteran's diagnosis of AA. The examiner stated that it was only before the brain biopsy that there was a consideration of other diagnoses of the brain mass, including lymphoma. However, after the biopsy the examiner pointed out the diagnosis of AA did not change. Further, the examiner explained the disease of AA is strictly a primary brain tumor. As the examiner explained, AA only involves brain cells and central nervous system cells which is distinct and separate from the blood cells involved with leukemia or lymphoma as well distinct from the soft tissue systems involved with soft tissue sarcoma. Therefore, the examiner opined that it was less likely than not that the Veteran had any other diagnosis for the cancer that was responsible for his death, or that his brain cancer "qualifies as a B-cell leukemia, soft tissue sarcoma, or any other disease listed in 38 C.F.R. § 3.309(e)". 

The record does not contain any evidence that the Veteran has ever been diagnosed with a form of cancer listed in 38 C.F.R. § 3.309(e) at any point during the appeal period. Since there is no competent evidence of a qualifying disease, there can be no valid claim for presumptive service connection based on herbicide exposure for such disability in this case. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As it relates to anaplastic astrocytoma, this disability is not a presumptive condition associated with toxic herbicide agent exposure under 38 C.F.R. §§ 3.307 (a). Consequently, the presumptive provisions of 38 C.F.R. § 3.309 (e) do not apply to that disability.

Turning to the presumption in favor of chronic diseases and continuity of symptomatology, tumors of the brain are recognized as chronic diseases for VA purposes. 38 C.F.R. § 3.309(a). In January 2016 the appellant submitted an excerpt from the Code of Federal Regulations which stated that malignant tumors are presumed to be due to military service if they manifest within one year of discharge. Here, though, the medical evidence does not show that the Veteran's anaplastic astrocytoma manifested in service or within one year of his separation from service. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Examination of all of the service medical records, post-service military records, or private records do not record any manifestation of any brain tumor disease or symptoms until October 2015. As such, service connection based on the presumption in favor of chronic diseases or continuity of symptomatology for anaplastic astrocytoma is not warranted in this case. Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a).

Direct Service Connection for Brain Cancer

As noted previously, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection for disability due to exposure to herbicides with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1041 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure.

Here, the Veteran's service treatment records are silent for any complaints, treatment or diagnosis of a brain cancer during active service. Notably, the December 1967 separation examination reveals that the clinical evaluation of all of his body systems were normal. 

Private treatment records reflect that the Veteran was diagnosed malignant tumor of the brain, specifically anaplastic astrocytoma in October 2015. 

A VA medical opinion was obtained in September 2020. At that time the examiner opined that it was less likely than not that the Veteran's brain cancer began during service or was related to any in-service event, including herbicide exposure. In providing a rationale the examiner explained that AA is a rapidly progressive condition. The examiner explained that if the condition would have begun in service the disease would have caused his death in service or shortly after, but the Veteran would not have lived 49 years post-discharge. The examiner also noted that herbicide exposure is not a listed cause of AA according to the National Institute of Health or the International Agency for Research on Cancer. Furthermore, after a review of his STRs, the examiner concluded that there was no identified incident in service which would have caused the Veteran's AA. 

The Board finds the September 2020 VA opinion to be highly probative. The Board notes the opinion was authored by a VA physician based on extensive and detailed discussion with conclusions based on a review of the Veteran's complete history. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This examiner reviewed the claims file and provided opinions that were extremely comprehensive, sufficiently clear, and had well-reasoned rationales. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). 

The Board acknowledges the appellant's theory that the Veteran's brain cancer was related to his herbicide exposure while in Vietnam, and also the Veteran's lay statements to that affect while he was still alive. Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran or the appellant can observe symptoms related to anaplastic astrocytoma, they are competent to comment on and endorse these symptoms. However, the determination of the etiology of the Veteran's anaplastic astrocytoma is a complex medical determination beyond her competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board finds that the appellant's and other lay statements of record cannot be accepted as competent evidence sufficient to establish service connection for anaplastic astrocytoma.

In addition, the Board finds that the gap in time between the Veteran's last date of active service, in December 1967, to his initial evaluation by any medical provider regarding his brain cancer in October 2015 to be probative of a lack of nexus between the diagnosed disability and active service. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

The Board finds the preponderance of the evidence is against a finding of a causal connection between the Veteran's AA and his active duty service. Although the Veteran had established a current disability prior to his death and an in-service injury, event or disease, the preponderance of the evidence weighs against a finding that the Veteran's anaplastic astrocytoma is causally related to his service or is related to herbicide exposure. In addition, after considering the length of time between service and post-service diagnosis and determining that the Veteran does not meet the requirements for any relevant presumptions, the Board finds that the preponderance of the evidence is against the appellant's claim of service connection for anaplastic astrocytoma as cause of death. 

Prostate Cancer 

In a June 2017 Statement in Support of the Case the appellant's representative argued that the Veteran's medical records indicate that the Veteran had elevated levels of prostate-specific antigen (PSA) dating back to October 23, 2009 and this indicated that he suffered from prostate cancer. The representative then argued that as prostate cancer is presumed to be related to herbicide agent exposure, the Veteran should be service connected for cause of death. 

The Board acknowledges that prostate cancer is included on the list of disabilities that are entitled to presumptive service connection based on herbicide exposure, effective as of August 31, 2010. See 38 C.F.R. § 3.309(e).

The Veteran's prior medical history is silent for any complaints, treatment or diagnosis of prostate cancer during or post- service.

VA obtained a medical opinion in September 2020 to determine whether the Veteran had a diagnosis of prostate cancer during his lifetime, and if so, if the disease caused or contributed to his death. Upon review of the claim file the September 2020 VA examiner concluded that the available evidence did not indicate that the Veteran was ever diagnosed with prostate cancer during his lifetime. The examiner pointed to the VA treatment records which showed that all of the Veteran's PSAs through August 13, 2015 were 1.27 or below, which the examiner states was well within the normal limits of 0-4. The examiner also noted that the Veteran's medical lists did not include any benign prostate-related medication and the disease was listed no where in his prior medical history. 

The Board finds the September 2020 VA opinion to be highly probative. The Board notes the opinion was authored by a VA physician based on extensive and detailed discussion with conclusions based on a review of the Veteran's complete history. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This examiner reviewed the claims file and provided opinions that were extremely comprehensive, sufficiently clear, and had well-reasoned rationales. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005).

The Board acknowledges the appellant's theory that the Veteran's medical records indicate that he had elevated levels of PSA and therefore she believes that he had a diagnosis of prostate cancer. Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran or the appellant can observe symptoms related to prostate cancer, they are competent to comment on and endorse these symptoms. However, the determination of a diagnosis of prostate cancer is a complex medical determination beyond her competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board finds that the appellant's and other lay statements of record cannot be accepted as competent evidence sufficient to establish a diagnosis of prostate cancer.

As stated above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists).

Here, there is no evidence of record which establishes that the Veteran had any diagnosis of prostate cancer at any point during the period on appeal. None of the medical evidence of record indicated that he had any diagnosed disorders or disabilities involving his prostate. Additionally, there is no indication that the Veteran ever sought treatment for any condition of his prostate.

The preponderance of the medical evidence of record, then, establishes that the Veteran does not have a diagnosis of disorders or disabilities of the prostate during the appeal period. Indeed, no underlying disability/ies have been clinically diagnosed during the appeal period or proximate thereto. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The claims for service connection for this, therefore, must be denied because the first essential element for the grant of service connection, competent evidence of the disability for which service connection is sought, is not met.

Coronary Artery Disease 

The record reflects that the Veteran was awarded service connection for his CAD, effective August 23, 2013.  Therefore, the Board in the July 2020 remand, directed that a medical opinion be obtained to determine if the Veteran's CAD caused or significantly contributed to his death. 

In September 2020, a VA examiner opined that it was less likely than not that the Veteran's service- connected coronary artery disease (i) primarily caused his death, (ii) substantially contributed to his death,(iii) resulted in debilitating effects and general impairment of health to an extent that would render the Veteran materially less capable of resisting the effects of the diseases primarily causing death, or (iv.) was of a progressive or debilitating nature, such that it had a material influence in accelerating death.  In providing a rationale, the examiner explained that CAD and stent treatments were listed only in the Veteran's past medical history of  his medical records leading to his death and were not noted as clinically apparently causing problems because his last stent treatment was in 2014.  The examiner pointed to an Echo which was completed at a VA treatment facility in July 2015, which was less than 6 months before the Veteran passed away, and showed very good function of his left ventricle, ejection fraction of 60-65%, with normal left ventricle size, function and wall motion. Ejection fraction, as the examiner explained, is an objective measure which isolates left ventricle function and is more accurate than estimated METs, which can be heavily influenced by an intercurrent condition such as AA. The examiner also explained that the results of the July 2015 Echo meant that there was no evidence of significant prior myocardial infraction and that the stents were keeping the Veteran's CAD under control.  The examiner concluded that the Veteran would not have been having any significant symptoms of his CAD and that in the absence of his AA he would have likely lived for years based on his excellent heart function. 

The Board finds the September 2020 VA opinion to be highly probative. The Board notes the opinion was authored by a VA physician based on extensive and detailed discussion with conclusions based on a review of the Veteran's complete history. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This examiner reviewed the claims file and provided opinions that were extremely comprehensive, sufficiently clear, and had well-reasoned rationales. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005).

As there are no other probative opinions of record the Board finds that the preponderance of the evidence is against a finding that the Veteran's service- connected CAD caused or substantially contributed to the Veteran's death. 

(Continued to next page.)

Conclusion 

In addressing the appellant's claim, we have considered the medical evidence of record, applied the benefit of the doubt doctrine, and have sufficient evidence with which to reach a decision in this matter. Unfortunately, based on these findings, entitlement to service connection for the cause of the Veteran's death is denied because the weight of the evidence of record fails to show that a disability of service origin was the immediate or underlying cause of death or was etiologically related thereto. See 38 C.F.R. § 3.312.

In reaching this conclusion, the Board is very sympathetic to the appellant's circumstances and the emotional hardship that she has endured in the loss of her husband, the Veteran. Unfortunately, in reaching this conclusion, the Board has found that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim for service connection for cause of the Veteran's death must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

 

Michael A. Pappas

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Nettey, 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.