Citation Nr: 21064300 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 14-38 304A DATE: October 19, 2021 ORDER Entitlement to service connection for the cause of death is denied. FINDING OF FACT 1. The Veteran died on December [REDACTED], 2011. The cause of death was cardiopulmonary arrest, ischemic cardiomyopathy, congestive heart failure, and coronary artery disease. The other significant conditions included CABG, pacemaker, aortic stenosis, and pulmonary hypertension. 2. At the time of his death, the Veteran was service connected for generalized anxiety disorder, tinnitus, bilateral hearing loss, and multiple burn scars. 3. A disability of service origin did not cause or contribute materially to the cause of death. CONCLUSION OF LAW The criteria for establishing service connection for the cause of the Veteran's death are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1310, 5103, 5103A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably with the United States Army Air Corps from February 1943 to November 1945. The Veteran was awarded the Purple Heart for his service during World War II. The Veteran died in December 2011. The Appellant in the present appeal is his surviving widow. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Appellant testified before the undersigned Veterans Law Judge at a Board videoconference hearing in July 2018. A transcript of the hearing has been associated with the record. These claims were previously remanded by the Board in October 2018, July 2020, and April 2021 decisions. The Board finds that the RO has substantially complied with the most recent April 2021 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the appellant had submitted a new hearing request, but the appellant withdrew the request before a new hearing was scheduled. This appeal has been advanced on docket pursuant to 38 C.F.R. § 20.900 (c); 38 U.S.C. § 7107 (a)(2). 1. Entitlement to service connection for the cause of death The appellant contends and asserts that the Veteran's hypertension and cardiac issues that ultimately resulted in his death were secondary to his service-connected generalized anxiety disorder (GAD). Service connection for the cause of the Veteran's death may be granted if a disability incurred in or aggravated by service was either the principle or a contributory cause of the Veteran's death. 38 U.S.C. § 131; 38 C.F.R. § 3.312 (a); see also 38 U.S.C. § 1110; 38 C.F.R. § 3.303. For a service-connected disability to be the principle cause of death it must singly or with some other condition be the immediate or underlying cause or be etiologically related. 38 C.F.R. § 3.312 (b). For a service-connected disability to be a contributory cause of death it must have contributed substantially or materially and combined to cause death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312 (c)(1). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it 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. Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312 (c)(3). At the time of his death, the Veteran was service connected for generalized anxiety disorder, tinnitus, bilateral hearing loss, and multiple burn scars. The appellant's theory of the case is that either the Veteran's cardiac condition was secondary to or aggravated by his service-connected generalized anxiety disorder, or, that the Veteran's hypertension was secondary or aggravated by his generalized anxiety disorder, which, in turn, aggravated his heart condition. In February 2013, a private cardiologist, Dr. D.W., submitted an opinion that the Veteran's hypertension and anxiety disorder contributed to his overall cardiac failure and death in 2011. The appellant has submitted an opinion by the Veteran's private physician from March 2013 opining that "it is as likely as not [that] his heart condition was related to decades of mental health stress or at least his heart condition was made worse by his mental health condition." The private physician, Dr. U.R., did not provide any rationale for his opinion. The VA obtained a medical opinion in May 2019. That VA examiner opined that the Veteran's heart condition was not due to, caused by, or otherwise aggravated by the Veteran's service-connected GAD. As rationale, the examiner noted that the Veteran's coronary artery disease was the result of narrowing of the coronary arteries resulting in myocardial ischemia. The examiner also indicated there is no evidence of record nor any evidence-based medical consensus to support the claim that service-connected generalized anxiety disorder caused the cardiac conditions for the Veteran. An addendum VA opinion was obtained in September 2020. The September 2020 VA examiner considered the February 2013 opinion of Dr. D.W. and the March 2013 opinion of Dr. U.R. The examiner concluded that it is less likely than not that the Veteran's cardiac conditions were proximately due to or the result of the Veteran's service-connected GAD. The examiner explained that the opinions of Dr. D.W. and Dr. U.R. failed to provide any supporting evidence or rationale to support their opinions, and that the Veteran had numerous other risk factors including hyperlipidemia, being male, history of tobacco use, hypertension, a family history of heart disease, and his age. Another VA addendum opinion was obtained in December 2020 from a cardiologist. The examiner concluded that the Veteran's heart disease was not due to or aggravated by the Veteran's GAD, and the heart condition was less likely than not (less than 50 percent probability) either caused by or aggravated by his service-connected GAD. As rationale, the cardiologist indicated the Veteran had numerous risk factors for heart disease and could find no evidence to support that generalized anxiety disorder causes chronic multivessel obstructive coronary disease and ischemic cardiomyopathy. In June 2021, another VA examiner provided an addendum opinion. The examiner concluded that the Veteran's heart condition was less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected GAD. As rationale, the examiner indicated that the current, widely accepted, peer-reviewed literature has not established GAD, PTSD, or related psychological comorbidities as a cause of essential hypertension. The examiner continued by noting there was no evidence that the Veteran's hypertension was aggravated by any cause. The examiner also concluded that the Veteran's death was caused by coronary artery disease and related cardiomyopathy, and not a result of hypertension, and, thus, more than likely, the Veteran would have had coronary artery disease independent of his diagnosis of hypertension. Most recently, in July 2021, an addendum opinion by a VA cardiologist was obtained. The cardiologist concluded that a review of the current medical literature and research shows no physiologic or biomechanical causal relationship between a mental health condition (PTSD, GAD, MDD) and a physiologic condition like hypertension. The examiner noted that while anxiety can cause a temporary elevation in blood pressure, it does not cause or permanently aggravate primary or secondary hypertension. Thus, the cardiologist concluded that it was less likely than not that the Veteran's generalized anxiety disorder substantially or materially contributed to death or that it combined with other factors caused death, or that it aided or lent assistance in the production of death. In conclusion, the July 2021 VA examiner opined that the Veteran's heart condition was instead due to his other cardiac conditions and long history of chronic heart disease instead of his generalized anxiety disorder. The rationale was that there is no widely accepted peer-reviewed literature that has found a link between mental conditions and cardiac conditions. The Board acknowledges the opinions of Dr. U.R. and Dr. D.W. but finds the opinions of the VA cardiologist more probative because it contains an adequate rationale and considers all of the relevant evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Barr v. Nicholson, 21 Vet. App. 303 (2007), Stefl v. Nicholson, 21 Vet. App. 120 (2007), Prejean v. West, 13 Vet. App. 444 (2000). The appellant believes Veteran's heart condition was aggravated by his generalized anxiety disorder, a service-connected disability. However, the appellant in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, anatomical relationships, and pathology. Therefore, it is outside the competence of the appellant in this case because the record does not show that they have the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the July 2021 VA cardiologist's opinion. Accordingly, while sympathetic to the Appellant's claim, the Board finds that service connection for the cause of the Veteran's death is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Appellant's claim of entitlement to service connection for the cause of the Veteran's death. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.D. Taylor, 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.