Citation Nr: 21067211 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 14-35 419 DATE: November 3, 2021 REMANDED Service connection for the Veteran's cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1995 to June 1998. He died in May 2011. The Appellant is his surviving spouse. This matter is on appeal from rating decisions denying service connection for the cause of his death. In December 2018, the Appellant testified at a hearing before the undersigned. The Board remanded this matter to the agency of original jurisdiction (AOJ) for additional development in March 2019. Service connection for the Veteran's cause of death thereafter was denied by the Board in May 2020. However, the United States Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Partial Remand (JMPR) in February 2021. This matter accordingly was remanded back to the Board for readjudication. In June 2021, the Board determined that readjudication could not be undertaken without once again remanding to the AOJ for additional development. The Board unfortunately makes this same determination now. Veteran's Cause of Death The Veteran was an inpatient at the Martinsburg, West Virginia VA medical center domiciliary when he died. His amended death certificates (those dated in 2012 and 2019 ) note intoxication from combined medications as his immediate cause of death. Citalopram, tramadol, and hydromorphone consistently were identified in this regard, and promethazine was identified once as well. Intravenous drug abuse/injection also was referenced in describing his death. The latest amended death certificate additionally notes hypertensive cardiovascular disease as a significant condition contributing to the Veteran's death. At that time of his death, the Veteran was service-connected for degenerative disc disease (DDD) of the lumbar spine rated 40 percent disabling, right knee strain rated 10 percent disabling, tinnitus rated 10 percent disabling, and left ear hearing loss rated noncompensable or 0 percent disabling. He had prescriptions for tramadol and naproxen to manage his back and knee pain. While he also was prescribed promethazine, it was for nausea and not any of the aforementioned service-connected disabilities. Citalopram similarly was prescribed for mood and depression rather than the aforementioned service-connected disabilities. The Veteran was not prescribed hydromorphone. An August 2011 Toxicology Report shows that the level of tramadol in the Veteran's blood was at a therapeutic concentration when he died. The level of hydromorphone was at a subtherapeutic concentration, while citalopram was at an elevated concentration. Despite the abuse of non-prescribed hydromorphone and over-use of prescribed citalopram, the concentrations of these drugs was judged insufficient to cause death in a September 2012 Report of Death Investigation and Post-Mortem Findings. It therefore was opined that the Veteran died of uncertain causes. To comply with the JMPR granted by the Court, the Board's June 2021 remand directed that a medical opinion be obtained regarding the Veteran's cause of death. Medical opinions must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2007). However, the medical opinion rendered here in July 2021 is not adequate for two reasons. It first appears to be based at least partially on an inaccurate factual premise. The opining physician indeed stated that the tramadol and citalopram in the Veteran's blood when he died were at or below therapeutic levels. This is true of tramadol, but the August 2011 toxicology report clearly documents citalopram at an elevated concentration. The opining physician second provided little explanation to support the conclusion that none of the Veteran's service-connected disabilities were related to his death. It simply was noted that levels of tramadol and citalopram would not have caused his death and that he was not prescribed hydromorphone. Without detailed reasoning, the Board's readjudication would not be fully informed. Another medical opinion, in sum, is required. To help ensure this opinion is adequate, the Board reminds the medical professional who renders it that service connection for the Veteran's cause of death is warranted if a service-connected disability was either the principal or a contributory cause of death. 38 C.F.R. § 3.312(a). A service-connected disability is the principal cause of death when it, 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). A service-connected disability is 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. 38 C.F.R. § 3.312(c)(1). Showing that it casually shared in producing death is not sufficient. Rather, it must be shown that there was a causal connection. Id. This matter is REMANDED for the following action: 1. Arrange for a qualified VA medical professional without previous involvement in this matter to review the claims file and then answer the following: a. Was the tramadol prescribed for the pain attributed to the Veteran's service-connected DDD of the lumbar spine and service-connected right knee strain the immediate cause of his death, the underlying cause of his death, or etiologically related thereto? b. Did the tramadol prescribed for the pain attributed to the Veteran's service-connected DDD of the lumbar spine and service-connected right knee strain contribute substantially or materially to his death, combine to cause his death, or aid or lend assistance to the production of his death? A detailed explanation is required to support the answer for each question. This means that relevant medical principles and/or medical literature should be discussed as it relates to medical and lay evidence specific to the Veteran. A citation or copy for any medical literature referenced finally must be provided. 2. Then readjudicate this matter. If it remains denied, follow established procedure for returning it to the Board. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Becker 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.