Citation Nr: 21068614 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 17-22 434 DATE: November 10, 2021 REMANDED Entitlement to service connection for the cause of Veteran's death is remanded. REASONS FOR REMAND The Veteran had service in the United States Navy from December 1981 to October 30, 1990 characterized as honorable and from October 31, 1990 to September 1991 characterized as other than honorable. He died in November 2016. The appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2021, the appellant testified before the undersigned Veterans Law Judge. A hearing transcript is associated with the record. Entitlement to service connection for the cause of Veteran's death The appellant contends that the Veteran's death stems from his service-connected PTSD. The appellant argues that (1) stress, panic attacks, and anxiety caused by the Veteran's service-connected PTSD and/or (2) medication used to treat PTSD elevated his blood pressure uncontrollably affecting his heart and resulting in his death. See Hearing Transcript (March 2021). The Veteran passed away on November 24, 2016. His death certificate lists the immediate cause of death was hypertensive atherosclerotic cardiovascular disease; no underlying or secondary cause of death was indicated. See Death Certificate (January 2017). At the time of his death, the Veteran was service-connected for PTSD, tinnitus, and erectile dysfunction. 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. 38 C.F.R. § 3.312(a). A principal cause of death is one which, 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 contributory cause of death is one which contributed substantially or materially to cause death, combined to cause death, or aided or lent assistance to the production of death. See 38 C.F.R. § 3.312(c)(1). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. VA treatment records document medication management for the following prescriptions: ammonium lactate 12% lotion, mupirocin calcium 2% topical cream, terbinafine 1% cream, cyanocobalamin injections for anemia, cyclobenzaprine as a muscle relaxant, meloxicam, bupropion for depression, simvastatin for cholesterol, quetiapine fumarate for sleep, propranolol for heart/blood pressure, mirtazapine for depression, prazosin for nightmares by VA doctors and clonazepam and lamotrigine by non-VA medical providers. See CAPRI (August 2012). To ensure that VA has met its duty to assist the claimant, the Board finds that remand is required as explained below. Wood v. Peake, 520 F.3d 1345, 1349 (Fed. Cir. 2008); DeLaRosa v. Peake, 515 F.3d 1319, 1321-22 (Fed. Cir. 2008). First, in a cause of death claim, VA has a duty to obtain a medical opinion if such is needed to assist the appellant in substantiating the claim. DeLaRosa v. Peake, 515 F.3d 1319 (Fed. Cir. 2008). The evidentiary record does not contain a medical opinion as to whether the Veteran's PTSD and/or medications taken to treat his PTSD caused, contributed to, or hastened death. The Boards finds that the matter must be remanded for a medical opinion as the Board may not substitute its own medical opinion for that of a medical professional. Second, though the appellant testified that the Veteran received all treatment at the VA, this is not supported by the medical records in evidence which show the Veteran obtained prescriptions for medication from non-VA providers. Additionally, records from the Fort Worth VA Clinic document only two unrelated encounters with the Veteran over a period of three years which is not indicative of a pattern of ongoing care. See CAPRI (March 2017). As VA treatment records do not appear to be complete and the evidence suggests that there are outstanding private medical records, a remand is required to obtain them. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from his release from active duty in September 1991 to the Present. 2. Ask the appellant to complete a VA Form 21-4142 for all relevant non-VA medical providers. Make two requests for the authorized records from all identified sources unless it is clear after the first request that a second request would be futile. All attempts to obtain these records must be documented in the claims file; and the appellant must be notified if requested records are not obtained. 3. Obtain a medical opinion from an appropriate clinician regarding the Veteran's cause of death. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. The medical opinion should, at a minimum, reflect consideration of (i) the documented history; (ii) the lay contentions (e.g., PTSD and/or medications for PTSD caused or contributed to the Veteran's death and uncontrolled blood pressure was caused or aggravated by his service-connected PTSD); and (iii) the medical evidence of record. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The examiner must opine on: Principal Cause of Death (b.) Whether the Veteran's service-connected PTSD and/or medications to treat PTSD, singly or jointly with some other condition, at least as likely as not was the immediate or underlying cause of death or is otherwise etiologically related thereto. Explain. Consider and address the appellant's theory that PTSD caused stress and panic attacks/anxiety that caused increased blood pressure that led to Veteran's death from heart disease; and that his medications taken to treat PTSD let to increased blood pressure that led to the Veteran's death from heart disease. Contributory Cause of Death (c.) Whether the Veteran's service-connected PTSD and/or medications to treat PTSD at least as likely as not: 1. Contributed substantially or materially to his death; 2. Combined to cause his death; or 3. Aided or lent assistance to the production of his death. Explain. NOTE: 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. See 38 C.F.R. § 3.312(c)(1). (d.) Whether the Veteran's service-connected PTSD and/or medications to treat PTSD at least as likely as not involved processes affecting vital organs. If so, whether the Veteran's service-connected PTSD and/or medications to treat PTSD at least as likely as not resulted in debilitating effects and general impairment of health to the extent that would render the person less capable of resisting the effects of either disease or injury primarily causing death. Explain. (e.) Whether the Veteran's service-connected PTSD at least as likely as not was of such severity as to have a material influence in accelerating death. Consider the appellant's theory that the Veteran's PTSD caused stress on his heart resulting in uncontrolled blood pressure. Explain. NOTE: The clinician must consider that it would not generally be reasonable to hold that a service- connected condition accelerated death unless such condition affected a vital organ and was itself of a progressive or debilitating nature. See 38 C.F.R. § 3.312(c)(4). 4. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Edwards 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.