Citation Nr: 21069263 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 15-28 328 DATE: November 18, 2021 ORDER Entitlement to service connection for the Veteran's cause of death is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the cause of the Veteran's death was related to or caused by service; nor does the evidence show that any of the Veteran's service-connected disabilities caused or contributed to his 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, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from September 1974 to November 1980. The Veteran died in November 2013. The appellant is his surviving spouse. This matter is before the Board of Veterans' Appeals (the Board) on appeal from a July 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the appellant testified before the undersigned Veterans Law Judge at a video conference hearing. A transcript of the hearing is of record. This case was previously remanded by the Board in March 2019 and most recently in May 2021, for further development. As the actions specified in the remand have been substantially completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Duties to Notify and Assist With respect to the appellant's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38C.F.R. §3.159. Neither the appellant nor her representative have advanced any procedural arguments in relation to VA's duties to notify and assist; therefore, the Board will proceed with appellate review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Service Connection for Cause of Death Dependency and Indemnity Compensation (DIC) benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. § 3.5. The cause of the veteran's death will be considered to be due to a service-connected disability when the evidence establishes that such a disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312 (a). For a service-connected disability to be considered the principal or primary cause of death, it must be singly, or with some other condition, be the immediate or underlying cause, or be etiologically related thereto. 38 C.F.R. § 3.312 (b). In determining whether a service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; or 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). The Veteran died in November 2013. His death certificate identifies hemoperitoneum sequela, mesenteric hematoma, and atherosclerotic cardiovascular disease with congestive heart failure sequela as the primary causes of death. Diabetes mellitus type II, hypertension, atrial fibrillation, obesity, renal failure, and obstructive sleep apnea are listed as contributory causes. At the time of his death, the Veteran was service connected for chronic left maxillary sinusitis, mood disorder with depression, chronic lumbosacral strain with degenerative disc disease, degenerative joint disease of the left ankle, arthritis of the right ankle, bilateral hearing loss, and tinnitus. The question before the Board is whether any of the service-connected disabilities caused or materially contributed to the Veteran's cause of death. The appellant has put forth several arguments in support of her claim for service connection for the cause of the Veteran's death. First, she alleges that the Veteran's service-connected mood disorder and depression may have contributed to his heart disease, atrial fibrillation, and hypertension. In support of her claim, the appellant has cited to medical literature that suggests that there may be a direct link between depression and adverse cardiac events, such as high blood pressure, arterial damage, irregular heart rhythms, and heart disease. Second, the appellant argues that the Veteran's service-connected lumbar spine disability led to weight gain and obesity, which in turn caused his hypertension and diabetes mellitus. Third, the appellant argues that the Veteran's service-connected maxillary sinusitis may have caused his obstructive sleep apnea. Turning to the relevant evidence of record, the Veteran underwent a VA examination in October 2001. The Veteran complained of back pain with weakness, stiffness, fatigue, and lack of endurance. The Veteran also complained of nasal congestion, difficulty in breathing through the nose, and episodes of sinusitis since October 1977. The Veteran reported that he required bedrest 4-5 times per year for his congestion, which at times, affected his breathing through the nose. The examiner also noted that the Veteran has suffered from hypertension since April of 1998. The Veteran reported he could sit for 20 to 30 minutes at a time, stand for 20 minutes at a time, and walk 2-3 city blocks at a time. After reviewing the Veteran's claims file, he opined that it is at least as likely as not that the Veteran's chronic lumbar strain led to weight gain which led to hypertension. No further rationale was provided. A November 2013 autopsy report lists the major pathologic findings as hemoperitoneum likely due to mesocolonic hemorrhage, in addition to evidence of congestive heart failure, including pulmonary edema, congestion of multiple organs, evidence of hypokinesis with right atrial clot, cardiomegaly, valvular dilatation, and right ventricular hypertrophy. See March 2014 Addendum to Autopsy Report. The VA obtained a medical opinion in June 2015. The examiner was asked to provide an opinion addressing whether any of the Veteran's service-connected disabilities contributed substantially or materially to the Veteran's death. After reviewing the claims file, the examiner concluded that there is no evidence to support or suggest that any of the Veteran's service-connected disabilities caused or contributed to his death in any way. The examiner noted that the Veteran had significant underlying medical co-morbidities contributing to his death such as heart disease, diabetes and chronic kidney disease with complications. The examiner explained that although acute and chronic stress have long been suspected as risk factors for myocardial infarction (MI) and sudden cardiac death, the evidence for a causal link has not been definitively determined. The examiner went on to state that it is well known that mental stress can temporarily exacerbate almost any physical condition; however mental stressors do not cause or permanently worsen physical conditions. PTSD and other psychiatric conditions are frequently comorbid with physical conditions. Major risk factors for coronary heart disease, including positive family history, hyperlipidemia, hypertension, smoking, diabetes, male gender, and advanced age, are much more likely causes of coronary heart disease than the possible contribution of psychosocial factors, including PTSD, stress, depression and anxiety. Pursuant to a March 2019 decision, the Board found the June 2015 opinion to be inadequate as the examiner did not consider all of the Veteran's service-connected disabilities, the appellant's contentions, nor the Veteran's other primary or contributory causes of death. Accordingly, VA obtained addendum VA opinions in November and December 2020. However, the Board found both opinions to be inadequate as both opinions were conclusory in that the examiners failed to provide sufficient medical rationale to support their negative findings. Moreover, the opinions only very broadly addressed the appellant's contentions without any specific consideration of the individual facts of the Veteran's case, to include his medical history. Accordingly, the Board remanded the matter again in May 2021 to obtain an adequate VA opinion. In June 2021, the RO obtained an addendum opinion. After reviewing the claims file, the examiner opined that based on the body of current medical knowledge and the evidence of record, that it is less likely than not that one or more of the Veteran's service-connected disabilities contributed substantially or materially to the cause of the Veteran's death, combined to cause death, or aided or lent assistance to the production of death. The examiner concluded that the inciting incident which began the decline of the Veteran was exacerbation of congestive heart failure (CHF), and is not related to the Veteran's service-connected disabilities. The examiner noted a number of risk factors, which did not include any of the Veteran's service-connected disabilities or the appellant's theories of entitlement, as determined by the Mayo Clinic for heart failure for which there is consensus among the medical community as the causation/pathophysiology of this disease. The examiner noted that the Veteran had a combination of convincing contributing risk factors which led to exacerbation of CHF. Addressing the two medical articles submitted by the appellant, the examiner noted that references made to depression and hypertension in the articles are discussing untreated depression. However, the examiner noted that the Veteran's depression was treated at the time of his death, and that he was on prescription medication. Therefore, the examiner concluded that it is unlikely that his mood disorder was a contributing factor to his death. The examiner stated that the medical community holds consensus around pathophysiology of heart disease, atrial fibrillation, and hypertension, which does not include mood disorders. The examiner also considered whether the Veteran's service-connected lumbar spine disability led to the development of obesity, which in turn caused hypertension and diabetes mellitus. The examiner stated that obesity, hypertension and diabetes mellitus type II are all multifactorial conditions that cannot be attributed to one factor. As well described by the Mayo Clinic, "although there are genetic, behavioral, metabolic and hormonal influences on body weight, obesity occurs when you take in more calories than you burn through exercise and normal daily activities. Your body stores these excess calories as fat." The examiner stated that inactivity, which could be a result of the Veteran's service-connected lumbar spine disability can be a contributing factor to obesity. However, as obesity is a multifactorial disease, a single factor causal relationship cannot be established. Additionally, the examiner noted that obesity itself could have worsened/aggravated the Veteran's service-connected lumbar disability or other sites of osteoarthritis. Overall, the examiner concluded that inactivity due to a lumbar spine disability alone cannot cause obesity. Finally, the examiner noted that a review of the medical literature suggests that "a decreased ratio of maxillary sinus volume to whole nasal airway volume is associated with adult OSA. However, OSA severity is not associated with either maxillary sinus volume or whole nasal airway volume". The risk created by maxillary sinusitis in relation to OSA, would be the inflammation leading to a decrease in maxillary sinus volume. However, this study found that there is predictive value in maxillary sinus volume and OSA but the severity is not affected. The causal relationship is well established with obesity. Overall, the examiner noted that minimal medical literature examining this relationship leads to insufficient evidence to link the Veteran's service-connected maxillary sinusitis as a cause or aggravating factor to his Veteran's obstructive sleep apnea. The Board acknowledges that the October 2001 VA opinion is favorable to the appellant's claim, however as the examiner provided no rationale, and no citations to medical literature to support his conclusion, the Board accords the opinion minimal probative weight. The Board finds the June 2021 examiner's opinion to be highly probative as to the question of whether any of the Veteran's service-connected disabilities caused or materially contributed to the Veteran's cause of death. In this regard, the opinion is based on a detailed review of the Veteran's medical history, lay statements and medical literature submitted by the appellant, and the application of current medical principles and the examiner's own expertise as a physician to the facts of the Veteran's case. The examiner provided a clear, well-reasoned medical rationale to support his conclusion that is consistent with the evidence of record and was responsive to each question posed in the Board's remand directives. See Nieves-Rodriguez, 22 Vet. App. at 295; see also Prejean, 13 Vet. App. at 448-49; Guerrieri, 4 Vet. App. at 470-71. In summary, the Board finds that the claims file does not contain competent and credible evidence that the Veteran's primary or contributory causes of death, were related to any of the Veteran's service-connected disabilities. Significantly, the most probative medical opinion evidence, as outlined above, weighs against the appellant's claim for service connection for the Veteran's cause of death. Thus, the Board finds that the most persuasive medical evidence of record does not support a finding that the any of the Veteran's service-connected disabilities immediately caused or contributed to his death. In making this determination, the Board acknowledges the contentions put forth by the appellant including, that the Veteran's service-connected mood disorder and depression may have contributed to his heart disease, atrial fibrillation, and hypertension, that his service-connected lumbar spine disability led to the development of obesity, which in turn caused hypertension and diabetes mellitus, and that the Veteran's service-connected maxillary sinusitis may have caused or aggravated the Veteran's obstructive sleep apnea. Although the appellant is competent to relay lay-observable symptoms, she is not competent to opine as to the cause of the Veteran's death, as such is a complex medical question beyond the knowledge of a layperson. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the Board finds that June 2021 VA opinion as probative evidence against the claim. Although the Board is deeply sympathetic to the appellant, the Board has no authority to grant claims on an equitable basis; instead, the Board is constrained to follow specific provisions of law. See 38 U.S.C. § 7104; Taylor v. West, 11 Vet. App. 436, 440-41 (1998); Harvey v. Brown, 6 Vet. App. 416, 425 (1994). The Board emphasizes that the denial of this claim does not in any way diminish the Veteran's honorable service to our country. Accordingly, the claim of entitlement to service connection for the cause of the Veteran's death is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Gates 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.