Citation Nr: 21070259 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 18-24 395 DATE: November 23, 2021 REMANDED Entitlement to service connection for the cause of the Veteran's death is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1943 to December 1945. The Veteran died in January 2017. The appellant is the Veteran's surviving spouse. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a July 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2020, the appellant testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In June 2020 and in August 2021, the Board remanded the claim for further development. The Board has advanced this case on the docket due to advance age. 38U.S.C. §7107(b); 38C.F.R. §20.902(c) Entitlement to service connection for the cause of the Veteran's death is remanded. The appellant, and her representative, contends that the Veteran's cause of death is a result of hypertension that was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). See Hearing Transcript at 8 (April 2020). In elaborating, the representative argues that the Veteran's PTSD preceded the onset of his hypertension and, therefore, caused the disability. Id. at 10. The appellant, additionally, contends that the Veteran "died from a fall, causing a broken hip and complications and the inability to rehab to return home." In this regard, the appellant argues that the Veteran's PTSD caused him to snap and subsequently fall. See Correspondence (January 2021). For reasons explained below, the Board finds that remand is necessary. VA medical opinion, dated in September 2021, reflects that the Veteran's hypertension was less likely than not proximately due to or the result of his service-connected PTSD. In support of this conclusion, the opinion notes, among other things, that the onset of hypertension preceded the PTSD diagnosis, and that the Veteran started to report mental health concerns in 2011. The opinion, additionally, cites to treatment records showing that the Veteran's hypertension preceded the PTSD diagnosis and that it was "fairly controlled." The Board finds the opinion inadequate as it is unclear whether the clinician, in forming the opinion, considered causation and aggravation as independent concepts. See Atencio v. O'Rourke, 30 Vet. App. 74, 90-91 (2018) (holding that a medical opinion was inadequate when it was unclear whether the examiner had clearly provided a rationale that dealt with causation and aggravation as independent concepts); see also El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (emphasizing that a specific inquiry directly addressing aggravation, separate from whether a service-connected disability caused the disability, is necessary when an examiner addresses secondary service connection). Initially, the Board observes that the opinion provides the similar medical findings and identical rationale to support the conclusions. Indeed, in providing an opinion, the clinician appears to have mixed the theories of causation and aggravation, and without a more detailed explanation, the Board is unable to interpret the opinion to determine whether the clinician clearly provided a rationale that dealt with causation and aggravation as independent concepts. The Board observes that aggravation of a nonservice-connected disability by a service-connected disability is independent of direct causation and must ensure that medical opinions are adequate on that question. See Allen v. Brown, 7 Vet. App. 439 (1995). Although the same medical rationale may apply to both theories, the Board, on its own, is unable to make this unsubstantiated medical finding or conclusion. The Board, thus, can only consider independent medical evidence to support this finding or conclusion. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Next, in finding that the Veteran's PTSD was not of such severity as to have a material influence in accelerating death, the opinion found that the record "lacks a psychiatric admission for any mental health acute crisis." The opinion, however, is absent a reasoned medical explanation connecting the medical finding to the conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that "a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two"). In this regard, although the opinion notes that the record is absent for any psychiatric admission, the essential rationale connecting the medical finding to the conclusion is not discernable. Indeed, the opinion does not reveal a discussion or explanation on the relevance of psychiatric admissions, and the Board is not competent to substitute its own medical rationale for that of the opinion. Colvin, 1 Vet. App. at 175. Accordingly, the Board finds that there has not been substantial compliance with its prior remand, and therefore further remand is required. Stegall v. West, 11 Vet. App. 268 (1998). Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matter is REMANDED for the following actions: 1. Obtain an addendum 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 caused or contributed to the Veteran's death and hypertension 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 clinician must opine on: Secondary Service Connection (a) Whether the Veteran's hypertension was at least as likely as not (1) proximately due to service-connected PTSD, or (2) aggravated beyond its natural progression by service-connected PTSD. Provide a rationale that deals with causation and aggravation as independent concepts. Explain. If so, was the hypertension a principal or contributory cause of death. Explain. Principal Cause of Death (b) Whether the Veteran's service-connected 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 Contributory Cause of Death (c) Whether the Veteran's service-connected PTSD at least as likely as not: a. Contributed substantially or materially to his death; b. Combined to cause his death; or c. 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 at least as likely as not involved processes affecting vital organs. If so, whether the Veteran's service-connected 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 had worsened prior to his death causing him to fall, break a hip, have complication, and the inability to rehab and return home. 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). 2. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion 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. (Continued on next page) 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Griffey, 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.