Citation Nr: 21075115 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 16-12 742 DATE: December 17, 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 October 1966 to October 1968, to include service in the Republic of Vietnam. He died in July 2013, and the appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision. The appellant testified at a hearing before the undersigned Veterans Law Judge in April 2017. A transcript is of record. In September 2018 and February 2020, the Board remanded the case for further development. The case has since been returned to the Board for appellate review. Upon review, the Board finds that a remand is needed prior to adjudication of the appeal. In a May 2020 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's cause of death was causally or etiologically related to his military service, including exposure to herbicide agents therein. In so finding, the examiner stated that the Veteran had multiple documented medical conditions that could have led to his terminal fall, including blood clots. In addition, the examiner opined that, given the Veteran's prior history of venous thromboembolic disease (blood clot), there was a strong possibility that any chest pain he experienced represented a recurrent blood clot. The examiner also stated that blood clots are known to cause sudden death. Nevertheless, in rendering his negative opinion regarding the cause of the Veteran's death, the examiner did not provide specific rationale regarding a blood clot disorder. In particular, the examiner did not address the relevance, if any, of the Veteran's private physician's February 2016 statement that peripheral artery disease could be caused by Agent Orange exposure. In addition, the examiner stated that "no medical records for the final year and a half of the Veteran's life were submitted." However, on review, the claims file contains copies of some private treatment records dated during that time period. See, e.g., March 2012 private medical evaluation (noting an assessment of right lower extremity deep venous thrombosis). As such, it appears the examiner's opinion was based, in part, on an inaccurate or incomplete factual premise. Based on the foregoing, a remand is necessary to obtain an additional medical opinion. The Board notes that the Veteran's post-service medical records document complaints of depression. See, e.g., May 1997 and April 2014 private medical records. In a July 2020 correspondence, the Veteran's daughter, a licensed professional clinical counselor, reported that the Veteran returned from his service in the Republic of Vietnam with posttraumatic stress disorder (PTSD). She also stated that the Veteran likely suffered from major depressive disorder. In addition, the Veteran's daughter stated that he did not receive treatment for his mental health, which ultimately contributed to his death because his mindset was against seeking proper care for his overall health needs. The Veteran's daughter further stated that the Veteran's mental health status was greatly impacted by fighting a war. The Veteran's daughter did not provide any specific details regarding an in-service stressor or explain how the Veteran met the diagnostic criteria for PTSD. Moreover, the Veteran's daughter did not provide supporting rationale for her opinion that the Veteran's mental health status was greatly impacted by fighting a war. Therefore, the Board finds that a VA medical opinion is needed. See 38 U.S.C. § 5103A(a); DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008); Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008). On remand, the appellant should also be afforded an opportunity to provide details regarding any in-service stressors. Lastly, the Board notes that the Veteran's complete service personnel records are not associated with the claims file. As these records may contain relevant evidence, on remand the agency of original jurisdiction (AOJ) should obtain a complete copy of the Veteran's military personnel records. The matters are REMANDED for the following action: 1. The AOJ should request that the appellant provide the names and addresses of any and all health care providers who treated the Veteran prior to his death that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. The AOJ should obtain and associate the Veteran's complete service personnel records with the claims file. 3. The AOJ should request that the appellant provide additional information and details regarding any in-service stressors. The AOJ should then take all appropriate steps to verify any claimed stressor(s). 4. After completing the foregoing development, the AOJ should refer the claims file to a suitably qualified VA examiner for a medical opinion to address the cause of the Veteran's death. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and the appellant's assertions. The Veteran's death certificate lists the immediate cause of death as blunt force trauma to the head. The other significant conditions identified as contributing to his death were peripheral neuropathy of the legs and feet. The appellant has contended that the Veteran had ischemic heart disease that caused or contributed to his death. The appellant has also contended that the Veteran's peripheral neuropathy, avascular necrosis, peripheral artery disease, and peripheral vascular disease were related to his exposure to Agent Orange. She further stated that the Veteran's gall bladder cancer returned prior to his death. The Veteran's daughter has further contended that the Veteran had a mental health disorder that contributed to his death because it resulted in a mindset that was against seeking proper medical care. See July 2021 correspondence. It should be noted that the Veteran, the appellant, and the Veteran's daughter are competent to attest to factual matters of which they have first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran or the appellant, the examiner should state this with a fully reasoned explanation. It should also be noted that the Veteran is presumed to have been exposed to herbicide agents, including Agent Orange during service. (a) The examiner should indicate whether the Veteran had any form of ischemic heart disease prior to his death, to include, but not limited to, acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery, and stable, unstable and Prinzmetal's angina. In so doing, the examiner should address the relevance, if any, of an October 2010 private arterial examination that documented atherosclerotic plaque in the common iliac artery. (b) If the Veteran had ischemic heart disease, the examiner should state whether it is at least as likely as not that the disorder caused his death; contributed substantially or materially to his death; combined with another disorder to cause his death; or aided or lent assistance to his death. (c) If the Veteran did not have ischemic heart disease or the examiner determines that the disorder was not a principal or contributory cause of his death, the examiner should state whether it is at least as likely as not that the Veteran's cause of death was causally or etiologically related to his military service, including exposure to herbicide agents therein (notwithstanding the fact that it may not be a presumed association). (d) The examiner should address whether it is at least as likely as not that the Veteran had a blood clot disorder that manifested in or was otherwise causally or etiologically related to his military service, including exposure to herbicide agents therein (notwithstanding the fact that it may not be a presumed association). If the Veteran had a blood clot disorder in service or that is otherwise related thereto, the examiner should state whether it is at least as likely as not that the disorder caused his death; contributed substantially or materially to his death; combined with another disorder to cause his death; or aided or lent assistance to his death (e) The examiner should identify any acquired psychiatric disorders that were present prior to the Veteran's death. In so doing, the examiner should consider the July 2020 correspondence from the Veteran's daughter regarding his mental health condition. For each psychiatric disorder identified other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or was otherwise causally or etiologically related to the Veteran's military service. With regard to PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events and any stressors related to fear of hostile military or terrorist activity may be considered for the purpose of determining whether exposure to an in-service stressor resulted in PTSD. The examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD were satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the Veteran's symptomatology and any verified in-service stressor. If the Veteran had an acquired psychiatric disorder in service or that is otherwise related thereto, the examiner should state whether it is at least as likely as not that the Veteran's disorder caused his death; contributed substantially or materially to his death; combined with another disorder to cause his death; or aided or lent assistance to his death. In rendering his or her opinions, the examiner should consider the following: 1) a February 16, 1986, ECG report that noted borderline accelerated AV conduction and nondiagnostic inferior T changes; 2) a November 2009 ECG report that noted a T wave abnormality and to consider anterior ischemia; 3) a November 2009 transthoracic echocardiogram; 4) a December 2012 emergency room record that noted a physical examination showed a normal cardiovascular system; 5) the appellant's April 2017 testimony that the Veteran complained of chest pain prior to his death; 6) the April 2014 and February 2016 private medical opinions from Dr. T.S.; 7) the May 2020 VA medical opinion; and 8) the medical article abstract submitted by the appellant in July 2020 regarding coronary and carotid atherosclerosis. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. The AOJ should ensure that there has been compliance with the foregoing directives and conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Wulff, 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.