Citation Nr: 21077208 Decision Date: 12/29/21 Archive Date: 12/28/21 DOCKET NO. 17-51 633 DATE: December 29, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is denied. FINDING OF FACT The Veteran's death certificate lists the immediate cause of death as cardiopulmonary arrest, due to or as a consequence of severe pulmonary fibrosis (end stage lung); other significant conditions contributing to death but not resulting in the cause given was pulmonary ventilator (days); the evidence does not show that the listed causes of his death were related to his active military service. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C. §§ 1110, 1112, 1310, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1963 to August 1984, to include service in Vietnam. He died in May 2014, and the appellant is his surviving spouse. She has been substituted as the claimant for the purpose of processing her claim of service connection for the cause of the Veteran's death. This case is before the Board of Veterans' Appeals (Board) on appeal of a Department of Veterans Affairs (VA) rating decision in March 2015 (denying service connection for the cause of the Veteran's death). Entitlement to service connection for the cause of the Veteran's death is denied. When a veteran dies from a service-connected or compensable disability, VA will pay dependency and indemnity compensation (DIC) to such veteran's surviving spouse, children, and parents. 38 U.S.C. § 1310. In a claim where service connection was not established for the fatal disability prior to the death of the veteran, the initial inquiry is to determine whether the fatal disorder was incurred in or aggravated by service. The Board must determine whether the fatal disorder should have been service-connected. 38 C.F.R. § 3.312. Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). A death will be considered to result from a service-connected disability when the evidence establishes that a disability which is causally related to service, was either the principal or a contributory cause of the veteran's death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312 (a). For a service-connected disability to constitute a principal cause of death, it must be shown to be the primary cause of death when such disability, 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). For a service-connected disability to constitute a contributory cause of death, it must be shown to have contributed substantially and materially to the veteran's death; combined to cause death; aided or lent assistance to the production of death; or resulted in debilitating effects and general impairment of health to an extent that would render the veteran materially less capable of resisting the effects of other disease or injury causing death, as opposed to merely sharing in the production of death. 38 C.F.R. § 3.312(c). Although there are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, even in such cases, consideration must be given to whether there may be a reasonable basis to hold that a service-connected condition was of such severity as to have a material influence in accelerating death, where the service-connected condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c). After consideration of the evidence and the applicable law, the Board finds that the preponderance of the evidence is against the appellant's claim of service connection for the cause of the Veteran's death. The appellant asserts that service connection for the cause of the Veteran's death is warranted because his fatal conditions, particularly the severe pulmonary fibrosis listed on his death certificate, were related to his conceded exposure to Agent Orange during service. At the time of the Veteran's death in May 2014, his service-connected disabilities were posttraumatic stress disorder (PTSD) and left eye glaucoma. His death certificate lists the immediate cause of death as cardiopulmonary arrest, due to or as a consequence of severe pulmonary fibrosis (end stage lung); other significant conditions contributing to death but not resulting in the cause given was pulmonary ventilator (days). There is no evidence to suggest that his service-connected disability caused or contributed to cause his death, and the appellant has not so alleged. The Veteran's service treatment records (STRs) do not reflect any complaints, findings, or diagnosis of the conditions noted on his death certificate. Thus, based on STRs alone, the conditions listed on the death certificate are not shown to have been manifested during service. Thus, service connection for these disabilities under 38 U.S.C. § 1110 and 38 C.F.R. § 3.303(a) is not warranted. The appellant's primary theory of entitlement is that service connection for the Veteran's fatal severe pulmonary fibrosis is warranted on the basis that it is due to exposure to Agent Orange during his wartime service during the Vietnam Era. However, pulmonary fibrosis is not listed among the diseases enumerated under C.F.R. § 3.309(e) (as a disease associated with exposure to herbicide agents). Thus, the presumptive provisions in 38 U.S.C. § 1116 (for diseases associated with exposure to herbicide agents) do not apply to this diagnosis. See 38 C.F.R. §§ 3.307 (a)(6)(iii), 3.309(e). The analysis turns to whether the claim can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Regarding the lay evidence of record, the Board acknowledges the appellant's statements to the effect that the Veteran's cause of death is attributable to Agent Orange exposure in service. However, her statements are not competent evidence in the matter. Whether he was exposed to Agent Orange is a factual determination for the Board, and it has been determined that such exposure has not been established. Further, it is neither argued nor shown that she is qualified through specialized education, training, or experience to offer an opinion on the question of the cause of the Veteran's death, including whether his fatal conditions may be attributed to service. Laypersons are competent to provide opinions on some medical issues, but the etiology of the Veteran's fatal conditions falls outside the realm of common knowledge of a layperson. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Lay assertions that the Veteran's death may be related to his military service have no probative value. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A review of the record demonstrates that a 1977 chest x-ray revealed calcified nodular densities adjacent to the right hilum, probably representing old granulomatous disease. In addition, there was a possible increased density behind the left heart border. At the time of the Veteran's May 1984 retirement examination, he was noted to have bilateral hilar fullness, greater on the left than the right. Differential diagnoses included lymphoma, sarcoid, or granulomatous disease. At the time of an August 1984 consult, the Veteran was found to have old calcifications hila. The Veteran was also being tested for sarcoidosis. A March 2015 VA opinion was obtained in conjunction with the appellant's claim. The examiner indicated that it was less likely as not that the Veteran's abnormal chest x-ray in 1977, which probably represented old granulomatous disease, led to the development and diagnosis of pulmonary fibrosis. The examiner reported that the finding of "old granulomatous disease" was common on chest X-rays and rarely of any clinical significance. It was often postulated that the finding was associated with certain fungal or microbacterial infections that have resolved, with the exception of leaving behind the granulomas found on X-ray. This did not go on to develop into more serious lung disease. In an April 2017 VA opinion, the examiner indicated that the Veteran's service treatment records did not reveal a diagnosis which more likely as not contributed to the Veteran's death. The examiner indicated that the Veteran died from interstitial fibrosis. There were no serious chronic conditions affecting the lungs that were found in the service records. The examiner noted that the Veteran did have the previously discussed granulomas, but this was a benign condition that in no way would have contributed to his death. In the May 2020 Board remand, it was noted that while the examiners provided the requested opinions, they did not address the notations of sarcoidosis in the service treatment records or at the time of the August 1984 consult. There had also been no opinion rendered as to whether the Veteran's pulmonary fibrosis was related to his period of service, to include as a result of exposure herbicides in service. Accordingly, pursuant to the May 2020 Board remand, a VA opinion was obtained in June 2020. The June 2020 VA examiner opined that based on review of body of evidence and relevant medical literature and in accordance with accepted medical principles, it is less likely than not that Veteran's cause of death is etiologically related to service, to include herbicide exposure. As rationale, the examiner stated, 1) [The] Veteran's STRs are silent on any herbicide or other exposures that would lead to pulmonary fibrosis or any pulmonary disease, other than his long history of cigarette smoke exposure. His [May 21, 1984] Retirement exam notes Veteran smoked 1.5 PPD for 17 years. A 2012 PCP visit noted Veteran smoked cigars. His CT scans in 2014 noted that Veteran had developed COPD. The leading cause of COPD is smoking. 2) This Veteran presented at age 67 with a 1 year history of exertional dyspnea. Patients with idiopathic pulmonary fibrosis typically present at age 60 years or older, and the majority of patients have a history of cigarette smoking. (Clinical manifestations and diagnosis of idiopathic pulmonary fibrosis. UpToDate). 3). Veteran had calcified hilar lymph node granulomas noted on a chest x-ray from 1977 and again on a 1984 chest x-ray. He was seen 8/17/84 for an Internal Medicine consult to address the chest x-ray findings. History notes Veteran was asymptomatic, physical exam was normal and assessment was old calcification of hila. Plan was to place PPD and get CEA level for sarcoidosis. Results of these tests were not found in the Veterans records. 4). The granulomatous hilar node changes noted in 1977 were not noted to change on his subsequent 1984 chest x-ray. The right hilar granulomatous lymph nodes were also noted on his chest CT on [May 8, 2014]. The changes on his in service chest x-rays were not disease of the lung parenchyma; they were calcification of hilar lymph nodes. Granulomas develop due to past fungal infections from such things as a histoplasmosis infection or from sarcoidosis. 5) Veteran had no complaints of shortness of breath noted in his STRs or in available post-service records from 2001 until he first complained at a [May 16, 2013] PCP visit of a 1 year history of shortness of breath with exertion which had worsened over the last couple weeks. A subsequent [August 15, 2013] Chest CT noted bilateral interstitial lung disease with bronchiectasis involving the lung bases, appearance raises suspicion for chronic interstitial lung disease such as pulmonary interstitial fibrosis. The scan also noted the previously known mildly enlarged right hilar lymph node that had been noted on his in-service chest x-rays. The chest CT findings note Veteran had now developed pulmonary fibrosis. This is a disease of the lung tissue and not granulomatous hilar lymph nodes. 6) Veteran's hilar lymph node granulomas noted in service are in no way connected to his subsequent development of pulmonary fibrosis, which is a disease of the lung tissue itself. Old granulomatous hilar nodes do not cause or contribute to development of pulmonary fibrosis. They are totally separate and unrelated medical conditions. 7) Pulmonary fibrosis is an idiopathic disease of the lung tissue; the cause is not known. The reviewing physician's opinion reflects familiarity with the Veteran's record, and includes rationale that cites to supporting factual data. It is probative evidence in the matter, and the Board finds it persuasive. There is no equally (or more) probative evidence in the record that the listed underlying cause of death (pulmonary fibrosis) was etiologically related to the Veteran's service, to include his conceded herbicide exposure. It is also not alleged, nor does the record suggest, that service-connected PTSD and left eye glaucoma contributed materially to cause, or hastened, the Veteran's death. The Board acknowledges the appellant's sincere belief that the Veteran's cause of death was etiologically related to his military service and herbicide exposure therein. However, the etiology of his primary death-causing disease (pulmonary fibrosis) is a medical question. She is a layperson and her own opinion is not competent evidence in the matter. (CONTINUED ON NEXT PAGE) Accordingly, the Board finds that the preponderance of the evidence is against the claim of service connection for the cause of the Veteran's death; that there is no reasonable doubt that may be resolved in the appellant's favor (see 38 U.S.C. § 5107(b)); and that the appeal in the matter must be denied. JOHN G. SETTER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Griffith 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.