Citation Nr: 21077474 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 17-30 761 DATE: December 29, 2021 REMANDED Service connection for the cause of the Veteran's death is remanded. Entitlement to burial benefits is remanded. Entitlement to an increase in death pension is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1965 to October 1968. He died in June 2016. The appellant is his surviving spouse. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2016 decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In September 2019, the appellant testified at a video-conference hearing before the undersigned Veterans Law Judge (VLJ). The Veteran's claims file contains a copy of the transcript. In August 2020, the issues were before the Board and remanded for further development, specifically to obtain a medical opinion as to whether the Veteran's coronary artery disease (CAD) was a principal cause of death or contributed substantially or materially to his death. In March 2021, the Veteran's claims file was reviewed by a VA clinician. The clinician opined that it was less likely as not (less than 50 percent probability) that the Veteran's coronary artery disease was a principal cause of death or contributed substantially or materially to his death. The rationale provided was that the Veteran's death certificate listed chronic obstructive pulmonary disease (COPD) as the only cause of death, with no mention of any other significant conditions contributing to his death. The clinician noted that the Veteran's medical record contain a diagnosis of CAD and that his medications were primarily related to his COPD, with two preventative medications related to CAD. The clinician concluded that there is no evidence that the Veteran's CAD was a principal cause of death or contributed substantially or materially to his death. A supplemental statement of the case (SSOC) denying the claims was issued in March 2021. In April 2021, the appellant provided a nexus letter from the Veteran's private provider. In a July 2021 letter, the appellant was notified that the VLJ who conducted the September 2019 Board hearing was no longer at the Board. In August 2021, the appellant responded that she did not want another hearing. 1. Service connection for the cause of the Veteran's death is remanded. Unfortunately, after review of the record, the Board finds that another remand for further development is warranted. The Board finds that the RO did not substantially comply with its August 2020 remand directives because the March 2021 VA opinion did not adequately address whether the Veteran's CAD contributed to his death, as the opinion did not address whether the Veteran's heart condition combined to cause the Veteran's death; or aided or lent assistance to the production of the Veteran's death. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also finds that the April 2021 private nexus letter inadequate for rating purposes because the clinician did not address or provide reasons and bases for the opinion. Moreover, this private provider did not discuss whether the Veteran's CAD contributed to substantially or materially to the Veteran's death; combined to cause the Veteran's death; or aided or lent assistance to the production of the Veteran's death. As there is no adequate opinion of record, the Board finds an additional remand is necessary in order to obtain an adequate opinion to allow the Board to make a fully informed decision regarding the appellant's claim. The RO is advised that this case has been remanded by the Board twice (including the remand herein), with this remand caused by Stegall violations. Stegall, 11 Vet. App. at 271. Expeditious treatment and substantial compliance with remand directives are required. 2. Entitlement to burial benefits is remanded. 3. Entitlement to an increase in death pension is remanded. Because the burial benefits and pension claims are inextricably intertwined with the remaining service connection claim, those issues are also being remanded. See 38 C.F.R. § 4.16(a); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered); Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996) (claims are inextricably intertwined when they have common parameters, such as when the outcome of one may affect the outcome of the other. And to avoid piecemeal adjudication of these types of claims, they should be considered together). The matters are REMANDED for the following actions: 1. Forward a copy of the Veteran's electronic claims file and this REMAND to the appropriate VA clinician for review. The clinician is asked to provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent probability or more) that the Veteran's coronary artery disease: (i) served as an immediate or underlying cause of the Veteran's death; (ii) is etiologically related to the Veteran's death; (iii) contributed substantially or materially to cause his death; (iv) combined to cause his death; OR (v) aided or lent assistance to the production of his death. In so doing, the examiner is asked to directly address the April 2021 private nexus statement. The clinician must provide a comprehensive report including rationales for all opinions and conclusions reached. It would be helpful if the clinician would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50 percent), "at least as likely as not" (meaning likelihood of at least 50 percent), or "less likely than not" or "unlikely" (meaning that there is a less than a 50 percent likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it to find against it. The clinician should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. If the clinician cannot provide an opinion because it cannot be determined from current medical knowledge, or the actual cause cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). If the clinician relies upon any medical treatises or other medical scholarship in rendition of the opinion, it is requested that those reference materials be so noted in the response. 2. Upon completion of the above-directed development, readjudicate the issues of service connection burial benefits and increase in death pension. B. J. KOMINS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Camille NeSmith, 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.