Citation Nr: 21006808 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 14-13 832 DATE: February 5, 2021 ORDER Entitlement to service connection for hypertension to include as secondary to service-connected PTSD is denied. Entitlement to service connection for chronic renal disease is denied. Entitlement to service connection for ischemic heart disease with hypertensive cardiovascular disease is denied. Entitlement to service connection for cause of death is denied. FINDINGS OF FACT 1. The Veteran’s hypertension was not secondary to service-connected PTSD or any other service-connected disability, and was not otherwise related to an in-service injury or disease. 2. The Veteran’s chronic renal disease was not secondary to service-connected PTSD or any other service-connected disability, and was not otherwise related to an in-service injury or disease. 3. The Veteran’s ischemic heart disease with hypertensive cardiovascular disease was not secondary to service-connected PTSD or any other service-connected disability, and was not otherwise related to an in-service injury or disease. 4. The immediate cause of the Veteran’s death was sepsis, with additional causes including multiple organ failure with an underlying cause of chronic renal failure. The proximate and contributory causes of death were not service-connected and were not subject to service connection. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension to include as secondary to service-connected PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, and 3.310. 2. The criteria for entitlement to service connection for chronic renal disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, and 3.310. 3. The criteria for entitlement to service connection for ischemic heart disease with hypertensive cardiovascular disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, and 3.310. 4. The criteria for entitlement to service connection for cause of death have not been met. See 38 U.S.C. §§ 1110, 1131, and 1310; 38 C.F.R. §§ 3.303 and 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1946 to December 1948. He died in August 2015. The Appellant is the surviving spouse of the Veteran. The procedural history of these claims was set forth in detail in the September 2020 Board Remand. In the September 2020 Board Remand, the above-referenced claims were remanded to the RO for further evidentiary development and readjudication. The RO has substantially complied with the Board’s remand instructions with respect to the above-listed claims, so the Board may proceed to their merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). The Appellant’s representative argues that VA “failed its duty to assist in that VA did not provide etiologies from which reliable evaluation could have been made prior to the [Veteran]’s death and prior to final adjudication.” See January 2021 Post-Remand Brief. The various VA examinations and the evidence relating to the etiology of the claimed conditions is discussed in detail below. For purposes of the duty to assist, VA has obtained adequate expert opinions regarding the etiology of each of the claimed conditions. The most recent remand noted the inadequacy of the prior opinion regarding whether the Veteran’s service-connected disabilities aggravated his hypertension. The November 2020 VA examiner’s opinion remedies that deficiency and, in addition, provided additional opinion and reasoning supporting a finding that hypertension was not related to service or the Veteran’s service-connected disabilities. In short, there are competent, well-reasoned, persuasive opinions that establish that the Veteran’s hypertension was not related to his active service or to his service-connected disabilities and that his chronic renal disease and ischemic heart disease were caused by his hypertension and are not related to service or to any service-connected disabilities. The Appellant has not identified a specific alleged deficiency in the opinions beyond the general allegation of an inadequacy in the etiological opinions. The Board finds the opinions not only adequate, but convincing, in setting for the etiology of the Veteran’s claimed conditions. While a definitive cause of the Veteran’s hypertension was not established, the examiner did conclusively rule out in-service events or any of his service-connected disabilities. Therefore, the VA has fulfilled its duty to obtain adequate opinions. The Appellant has not raised any other specific issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Therefore, the Board does not need to discuss VA’s compliance with the duties to notify and assist. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In the context of claims for secondary service connection, the evidence must demonstrate an etiological relationship between the service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. Buckley v. West, 12 Vet. App. 76, 84 (1998). Secondary service connection may also be warranted for a nonservice-connected disability when that disability is aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Also, with regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused or aggravated by the service-connected disability. 1. Entitlement to service connection for hypertension to include as secondary to service-connected PTSD The Appellant contends that the Veteran developed hypertension as a result of his in-service experiences, including stress-inducing situations. Alternatively, she contends that his hypertension was the result of his service-connected disabilities, particularly including PTSD. With respect to direct service connection, the question for the Board is whether the Veteran had a current disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a diagnosis of hypertension, and evidence shows that he did suffer stressful situations during his service (e.g., the stressors that supported awarding service connection for PTSD), the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of hypertension began during service or was otherwise related to an in-service injury, event, or disease. Treatment records show the Veteran most likely was not diagnosed with hypertension until sometimes between 1962 and 1972, which is well over one decade after his separation from service. There were no allegations from him that his condition manifested within one year of service, so presumptive service connection is not applicable. Further, the August 2013 VA examiner opined that the Veteran’s hypertension was not at least as likely as not related to an in-service injury, event, or disease, including stressful events during his service. The rationale was that, because there were no blood pressure readings available from service and treating physician statements indicated likely onset more than 10 years after service, it would be unlikely in-service stressful events would have caused a delayed onset of hypertension. The examiner acknowledged an opinion by a treating physician who noted “stress brought about by war”, but again noted a delayed onset of hypertension would be unlikely to be related to stress that far in the past. The examiner also noted that, while the Veteran’s in-service experiences caused PTSD, the PTSD had onset after the diagnosis of hypertension and many of his acute PTSD symptoms had onset “after he stopped working in 1999”, decades after diagnosis with hypertension. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There are no favorable opinions. The record does contain a December 2012 Clinical Evaluation which discusses possible risk factors: “chronic smoker- he started smoking when it was introduced to him by his fellow soldiers and superiors during World War II. He stopped smoking [approximately] 1970s. No family history of hypertension (?)Stress, excessive and sustained adrenergic activation during war time.” However, this clinical evaluation was explicitly considered by the August 2013 VA examiner who noted the delayed onset of hypertension and specifically discussed the possibility that in-service stress resulted in later diagnosed hypertension (or cardiac condition): “Sustained adrenic activation would mean persistent production of adrenergic hormones such as adrenaline or noradrenaline would result to marked elevation in the blood pressure likely during service or immediately after military service and not many years after.” The December 2012 treatment note merely indicates a possible association of various factors, while the August 2013 VA examiner who addressed the December 2012 note provided reasoned basis for rejecting the theory that the Veteran’s hypertension was related to in-service events. The VA examiner’s opinion is entitled to greater probative weight regarding the most likely etiology of the Veteran’s hypertension. The letter from the Veteran’s treating physician, Dr. M., discusses that excessive sympathetic nervous system activation due to stress may have contributed to his hypertension. The doctor also stated the Veteran’s PTSD may have led to chronic elevated blood pressure. These opinions are speculative, though, considering use of the term “may”, and is not persuasive evidence of an actual causal link. The VA examiner’s opinion discussed above is far more probative. The letter from Dr. M. also mentions cigarette smoking as a potential cause of cardiovascular disease, presumably including hypertension, noting that the Veteran began smoking during service. However, service connection based on cigarette smoking during service is precluded by law. The greater weight of the evidence is against the Veteran’s claim of entitlement to service connection for hypertension on a direct basis. With respect to secondary service connection, the question for the Board is whether the Veteran’s hypertension was proximately due to or the result of, or was aggravated beyond its natural progress by, any service-connected disability to include PTSD. The Board concludes that the preponderance of the evidence is against such a finding. The August 2015 VA examiner opined that the Veteran’s hypertension was not caused by PTSD. The rationale was more focused on the theory of direct service connection and the stressors in service, so the Board will assign the opinion no probative weight with respect to secondary service connection. The November 2020 VA examiner opined that the Veteran’s PTSD did not cause or aggravate the Veteran’s hypertension. The examiner noted that PTSD may have periods of heightened symptoms (anxiety, flashbacks, stress) during which blood pressure can transiently rise from baseline. However, when PTSD symptoms return to baseline, the blood pressure will also return to baseline. The examiner explained that the PTSD effect is, therefore, temporary and not a worsening of hypertension beyond its natural progression. The examiner also relied on and discussed medical literature that notes a correlation, but not a causal relationship, between PTSD and hypertension. The examiner finally noted that the recognized causes and aggravators of hypertension include smoking, obesity, advancing age, and renal disease. This opinion is thorough, well-reasoned, and convincingly links the facts of this case with medical principles to reach a conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board assigns it significant probative weight. There is no competent, probative opinion linking the Veteran’s hypertension to any of his service-connected disabilities. Because the only competent opinion to the requisite legal standard regarding the etiology of the Veteran’s hypertension is against his claim, the greater weight of the evidence is against finding the hypertension was caused or aggravated by any service-connected disability. Entitlement to service connection for hypertension on a secondary basis is not warranted. The Veteran believed and the Appellant believes that the Veteran’s hypertension was related to an in-service injury, event, or disease or was proximately due to or the result of or aggravated beyond its natural progression by a service-connected disability. The Veteran and the Appellant in this case are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, the pathology and physiological causes of hypertension, the interaction of psychological stress and the cardiovascular system, and the interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and the Appellant in this case because the record does not show that either of them had the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners’ opinions. The Veteran’s claim of entitlement to service connection for hypertension, to include as secondary to PTSD, is denied. 2. Entitlement to service connection for chronic renal disease The Appellant contends that the Veteran developed chronic renal disease as a result of his in-service experiences, including drinking unsanitary water from rivers, eating unsanitary foods, and being malnourished during service. Alternatively, she contends that his chronic renal disease was the result of his service-connected disabilities, particularly hypertension, which the appellant contended should be service-connected. With respect to direct service connection, the question for the Board is whether the Veteran had a current disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a diagnosis of chronic renal disease, and giving him the benefit of every doubt as to the allegations of in-service drinking and eating of possibly unsanitary items and general nourishment, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of chronic renal disease began during service or was otherwise related to an in-service injury, event, or disease. Treatment records show the Veteran was not diagnosed with chronic renal disease until roughly fifty (50) years after service. Therefore, presumptive service connection is inapplicable. While the Veteran was competent to report subjective symptoms experienced intermittently since service, he was not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of chronic renal disease. The issue is medically complex, as it requires the ability to interpret diagnostic medical testing as well as knowledge of the renal system and the presentation and clinical features of renal disease. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the November 2015 VA examiner opined that the Veteran’s chronic renal disease was not at least as likely as not related to an in-service injury, event, or disease, including drinking unsanitary water, eating unsanitary food, or being malnourished. The rationale was that drinking or eating unsanitary water or food would likely first result in gastrointestinal issues like gastroenteritis due to parasites like amoebas, etc., and not renal disease. Similarly, malnutrition in service would not result in chronic renal disease diagnosed more than fifty (50) years after service. The Veteran was discharged in 1948 and the renal disease was diagnosed in 2011. The examiner went on to note that an August 2011 medical certification from the Veteran’s nephrologist made it “very clear that the etiology of the kidney disease [was] primarily hypertensive nephrosclerosis…with contributory factors from nephrolithiasis and benign prostatic hyperplasia/BPH.” The examiner noted that the hypertension had onset after service, so could not be a contributing, in-service event or illness. The examiner also noted an August 2010 private treatment record showing a urinary tract infection, nephrolithiasis, BPH, and diabetic nephropathy which renal conditions contributed to the renal injury of the Veteran. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There are no favorable opinions with respect to direct service connection. The greater weight of the evidence is against the Veteran’s claim of entitlement to service connection for chronic renal disease on a direct basis. With respect to secondary service connection, the question for the Board is whether the Veteran’s chronic renal disease was proximately due to or the result of, or was aggravated beyond its natural progress by service-connected disability to include PTSD. The Board concludes that the preponderance of the evidence is against such a finding. The November 2015 VA examiner opined that the Veteran’s chronic renal disease was not caused by his service-connected disabilities. The rationale was that the kidney disease had a “very clear” etiology which was “primarily hypertensive nephrosclerosis” with contributing factors of nephrolithiasis and benign prostatic hyperplasia/BPH. The examiner also noted that PTSD is not a known etiology of chronic kidney disease nor can it cause or aggravate a chronic kidney condition. The examiner noted that any causal relationship would be the reverse, where a kidney condition could cause a psychiatric condition such as PTSD or depression. This opinion is thorough, well-reasoned, and convincingly links the facts of this case with medical principles to reach a conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board assigns it significant probative weight. There is no competent, probative opinion linking the Veteran’s chronic renal disease to any of his service-connected disabilities. Notably, the Veteran’s hypertension is not service-connected. Because the only competent opinion to the requisite legal standard regarding the etiology of the Veteran’s chronic renal disease is against his claim, the greater weight of the evidence is against finding the chronic renal disease was caused or aggravated by any service-connected disability. The letter from Dr. M. indicated that chronic intake of pain killers or NSAIDs may have contributed to the chronicity of his hypertension and development of kidney injury, and that he frequently took NSAIDs to relieve the persistent pain of the knee condition. This opinion is not persuasive, first, because it is speculative due to use of the term “may,” and, second, service connection was not awarded for the knee condition. The VA examiner’s opinion above is far more persuasive as to the cause of the Veteran’s renal disease. Entitlement to service connection for chronic renal disease on a secondary basis is not warranted. The Veteran believed and Appellant believes that the Veteran’s chronic renal disease was related to an in-service injury, event, or disease or was proximately due to or the result of or aggravated beyond its natural progression by a service-connected disability. The Veteran and the Appellant in this case are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, the pathology and physiological causes of chronic renal disease, and the interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and the Appellant in this case because the record does not show that either of them had the medical training or credentials to make such a determination. Consequently, the Board gives more probative weight to the VA examiners’ opinions. The Veteran’s claim of entitlement to service connection for chronic renal disease, to include as secondary to service-connected disabilities, is denied. 3. Entitlement to service connection for ischemic heart disease with hypertensive cardiovascular disease The Appellant contends that the Veteran developed ischemic heart disease with hypertensive cardiovascular disease as a result of his in-service experiences, including stress and sustained adrenergic activation during war time. Alternatively, she contends that his ischemic heart disease with hypertensive cardiovascular disease was the result of his service-connected disabilities, particularly hypertension which the appellant contended should be service-connected. With respect to direct service connection, the question for the Board is whether the Veteran had a current disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a diagnosis of ischemic heart disease with hypertensive cardiovascular disease, and the evidence establishes in-service stressors, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of ischemic heart disease with hypertensive cardiovascular disease began during service or was otherwise related to an in-service injury, event, or disease. Treatment records show the Veteran was not diagnosed with ischemic heart disease with hypertensive cardiovascular disease until more than fifty (50) years after service. Therefore, presumptive service connection is inapplicable. While the Veteran was competent to report subjective symptoms experienced intermittently since service, he was not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of ischemic heart disease with hypertensive cardiovascular disease, as the issue is medically complex. Further, the November 2015 VA examiner opined that the Veteran’s ischemic heart disease with hypertensive cardiovascular disease was not at least as likely as not related to an in-service injury, event, or disease, including the stress of wartime. The rationale was that if the stress of wartime had resulted in excess of sustained adrenergic activation that caused hypertension and eventually cardiac disease, the hypertension would have developed earlier than 1962 to 1972 and cardiac disease would have developed prior to 2007. In fact, the current cardiac conditions, including ischemic heart disease, hypertensive cardiovascular disease, and cardiac arrythmias, are due to hypertension which is less likely than not related to service. The Veteran was discharged in 1948 and the cardiac disease was diagnosed in 2007. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There are no favorable opinions with respect to direct service connection. As noted above, the letter from Dr. M. also mentions cigarette smoking as a potential cause of cardiovascular disease, noting that the Veteran began smoking during service. However, service connection based on cigarette smoking during service is precluded by law. The greater weight of the evidence is against the Veteran’s claim of entitlement to service connection for ischemic heart disease with hypertensive cardiovascular disease on a direct basis. With respect to secondary service connection, the question for the Board is whether the Veteran’s ischemic heart disease with hypertensive cardiovascular disease was proximately due to or the result of, or was aggravated beyond its natural progress by service-connected disability to include PTSD. The Board concludes that the preponderance of the evidence is against such a finding. The November 2015 VA examiner opined that the Veteran’s ischemic heart disease with hypertensive cardiovascular disease was not caused by his service-connected disabilities. The rationale was that the ischemic heart disease with hypertensive cardiovascular disease was due to hypertension which, as discussed above, is not service-connected and is not otherwise related to service or to any service-connected disability. As discussed above, the examiner opined that the increased stress associated with PTSD that could cause temporary increases in blood pressure did not cause or aggravate the hypertension which, again, is the cause of the ischemic heart disease with hypertensive cardiovascular disease. The examiner further opined that the Veteran’s hypertension and its complications, including ischemic heart disease and hypertensive cardiovascular disease, are not related to the Veteran’s other service-connected disabilities. This opinion is thorough, well-reasoned, and convincingly links the facts of this data with medical principles to reach a conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board assigns it significant probative weight. There is no competent, probative opinion linking the Veteran’s ischemic heart disease with hypertensive cardiovascular disease to any of his service-connected disabilities. Notably, the Veteran’s hypertension is not service-connected. Because the only competent opinion to the requisite legal standard regarding the etiology of the Veteran’s ischemic heart disease with hypertensive cardiovascular disease is against his claim, the greater weight of the evidence is against finding the ischemic heart disease with hypertensive cardiovascular disease was caused or aggravated by any service-connected disability. Entitlement to service connection for ischemic heart disease with hypertensive cardiovascular disease on a secondary basis is not warranted. The Veteran believed and the Appellant believes that the Veteran’s ischemic heart disease with hypertensive cardiovascular disease was related to an in-service injury, event, or disease or was proximately due to or the result of or aggravated beyond its natural progression by a service-connected disability. However, neither the Veteran nor the Appellant in this case were competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, the pathology and physiological mechanics of heart and cardiovascular disease, the interpretation of complicated diagnostic medical testing, and the interaction of psychological stress and the cardiovascular system. Therefore, it is outside the competence of the Veteran and the Appellant in this case because the record does not show that they had the skills or medical training to make such a determination. Consequently, the Board gives more probative weight to the VA examiner’s opinions. The Veteran’s claim of entitlement to service connection for ischemic heart disease with hypertensive cardiovascular disease, to include as secondary to service-connected disabilities, is denied. 4. Entitlement to service connection for cause of death The Appellant claims that chronic kidney disease, stage V, was a primary or contributing cause to the death of the Veteran, her spouse, and, further, that the chronic kidney disease was secondary to service-connected PTSD and to hypertensive cardiovascular disease which, she contends, should have been service-connected. The law provides DIC benefits for a spouse of a Veteran who dies from a service-connected disability. See 38 U.S.C. § 1310. A service-connected disability is one that was incurred in or aggravated by active military service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). The death of a Veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. See 38 C.F.R. § 3.312(a). For a service-connected disability to be considered the principal or primary cause of death, it must singly, or with some other condition, be the immediate or underlying cause, or be etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which contributed substantially or materially to cause death, or aided or lent assistance to the production of death. See 38 C.F.R. § 3.312(c). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). The Veteran’s death certificate and treatment records relating to his final illness indicate that the immediate cause of his death was sepsis, with additional causes including multiple organ failure with an underlying cause of chronic renal failure. See September 2015 Certificate of Death. Therefore, the Board finds that, as the Appellant alleges, chronic renal disease was a contributory cause of the Veteran’s death. See 38 C.F.R. § 3.312(c). The determinative medical issue, therefore, is whether the Veteran’s chronic renal disease was etiologically related to his active service. As discussed above, the Veteran’s chronic renal disease (and his ischemic heart disease with hypertensive cardiovascular disease) were caused by his hypertension which is not service-connected, was not incurred in or related to his active service, and was not due to any of his service-connected disabilities, particularly including PTSD. Similarly, the evidence establishes, as discussed above, that the Veteran’s chronic renal disease was not caused or aggravated by any service-connected disabilities. Therefore, the Veteran’s chronic renal disease, which was a contributing cause of death, is not subject to service connection on either a direct or secondary basis, and so cannot be the basis of entitlement to service connection for cause of death. There is no allegation that any service-connected condition caused or contributed to the Veteran’s cause of death, nor is there any indication in the record that any of his service-connected conditions may have caused or contributed to his death. Due to the above findings that the Veteran’s hypertension, chronic renal disease, and ischemic heart disease with hypertensive cardiovascular disease are not subject to service connection, the appellant’s claim must fail. Entitlement to service connection for cause of death is denied. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kerry Hubers 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.