Citation Nr: 21011682 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 15-03 651A DATE: March 2, 2021 REMANDED Entitlement to service connection for cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1951 to February 1954. The Veteran died in June 2013. The appellant is the Veteran’s surviving spouse. This matter initially came before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) that denied the appellant’s claim of service connection for the cause of the Veteran’s death. In February 2019, the appellant testified at a Board hearing in Washington, D.C. before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In April 2020, the Board remanded the claim for further development, to include VA opinions. Regrettably, another remand is required to comply with the Board’s remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). As a final preliminary matter, the appellant’s representative has not submitted an informal hearing presentation (IHP) since this matter’s return to the Board from remand. Rather than delay the adjudication for an IHP, the Board will remand the claim and the appellant’s representative Given that the Board is remanding this matter again, there is no prejudice to the Veteran in adjudicating the claim in the absence of an IHP. Entitlement to service connection for the cause of the Veteran’s death The Board greatly regrets the additional delay, but for the following reasons, the case must be remanded. The appellant contends the Veteran’s coronary artery disease disability, for which he was not in receipt of service connection, was related to his service in the Korean War. She also contends the Veteran’s service-connected left hip and knee arthritis disabilities caused him to fall and fracture his hip in approximately February 2013, which led to surgery, from which he never fully recovered, and his death. Both of these are valid theories of entitlement under 38 C.F.R. § 3.312. In April 2020, the Board directed the RO to obtain a medical opinion from an appropriate specialist physician as to whether it was as least as likely as not that the Veteran’s coronary artery disease disability had its onset in service, or was otherwise related to service. The Board also directed the RO to obtain a medical opinion from an appropriate specialist physician to determine the impact, if any, that the Veteran’s service-connected left hip and knee arthritis disabilities had on his cause of death, to include the effects of the surgery he underwent after fracturing his left hip in a fall. The physician was to provide an opinion as to whether it was at least as likely as not that the Veteran’s service-connected left hip and knee disabilities were a contributory cause of the Veteran’s death. The physician was also to discuss the severity of the Veteran’s left hip and knee arthritis disabilities when providing an opinion on the impact of the Veteran’s service-connected left hip and knee arthritis disabilities on his cause of death and discuss whether these disabilities, to include the effects of the surgery on his fractured hip, rendered him less capable of resisting the effects of disease. In November 2020, a VA physician assistant noted that the Veteran was service-connected for left knee degenerative arthritis, left hip degenerative arthritis, and myositis ossificans left anterior femur prior to his death, and the Veteran’s cause of death was determined to be hypotension, end state renal disease, profound anemia with contributing factors of coronary artery disease, failure to thrive, peripheral vascular disease, and chronic obstructive pulmonary disease. The physician assistant found that the Veteran’s degenerative arthritis of the knee and hip and myositis ossificans were in no way related to or contributed to the Veteran’s cause of death. Additionally, the fall noted in the remand that caused the Veteran’s arthritis would not have resulted in any of the listed causes of death as the Veteran’s service-connected conditions affected only the knee and hip joint. There was no systemic involvement of degenerative arthritis, and there was no pathophysiology that would provide any connection or contribute in any way to the causes of death. The November 2020 VA opinion is inadequate for several reasons. First, there was no opinion offered in regard to whether the Veteran’s coronary artery disease disability had its onset in service or was otherwise related to service as was directed by the Board in its April 2020 decision. The opinion also did not substantially comply with the April 2020 remand directives in that a physician assistant, not an appropriate specialist physician, did not discuss the severity of the Veteran’s left hip and knee arthritis disabilities when providing an opinion on the impact of the Veteran’s service-connected left hip and knee arthritis disabilities on his cause of death and did not discuss whether these disabilities, to include the effects of surgery on his fractured hip after a fall, rendered him less capable of resisting the effects of disease. Regrettably, another remand is therefore warranted to comply with the Board’s April 2020 remand directives. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate). Accordingly, the matter is REMANDED for the following action: Obtain a medical opinion from an appropriate physician to opine whether (1) it is as least as likely as not (50 percent probability or more) that the Veteran’s coronary artery disease disability had its onset in service, or was otherwise related to service, and (2) whether it is at least as likely as not that the Veteran’s service-connected left hip and knee disabilities were a contributory cause of the Veteran’s death. The physician should discuss the severity of the Veteran’s left hip and knee arthritis disabilities when providing an opinion on the impact of the Veteran’s service-connected left hip and knee arthritis disabilities on his cause of death and discuss whether these disabilities, to include the effects of the surgery on his fractured hip, rendered him less capable of resisting the effects of disease. The claims file should be provided to and reviewed by the specialist physician. A complete rationale should accompany any opinion provided. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Styer, 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.