Citation Nr: 21027583 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 15-28 328 DATE: May 6, 2021 REMANDED Entitlement to service connection for the Veteran's cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from September 1974 to November 1980. The Veteran died in November 2013. The appellant is his surviving spouse. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the appellant testified before the undersigned Veterans Law Judge at a video conference hearing. A transcript of the hearing is of record. The Board remanded this matter in March 2019 for additional development. Unfortunately, as discussed below, the Board is not satisfied that there was substantial compliance with its prior remand; therefore, the appeal must be remanded once again. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Entitlement to service connection for the Veteran's cause of death is remanded. The appellant seeks service connection for the cause of the Veteran's death. The Veteran died in November 2013. His death certificate identifies hemoperitoneum sequela, mesenteric hematoma, and atherosclerotic cardiovascular disease with congestive heart failure sequela as the primary causes of death. Diabetes mellitus type II, hypertension, atrial fibrillation, obesity, renal failure, and obstructive sleep apnea are listed as contributory causes. At the time of his death, the Veteran was service connected for chronic left maxillary sinusitis, mood disorder with depression, chronic lumbosacral strain with degenerative disc disease, degenerative joint disease of the left ankle, arthritis of the right ankle, bilateral hearing loss, and tinnitus. The appellant has put forth several arguments in support of her claim for service connection for the cause of the Veteran's death. First, she alleges that the Veteran's service-connected mood disorder and depression may have contributed to his heart disease, atrial fibrillation, and hypertension. In support of her claim, the appellant has cited to medical literature that suggests that there may be a direct link between depression and adverse cardiac events, such as high blood pressure, arterial damage, irregular heart rhythms, and heart disease. Second, the appellant argues that the Veteran's service-connected lumbar spine disability led to weight gain and obesity, which in turn caused his hypertension and diabetes mellitus. Third, the appellant argues that the Veteran service-connected maxillary sinusitis may have caused his obstructive sleep apnea. In the March 2019 remand, the Board instructed the RO to obtain a VA medical opinion that adequately addresses the appellant's contentions. A VA medical opinion was obtained in November 2020. The VA examiner concluded that the Veteran's primary causes of death "are separate from the [service-connected] conditions in every way physiology wise." The examiner provided no further medical rationale for this finding. The examiner further noted that the Veteran's service-connected conditions "would not impact the function of the Veteran in the last month of his life." Thereafter, the VA examiner provided some general information about obesity and obstructive sleep apnea, but failed to explain how this information applies to the specific facts of the Veteran's case. The RO obtained an addendum VA medical opinion from a different VA examiner in December 2020. The VA examiner appears to have summarized the medical literature cited by the appellant regarding the possible link between depression and heart disease before concluding that "there is no objective evidence the Veteran's service-connected depression contributed substantially or materially to the cause of the Veteran's death, combined to cause death, or aided or lent assistance to the production of death." No further medical rationale was provided to support this conclusion. The Board finds both VA medical opinions obtained on remand to be inadequate to fairly adjudicate the appellant's claim. First, both opinions are conclusory in that the examiners failed to provide sufficient medical rationale to support their negative findings. Moreover, the opinions only very broadly address the appellant's contentions without any specific consideration of the individual facts of the Veteran's case, to include his medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two); see also Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (a mere conclusory opinion is insufficient to allow the Board to make an informed decision as to the weight to assign to a medical opinion). In light of the above, the Board is unable to find that substantial compliance with its prior remand has been achieved. See D'Aries, 22 Vet. App. at 105; see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Therefore, remand is again required to obtain an addendum medical opinion that complies with the Board's prior remand directives. See Stegall, 11 Vet. App. at 268. Accordingly, the matter is REMANDED for the following action: Forward the Veteran's claims file to a VA doctor (M.D.) of appropriate expertise, who has not previously provided an opinion, to provide a medical opinion that addresses the etiology of the Veteran's primary and contributory causes of death. The entire claims file, to include a copy of this REMAND, must be provided to the examiner and reviewed in full. That review must be noted in the report. Thereafter, the examiner must provide a fully-articulated medical opinion addressing the following: (a) Is it at least as likely as not (50 percent or greater probability) that one or more of the Veteran's service-connected disabilities contributed substantially or materially to the cause of the Veteran's death, combined to cause death, or aided or lent assistance to the production of death? In rendering the requested opinion, the examiner must specifically address EACH of the appellant's contentions that: (i) the Veteran's service-connected mood disorder and depression may have contributed to his heart disease, atrial fibrillation, and hypertension; (ii) the Veteran's service-connected lumbar spine disability led to the development of obesity, which in turn caused hypertension and diabetes mellitus; and/or (iii) the Veteran service-connected maxillary sinusitis may have caused or aggravated the Veteran's obstructive sleep apnea. The examiner must also specifically address the relevance of the following medical articles cited by the appellant: o Cardiac Disease & Depression, Cleveland Clinic, Department of Psychiatry and Psychology, available at https://my.clevelandclinic.org/health/diseases/1691 7-depression--heart-disease o Depression and High Blood Pressure, Chris Woolston, M.S., HealthDay, available at https://consumer.healthday.com/encyclopedia/depr ession-12/depression-news-176/depression-andhigh-blood-pressure-644943.html The examiner is reminded that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner must provide a complete rationale for any opinions offered, citing to the examiner's own expertise, medical principals, and/or evidence in the record, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. (Continued on next page) The Board reminds the examiner that failure to comply with the examination directives outlined herein will render the medical opinion inadequate and will result in further remand of the Veteran's claim. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, 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.