Citation Nr: 21039751 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 20-11 326 DATE: July 1, 2021 ORDER Service connection for an acquired psychiatric disorder, diagnosed as unspecified depressive disorder and unspecified anxiety disorder, is granted. A compensable disability rating for bilateral hearing loss is denied. A disability rating in excess of 30 percent for coronary artery disease is denied. The reduction in rating from 100 percent to 0 percent from March 1, 2015 through April 13, 2015 was proper; the appeal is denied. REMANDED Entitlement to service connection for end stage renal disease due to focal segmental glomerulosclerosis is remanded. Entitlement to service connection for the cause of the Veteran's death is remanded. Entitlement to dependency and indemnity compensation (DIC) under 38 U.S.C. § 1318 is remanded. FINDINGS OF FACT 1. The Veteran's psychiatric disability was proximately due to his service-connected prostate cancer. 2. The Veteran's bilateral hearing has been manifested by hearing acuity of no worse than Level III in the right ear and no worse than Level III in the left ear. 3. Estimated Metabolic equivalent (MET) testing shows the Veteran developed fatigue at a workload of greater than 5 but not greater than 7 METs. MET testing shows the Veteran did not develop these symptoms at a workload of 5 METs or less, and there was no evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent or more than one episode of active congestive heart failure in the prior year. 4. The discontinuance of the 100 percent evaluation for prostate cancer was not a formal rating reduction as the "reduction" was by operation of law in accordance with 38 C.F.R. § 4.115b, Diagnostic Code 7528. The procedural requirements of 38 C.F.R. § 3.105(e) were properly and appropriately followed. 5. As of March 1, 2015, the evidence does not demonstrate that the Veteran continued to receive any surgical, x-ray, or antineoplastic chemotherapy; had any continued active malignancy of his genitourinary system; or, had any local recurrence or metastasis of his prostate cancer, such that continued application of a 100 percent evaluation for prostate cancer was appropriate under 38 C.F.R. § 4.115b, Diagnostic Code 7528. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for psychiatric disability, diagnosed as unspecified depressive disorder and unspecified anxiety disorder, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 3. The criteria for a rating in excess of 30 percent for arteriosclerotic heart disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. 4. The reduction in rating from 100 percent to 0 percent from March 1, 2015 through April 13, 2015 was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105(e), 4.1, 4.7, 4.115b, Diagnostic Code 7528. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1968 to June 1971, to include service in the Republic of Vietnam. Unfortunately, the Veteran died in January 2018. His surviving spouse is the appellant. When this matter was initially before the Board in June 2020, the Board denied the appellant's claim of service connection for the cause of the Veteran's death. The appellant appealed the Board's June 2020 decision to the United States Court of Appeals for Veterans Claims (Court), which in a March 2021order, granted the parties' joint motion for remand, vacating the Board's June 2020 decision and remanding the case for compliance with the terms of the joint motion. 1. Entitlement to service connection for an acquired psychiatric disorder, claimed as PTSD. The appellant contends that he is entitled to service connection for an acquired psychiatric disorder, claimed as PTSD, for substitution purposes. The Board notes that when a Veteran makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. As such the Board has re-characterized the issue of entitlement to service connection for PTSD to an acquired psychiatric disorder. See, Clemons v. Shinseki, 23 Vet. App. 1 (2009). A September 2013 VA treatment record notes the Veteran had diagnoses of depression and anxiety, as well as "PTSD significant symptoms." It was further noted that he "feels depressed more days than not" and that he "does have significant health issues [which] contribute to this." The Veteran was afforded a VA PTSD examination in February 2014. It was noted that the Veteran's symptoms do not meet the DSM-5 diagnostic criteria for PTSD, but diagnoses of unspecified depressive disorder, unspecified anxiety disorder, and alcohol use disorder were rendered. Specifically, criteria D was not met for a diagnosis of PTSD. The VA examiner did not render an opinion regarding service connection but did note that the Veteran's kidney failure and his service-connected prostate cancer were "relevant to the understanding or management of the Mental Health Disorder". In Hernandez-Toyens v. West, 11 Vet. App. 379, 382-83 (1998) the Court observed that the Axis IV assessment includes a determination as to etiologically significant psychosocial stressors and finding that, by listing the veteran's military service as part of the Axis IV assessment, the examining physician made a determination that the veteran's period of service was an "etiologically significant psychosocial stressor" contributing to the current acquired psychiatric condition diagnosed under Axis I. Here, the Board finds that the examiner's notation that his service-connected prostate cancer was relevant to the understanding or management of his mental health disorder constitutes a medical determination. In a September 2014 letter, the Veteran's daughter, stated that during his radiation treatments, the Veteran became depressed, would have occasional outbursts, and slowly became less sociable. In a September 2014 letter, another of the Veteran's daughters, stated that after he had his prostate removed and went through radiation treatments, he became depressed and had occasional outbursts. She then stated that the outbursts became worse after his bypass surgeries and at times stated that he "would be better off dead" as it would be easier on others. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's acquired psychiatric disorder was, at least in part, proximately due to his service-connected prostate cancer. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for psychiatric disability, diagnosed as unspecified depressive disorder and unspecified anxiety disorder, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102." Increased Rating 2. Entitlement to a compensable disability rating for bilateral hearing loss. The appellant contends that she is entitled to a higher rating for bilateral hearing loss, for substitution purposes. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). At the March 2014 VA audiological examination for compensation purposes, the Veteran complained of difficulty hearing with background noise and at a distance. On the authorized audiological evaluation, the Veteran exhibited pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 55 80 70 LEFT 60 45 45 100 95 The average pure tone threshold from 1000 to 4000 Hertz was 59 decibels in the right ear and 71 decibels in the left ear. Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 84 percent in the left ear. The Veteran was diagnosed with right ear sensorineural hearing loss and left ear mixed hearing loss. Applying the results to Table VI, the findings yield a numeric designation of Level III in the right ear and Level III in the left ear. Entering the resulting bilateral numeric designation of Level III for the right ear and Level III for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 0 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. Based on the evidence above, a compensable rating for the Veteran's bilateral hearing loss is not warranted. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran's statement that he uses hearing aids. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran's main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable rating for hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a disability rating in excess of 30 percent for coronary artery disease. The appellant contends that she is entitled to a higher rating for coronary artery disease, for substitution purposes. Arteriosclerotic heart disease is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005, for arteriosclerotic heart disease (coronary artery disease). Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. One metabolic equivalent (MET) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. A January 2013 treatment record from Asheville Cardiology Associates notes the Veteran reported no exertional chest pain or shortness of breath over the prior year. It was further noted that he had no palpitations, presyncope, or syncope and denied any heart failure symptoms. A January 2014 treatment record from Asheville Cardiology Associates notes the Veteran's left ventricular function was normal. It was further noted that he was "reasonably active" was able to walk to his barn and back twice per day, had no exertional chest pain, had no change in his mild exertional shortness of breath, and had no orthopnea, paroxysmal nocturnal dyspnea, palpitations, pre-syncope, or syncope. The Veteran was afforded a VA ischemic heart disease examination in February 2014. A diagnosis of coronary artery disease was noted, as were continuous medication, percutaneous coronary intervention, myocardial infarction, and coronary bypass surgery. Exercise METs testing was not performed and noted as not applicable, but the Veteran endorsed fatigue and a METs level of greater that 5 to 7 METs was noted. It was further noted that a January 2013 echocardiogram revealed a left ventricular ejection fraction of greater than 55 percent. No functional impact on the Veteran's ability to work was noted. A June 2014 letter from Dr. H. L. Humphrey at the Charles George VAMC notes the Veteran had severe coronary artery disease with a history of coronary artery bypass grafting of 5 coronary vessels, one of which failed, with subsequent coronary stenting of his left main coronary artery and proximal left anterior descending artery. A June 2014 VA treatment record notes the Veteran had ben been "very active" working in his yard weed whacking and using a bush hog without chest discomfort. Stable shortness of breath and "very rare palpitation" were noted. He denied congestive heart failure symptoms. In a September 2014 letter, the Veteran's daughter, stated that he had shortness of breath and dizzy spells. In a September 2014 letter, an acquaintance of the Veteran, stated that he gets dizzy and has shortness of breath while walking or doing minor projects. An October 2014 VA treatment record notes the Veteran was "very active on his horse fam", "walks up hill intermittently all day long", and "[p]icks up large bails of hay for his horses without any [shortness of breath] or chest pain." He denied any palpitations, syncope, dizziness, or lower extremity edema. A November 2014 VA treatment record notes the Veteran underwent left heart catheterization, left ventricular angiography, coronary angiography, and bypass graft angiography. A left ventricular ejection fraction of 55 percent was noted with normal wall motion and no mitral valve regurgitation. A June 2015 VA treatment record notes myocardial perfusion was negative for ischemia and infarction and revealed that global left ventricular systolic function was normal with a left ventricular ejection fraction of 60 percent. No evidence of left ventricular dilatation was noted, and wall motion was normal. In a May 2016 letter, a private examiner noted that the Veteran reported having recent chest pain and shortness of breath. An October 2016 VA treatment record notes the Veteran reported that he gets shortness of breath at times. A November 2017 VA treatment record notes the Veteran had an echocardiogram which showed atrial fibrillation with competing junctional rhythm. A further November 2017 VA treatment record notes the Veteran reported that his cardiologist was aware of his atrial fibrillation and the Veteran stated that he was taking aspirin. The Veteran and his friends and family are competent to report his readily observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, medical records surrounding the lay statements tend to contradict the lay observations and show the Veteran was active and denied dizziness, and had, at most, intermittent shortness of breath. Considering all relevant evidence of record, the Board finds that throughout the appeal period, the Veteran's coronary artery disease was manifested by a workload of greater than 5 METs but not greater than 7 METs, fatigue, and occasional shortness of breath. These findings correspond to the criteria for a 30 percent rating under DC 7005. A higher 60 percent rating is not warranted unless there is more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Thus, the Board concludes that the Veteran's arteriosclerotic heart disease did not meet the criteria corresponding to a higher 60 percent rating. 4. Whether the reduction in rating from 100 percent to 0 percent from March 1, 2015 through April 13, 2015 was proper. The appellant asserts that the reduction in rating from 100 percent to 0 percent from March 1, 2015 through April 13, 2015 was improper. By way of procedural history, the Veteran requested that his 100 percent rating be made permanent in a May 2014 claim. In an August 2014 rating decision, the RO denied the request to make the rating permanent, stating that there is a likelihood of improvement, but continued the 100 percent rating. The Veteran filed a Notice of Disagreement (NOD), and during the pendency of the appeal, the RO, in October 2014 proposed to reduce the Veteran's rating to 0 percent. In a December 2014 rating decision, the RO reduced the Veteran's prostate cancer rating from 100 percent to 0 percent, which was subsequently restored to 100 percent, effective April 14, 2015. Diagnostic Code (DC) 7528, which pertains to malignant neoplasms of the genitourinary system, provides that following the cessation of surgery, chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months and any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105 (e). The rating criteria also provide that if there has been no local reoccurrence or metastasis, then a veteran's cancer is rated based on residuals as voiding dysfunction or renal dysfunction, whichever is the predominant disability. 38 C.F.R. § 4.115b. With regard to the rating reduction for prostate cancer, the Board has considered whether the claim at issue would be most appropriately characterized as a formal reduction issue under the substantive provisions of 38 C.F.R. §§ 3.343 and 3.344. In this regard, the Board finds that these provisions are not applicable in the present case. This is because the provisions of 38 C.F.R. § 4.115b, Diagnostic Code 7528, contain a temporal element for continuance of a 100 percent rating for prostate cancer residuals. Therefore, the RO's action was not a "rating reduction," as that term is commonly understood. See, Rossiello v. Principi, 3 Vet. App. 430, 432-33 (1992) (finding that a 100 percent rating for mesothelioma ceased to exist by operation of law because the applicable Diagnostic Code [6819] involved contained a temporal element for that 100 percent rating). Consequently, the provisions of 38 C.F.R. §§ 3.343 and 3.344, with respect to rating reductions and terminations of 100 percent ratings, are not applicable in this case. This is in essence a staged rating case. The Veteran was afforded a VA prostate cancer examination in March 2013. It was noted that the Veteran's prostate cancer was in remission and that his radiation and androgen deprivation therapy had ended in November 2003. It was noted that the Veteran had a voiding dysfunction that caused no urine leakage as the Veteran was on dialysis due to renal failure. Erectile dysfunction was noted, and the Board notes that the Veteran was given a separate rating for that condition. A March 2013 VA treatment record notes the Veteran's PSA had been less than 0.1 and that he had been "declared [cancer] clear by oncology." A March 2013 treatment record from Blue Mountain Urology notes that "[o]nce a patient is diagnosed with prostate cancer and had any type of treatment, there is always a recurrent factor" and that that the Veteran "will always be considered a prostate cancer patient." A December 2013 treatment record from Blue Mountain Urology notes that approximately one year prior, the Veteran's PSA was 0.13 which makes it "suspicious that the [Veteran] still has active prostate cancer." It was then noted that his August 2013 PSA was 0.064 and his December 2013 PSA was 0.09. A July 2014 VA treatment record notes the following PSA levels: 0.1 March 2013; less than 0.064 August 2013; 0.1 April 2014; and 0.1 July 2014. Malignant neoplasm of the prostate and elevated PSA were noted, as was "[n]o recurrence of prostate cancer". A May 2015 treatment records from Blue Mountain Urology notes the Veteran's PSA from 1 year prior was 0.09, and then 0.11 only 6 months prior. His (then) present PSA was noted as 0.21. The rise in his PSA was characterized as "concerning" and it was stated that he "may need radiation for possible progression of prostate cancer". It was then concluded that the Veteran "either has some residual adenoma or recurrent prostate cancer." An April 14, 2015 VA treatment record notes the Veteran had "active prostate cancer per rising psa despite dutasteride" and was prescribed bicalutamide. A December 2015 VA treatment record notes the Veteran reported taking Eligard shots every 2 months for his rising PSA. The Veteran was afforded a VA prostate cancer examination in March 2016. It was noted that the Veteran had rising PSA and was receiving hormone injections. His prostate cancer was characterized as active. It was noted that his PSA from the prior week was 0.064. Here, the evidence of record clearly shows that the Veteran's prostate cancer was in remission as of the March 2013VA examination. Though the evidence does show that Veteran had rising psa and that a private urologist found it was "concerning" for recurrence, no actual recurrence was definitively pronounced by a competent medical professional until the April 14, 2015 VA urology record. Here, the RO proposed the reduction based on the findings of the March 2013 examination. As the examination established that the Veteran's prostate cancer was in remission and showed no local reoccurrence or metastasis, the reduction of the 100 percent rating was proper. The absence of active cancer process is a material improvement in the prostate cancer disability under the ordinary conditions of the Veteran's life. DC 7528 further instructs that if there has been no local reoccurrence or metastasis, the disability is to be rated based upon residuals such as voiding dysfunction or renal dysfunction, whichever is predominant. Under the criteria for voiding dysfunction, disability requiring the use of absorbent materials which must be changed less than twice a day warrants a 20 percent disability rating. A 40 percent disability rating is assigned for disabilities marked by the wearing of absorbent materials which must be changed two to four times per day. A maximum schedular 60 percent disability rating is assigned for disabilities requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. See 38 C.F.R. § 4.115a. As noted above, VA examinations have found that the Veteran's residuals were a voiding dysfunction that did not cause leakage, and erectile dysfunction for which he was granted a separate rating. For all the foregoing reasons, the Board finds that the reduction of the disability evaluation for the Veteran's service-connected prostate cancer from 100 percent to 0 percent, effective March 1, 2015 through April 13, 2015, was proper. Further, a compensable rating during that period is not warranted as there were no findings that would support the assignment of a higher rating. See, Hart v. Mansfield, 21 Vet. App. 505 (2007). REASONS FOR REMAND 1. Entitlement to service connection for end stage renal disease due to focal segmental glomerulosclerosis is remanded. When VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran was afforded a VA kidney conditions examination in February 2014. The VA examiner noted that the Veteran's kidney condition was prior to his diagnosis of ischemic heart disease and that nephrology has stated that it is secondary to focal segmental glomerulosclerosis and opined that it is not secondary to his ischemic heart disease. Here, the examiner only addressed one service-connected condition and did not offer any opinion as to aggravation. Furthermore, the Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record. Lynch v. Wilkie, 30 Vet. App. 296, 304 (2018). If the Board determines that a claimed condition was caused by an unclaimed condition, the Secretary must investigate service connection for the unclaimed condition if there is evidence suggesting that it may be associated with service. DeLisio v. Shinseki, 25 Vet. App. 45, 54 (2011). This is because claimants may not have the medical or legal expertise to identify the precise disability for which they are seeking compensation, and VA has a duty to liberally construe their filings. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The Board notes that the Veteran made statements asserting that his kidney failure and hypertension were caused by his exposure to Agent Orange in Vietnam. He further asserted that his kidney failure was caused by his hypertension. As such, although the issue of entitlement to service connection for hypertension is not before the Board, VA must investigate whether the Veteran's hypertension was a disability of service origin to properly adjudicate the claim of service connection for kidney disease. The Veteran was afforded a VA hypertension examination in February 2014. The VA examiner opined against service connection, noting that the Veteran's hypertension pre-existed his ischemic heart disease. No opinion was obtained regarding aggravation. In light of the Veteran's service in Vietnam and his presumed Agent Orange exposure, as well as his contentions regarding his kidney and hypertension conditions, the Board finds that remand for VA examinations and medical opinions is necessary. See, Healey v. McDonough, 33 Vet. App. 312 (2021). Additionally, there is no opinion of record addressing whether the Veteran's kidney and hypertension conditions were caused by his exposure to herbicide agents. It is also noted that the National Academies of Sciences, Engineering and Medicine (NAS) issued an update in 2018. In "The Veterans and Agent Orange: Update 11 (2018)," NAS upgraded hypertension from its previous classification in the category of "limited or suggestive" evidence of an association to Agent Orange to the category of "sufficient" evidence of an association. According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. In light of the foregoing, the Board finds that an opinion addressing whether there is a relationship between the Veteran's hypertension and kidney conditions and exposure to herbicide agents should be obtained. Healey. 2. Entitlement to service connection for the cause of the Veteran's death is remanded. VA obtained medical opinions regarding service connection for the cause of the Veteran's death in May 2018 and January 2020. In both opinions, the VA examiner relied almost exclusively on the causes of death listed on the Veteran's death certificate. In Wood v. Peake, 520 F.3d 1345, 1347 (Fed.,2008), the United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that "[t]he government confirmed at oral argument that unlike the pathologist who drafted the autopsy report, the coroner who filled out the death certificate form was not a medical doctor, which is common. This disparity in qualifications, along with the vastly greater detail generally provided in autopsy reports, may be why the VA, in enacting 38 C.F.R. § 3.312, specifically named autopsy reports as particularly probative of what conditions contributed to death. See 38 C.F.R. § 3.312(a) ("[Causes of death] will be determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran, including, particularly, autopsy reports.") (emphasis added)." Here, numerous treatment records from the hospital where the Veteran was treated immediately prior to his death have been associated with the claims file, but these records were barely discussed by the examiner. Further, the January 2020 VA examiner stated that a January 2017 echocardiogram shows the Veteran's heart had normal pumping ability. What was not discussed in this opinion was that a November 2017 VA treatment record shows that an echocardiogram from that month revealed the Veteran had atrial fibrillation with competing junctional rhythm. Because the Board finds the May 2018 and January 2020 VA opinions to be inadequate, and because this matter is inextricably intertwined with the remanded matter of entitlement to service connection for kidney failure (and possibly with hypertension), a remand is required to obtain a new opinion as well as an autopsy report, if such is available. 3. Entitlement to DIC under 38 U.S.C. § 1318 is remanded. Because service connection for an acquired psychiatric disorder has been granted, and because the remanded issue of entitlement to service connection for kidney failure could affect the outcome, the matter of entitlement to DIC is inextricably intertwined and is therefore remanded. The matters are REMANDED for the following action: 1. Request that the appellant complete and return the required authorizations to obtain a copy of any autopsy report. 2. Obtain a VA medical opinion regarding service connection for the Veteran's end stage renal disease and hypertension. Are end stage renal disease or hypertension at least as likely as not related to service? The examiner must also address whether there is any etiology relationship between the Veteran's hypertension and his kidney disease. Are end stage renal disease or hypertension at least as likely as not related to service, including conceded exposure to Agent Orange? Are end stage renal disease or hypertension at least as likely as not proximately due to service-connected coronary artery disease or prostate cancer? Are end stage renal disease or hypertension at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected coronary artery disease or prostate cancer? Are end stage renal disease or hypertension at least as likely as not related to in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that the claimed conditions are not on the list of diseases that are presumptively associated with exposure to herbicide agents. In reaching this determination, the VA examiner must specifically address the National Academies of Sciences, Engineering and Medicine (NAS) 2018 update regarding the relationship between herbicide exposure and hypertension. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 3. Obtain an opinion from a VA examiner that addresses whether any of the Veteran's service-connected disabilities, to include in the aggregate, caused, contributed or hastened his death. The opinion and the report should include a discussion of the Veteran's medical history and the appellant's assertions. The examiner's attention is invited to the November 2017 VA treatment record which notes the Veteran had an echocardiogram which showed atrial fibrillation with competing junctional rhythm. The examiner should address this in their opinion. The examiner should address the April 2018 and July 2018 letters from Dr. A regarding the cause of the Veteran's death. The examiner should address the August 2018 letter from Dr. J. A. M., the Veteran's treating cardiologist, regarding the cause of the Veteran's death. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Keeley, Brian 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.