Citation Nr: 21041710 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-58 954 DATE: July 10, 2021 REMANDED Entitlement to death and indemnity compensation (DIC) based on service connection for the cause of the Veteran's death is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Marine Corps from April 1966 to April 1968. The Veteran passed away in 1989, and the appellant, his surviving spouse, is a qualified surviving family member for purposes of seeking dependency benefits. At the time of his death, the Veteran was not service-connected for any disability. The Veteran's death certificate lists pontine stroke (ischemic) as the immediate cause of death and basilar artery thrombosis as an underlying cause of death. The appellant asserts that the Veteran should have been service connected for the conditions listed on his death certificate. Initially, the appellant asserted that the conditions were due to Agent Orange exposure, which in turn purports a claim based on presumptive service connection. Additionally, the appellant asserts that the Veteran was exposed to contaminated water at Camp Lejeune and that it could have caused the conditions that led to his death. The Veteran's DD 214 reflects that he was stationed at Camp Lejeune. This matter was initially before the Board in March 2019, where it was remanded for additional development. Specifically, the Board determined that a VA examination was warranted to determine whether the Veteran's basilar artery thrombosis and/or ischemic stroke is etiologically related to service. Entitlement to DIC based on service connection for the cause of the Veteran's death is remanded. While the Board regrets further delay, for the reasons discussed below, the Board finds that the VA examinations are either unclear and/or inadequate for adjudicative purposes. In a June 2020 VA opinion, the examiner opined that it is less likely than not that basilar artery thrombosis and ischemic stroke was incurred in or caused by Camp Lejeune contaminated water (CLCW) exposure. The examiner listed risk factors related to basilar artery thrombosis and ischemic stroke. Yet the examiner conceded that the Veteran's medical records do not indicate any risk factors for basilar artery thrombosis or ischemic stroke. The examiner stated that the "weight of medical evidence does not currently support a causal relationship between CLCW exposure" and basilar artery thrombosis and ischemic stroke. However, the examiner did not discuss the medical evidence that shows no causal relationship exists. In the examiner's rationale, the discussion of basilar artery thrombosis and ischemic stroke does not pertain to the Veteran. For example, the examiner stated the following: In the United States, blacks have an age-adjusted risk of death from stroke that is 1.49 times that of whites [6]. The risk of stroke increases with age, however, one third of strokes occur in individuals younger than 65 years [7]. However, according to the Veteran's death certificate he is Caucasian and passed at the age of 41. It appears as though the examiner's rationale contains a general discussion of basilar artery thrombosis and strokes, as opposed to discussing the etiology of diseases specific to the Veteran and whether his disabilities are related to service. Therefore, the Board finds that the June 2020 opinion is inadequate. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In a January 2021 VA opinion, the examiner opined the following regarding pontine stroke: PONTINE ARTERY BARANCHES OUT FROM BASILAR ARTERY. AGENT ORANGE EXPOSURE IS KNOWN TO CAUSE ATHEROSCLEROTIC CARDIOVASCULAR DISEASE. HOWEVER BASILAR ARTERY THROMBOSIS THOUGH WITH THE SAME PATHOGENESIS OF ATHEROSCLEROSIS IS NOT LISTED IN THE AGENT ORANGE EXPOSURE AS A CAUSE. NO LITERATURE IS FOUND THAT WILL CONFIRM CASUAL RELATIONSHIP OF AGENT ORANGE TO CAUSE BASILAR ARTERY THROMBOSIS. THEREFORE, IT IS LESS LIKELY THAN NOT THAT THE VETERAN'S PONTINE STROKE WAS DUE TO AGENT ORANGE. Regarding basilar artery thrombosis, the examiner opined the following regarding basilar artery thrombosis: AGENT ORANGE EXPOSURE IS KNOWN TO CAUSE ATHEROSCLEROTIC CARDIOVASCULAR DISEASE. HOWEVER BASILAR ARTERY THROMBOSIS THOUGH WITH THE SAME PATHOGENESIS OF ATHEROSCLEROSIS IS NOT LISTED IN THE AGENT ORANGE EXPOSURE AS A CAUSE. NO LITERATURE IS FOUND THAT WILL CONFIRM CASUAL RELATIONSHIP OF AGENT ORANGE TO CAUSE BASILAR ARTERY THROMBOSIS. THEREFORE, IT IS LESS LIKELY THAN NOT THAT THE VETERAN'S BASILAR ARTERY THROMBOSIS WAS RELATED TO AGENT ORANGE EXPOSURE. RECORDS DID NOT DEMONSTRATE OR SUPPORT EXISTENCE OF BASILAR ARTERY THROMBOSIS CONDITION DURING SERVICE. THEREFORE, IT IS LESS LIKELY THAN NOT THAT THE VETERAN'S BASILAR ARTERY THROMBOSIS WAS NCURRED DURING, CAUSED BY OR OTHERWISE RELATED TO HIS ACTIVE SERVICE. The Board finds that the rationale is unclear as to the etiology and cause of the Veteran's basilar artery thrombosis and pontine stroke. The Board is uncertain as to whether the examiner is stating that basilar artery thrombosis being "not listed in the agent orange exposure as a cause" is pertaining to the presumptive list of diseases known to be caused by agent orange exposure, which does not prevent the appellant from establishing service connection. Regardless, no rationale or further analysis is discussed regarding the examiner's conclusion. The examiner also reiterates the same opinion regarding pontine stroke that was discussed for basilar artery thrombosis with no analysis. The Board also notes that lack of a diagnosis during service as a basis for a negative opinion is not sufficient. Therefore, the Board finds that the January 2021 opinion is inadequate for adjudicative purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, a remand is warranted to obtain an adequate medical opinion. The matter is REMANDED for the following action: 1. Forward the record to an appropriate medical professional to obtain a VA medical opinion regarding the nature and etiology of the Veteran's pontine ischemic stroke and basilar artery thrombosis. If possible, the opinion should be provided by an examiner who has not previously given an opinion in this case. The examiner should opine the following: a) Whether it is at least as likely as not (50 percent or greater) that the Veteran's pontine ischemic stroke was related to his Agent Orange exposure in Vietnam. The examiner is advised that the absence of pontine ischemic stroke from the list of conditions which are presumed to be the result of exposure to herbicides in Vietnam is not, by itself, a sufficient explanation for a negative opinion. The examiner must specifically address the relationship (if any) between Agent Orange exposure and pontine ischemic stroke. b) Whether it is at least as likely as not (50 percent or greater) that the Veteran's pontine ischemic stroke was related to contaminated water at Camp Lejeune. The examiner must specifically address the relationship between contaminants in Camp Lejeune and pontine ischemic stroke. c) Whether it is at least as likely as not (50 percent or greater) that the Veteran's pontine ischemic stroke was incurred during, caused by, or otherwise related to his active service. d) Whether it is at least as likely as not (50 percent or greater) that the Veteran's basilar artery thrombosis was related to his Agent Orange exposure in Vietnam. The examiner must specifically address the relationship between Agent Orange exposure and basilar artery thrombosis. e) Whether it is at least as likely as not (50 percent or greater) that the Veteran's basilar artery thrombosis was related to contaminated water at Camp Lejeune. The examiner must specifically address the relationship between contaminants in Camp Lejeune and basilar artery thrombosis. f) Whether it is at least as likely as not (50 percent or greater) that the Veteran's basilar artery thrombosis was incurred during, caused by or otherwise related to his active service. If the answer to (d), (e), or (f) is yes (i.e. service connection is established for basilar artery thrombosis), the examiner must opine as to whether such disorder at least as likely as not caused or contributed substantially or materially to the Veteran's death, or aided or lent assistance to the production of death. Please address the January 2021 VA examiner's determination that the basilar artery thrombosis contributed substantially or materially to the Veteran's death. If service connection for pontine stroke is established, as it is the immediate cause of death, additional inquiry is not required. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the examiner cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation for why an opinion cannot be rendered. In doing so, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. (Continued on the next page) The examiner is also advised that the appellant is competent to attest to the Veteran's observable symptoms as well as what the Veteran told her about his symptoms. If there is a medical basis to support or doubt the reports of symptomatology, the examiner should provide a fully reasoned explanation. Rebecca N. Poulson Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Adeleke, T. 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.