Citation Nr: 21042046 Decision Date: 07/11/21 Archive Date: 07/11/21 DOCKET NO. 16-41 858 DATE: July 11, 2021 ORDER Entitlement to service connection for cause of the Veteran's death is denied. FINDING OF FACT The disabilities that caused or contributed substantially or materially to the Veteran's death were not incurred in service, did not manifest to a compensable degree within a year of service separation, and may not otherwise be presumed to have been incurred therein. CONCLUSION OF LAW The criteria for entitlement to service connection for cause of the Veteran's death have not been met. 38 U.S.C. § 1110, 1112, 1116, 1310, 5107; 38 C.F.R. § 3.102, 3.303, 3.304, 3.307, 3.309, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1985 to December 2003. He died in September 2014. The Appellant is his surviving spouse. This appeal arose from a December 2014 rating decision (issued in January 2015) which denied entitlement to service connection for cause of the Veteran's death, accrued benefits, and death pension. The Appellant subsequently perfected an appeal as to the cause of death and accrued benefits claims and, in December 2019, testified before the undersigned Veterans Law Judge via video conference. During the hearing, the Appellant withdrew the accrued benefits claim, as reflected in the transcript of the hearing, which is associated with the claims file. Thereafter, in December 2020, the Board dismissed the accrued benefits claim and remanded the cause of death claim for additional evidentiary development, to include requesting the Appellant identify any outstanding medical evidence relevant to the claim. On remand, the Agency of Original Jurisdiction (AOJ) sent the Appellant a letter requesting that she provide completed authorization forms for all health care providers who treated the Veteran for hypertension or any related disabilities after service, but the Appellant did not respond. The AOJ also obtained a VA opinion. As such, the Board that all requested development has been conducted and, accordingly, the claim remaining on appeal has returned to the Board for further consideration. 1. Entitlement to service connection for cause of the Veteran's death The Appellant seeks service connection for cause of the Veteran's death. A death will be considered to result from a service-connected disability if the evidence establishes that a disability that is causally related to service, either caused or contributed substantially or materially to the Veteran's death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. As with any claim, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran's death certificate reflects that the immediate cause of death was an acute stroke due to or a consequence of essential hypertension and coronary atherosclerosis. The death certificate also lists arteriovenous malformation as a significant condition contributing to death. At the time of his death, service connection had been established for a lumbar strain with herniated disc, radiculopathy, and bilateral sacroiliitis, tinnitus, and a residual skin tag due to hemorrhoids. As an initial matter, the Board notes the evidence does not reflect, nor does the evidence reflect, that the Veteran's cause of death resulted from a disability for which service connection had been established. Instead, the Appellant has asserted that the Veteran had high blood pressure/hypertension and high cholesterol during service that continued after service and ultimately resulted in the stroke that caused his death. In this regard, the Appellant testified that, while not reflected in the service records, she recalls an incident in October 1999 when the Veteran experienced a serious dog bite and that, during initial and follow-up treatment, the Veteran's blood pressure was very high. During the December 2019 hearing, she testified that he was prescribed the medication, Pravastatin, at that time and remained on this type of medication for the remainder of his life. She also testified that, while there is no diagnosis of hypertension in the Veteran's service records, there were several subsequent times the Veteran experienced high or elevated blood pressure, as reflected in multiple entries that show systolic pressure over 140. The Appellant has also asserted that she believes the Veteran was suffering from atherosclerosis while serving and living in Portugal, as he frequently complained of pain and experienced numbness and tingling in his extremities. See December 2019 Appellant statement. In June 2020, a VA physician reviewed the claims file and opined that it is less likely than not that the Veteran's hypertension and coronary arteriosclerosis were incurred in or caused by a disease, injury, or event during service or were manifested to a compensable degree within one year of service. In this regard, the VA examiner stated that the available evidence, including the lay statements of record, do not support this claim and that other, more reasonable explanations for his conditions are identified in the evidence of record. As an initial matter, the examiner noted that it is unknown in the Veteran's stroke was hemorrhagic or occlusive in nature and further noted that it is unclear from available records as to when a diagnosis of hypertension was made. Nevertheless, the examiner noted that hypertension is defined as the persistent elevation of blood pressure, either diastolic, systolic, or both, above limits of normal and stated that evidence of persistently elevated blood pressure is not found in the service treatment records or in the record in the first 12 months following separation from service. The VA examiner noted the Appellant's report of the Veteran having elevated blood pressure following a dog bite in October 1999 and being prescribed Pravastatin at that time; however, the examiner noted that Pravastatin is a lipid lowering agent and would not be prescribed to treat hypertension. As for the Appellant's assertion that she believes the Veteran was suffering from atherosclerosis during service, the examiner stated that the Veteran's known lumbar spine conditions are the most reasonable explanation for his lower extremity symptoms based on documented confirmation with imaging. In this regard, the examiner noted that there is no evidence or references to concerns for peripheral vascular disease in the clinical records and further noted that it would be reasonable to expect blood pressure to be temporarily elevated in the circumstances of a dog bite, even for several days, as a normal physiologic response to stress and still not meet the diagnostic criteria for hypertension. With respect to the Appellant's assertion regarding multiple entries showing elevated blood pressure readings during service, the examiner stated that, by definition, blood pressure remains elevated at all times and during all assessments in patients with hypertension. In this regard, the examiner noted that the Veteran's blood pressure was normal at all times in the STRs, thus not meeting the diagnostic criteria for hypertension. The VA examiner specifically identified an adult preventative and chronic care flowsheet in the STRs that documented blood pressure readings taken in 1998, 1999, and 2002 and noted that only the reading in 1998 was mildly elevated and made no mention of any medications. See e.g., AF Form 1480A, Jun 97. The examiner further noted that the 2003 separation examination showed normal blood pressure and made no mention of a history of hypertension and stated that, in the absence of any antihypertensive medications, this confirms that any elevations of blood pressure during service were episodic. The examiner stated that inheritance and cigarette smoking are both leading risk factors for atherosclerosis and stroke while noting that a 2003 QTC examination shows the Veteran had normal blood pressure in the lying and sitting positions and also showed the Veteran had a family history of stroke and being a cigarette smoker. Based on the foregoing, the Board finds the preponderance of the evidence weighs against a finding that hypertension, atherosclerosis, or any other disability that caused or contributed substantially or materially to the Veteran's death are causally related to his active service. In evaluating this claim, the Board ascribes the most probative value to the June 2020 VA opinion, as it is based upon review the lay and medical evidence of record and the examiner's medical expertise and knowledge. As shown above, the VA examiner considered and directly addressed the Appellant's assertions regarding the Veteran's elevated blood pressure readings during service, as well as her statements purporting to attribute his symptoms of lower extremity pain, numbness, and tingling to atherosclerosis. However, the examiner identified medical evidence of record that weighed against the Appellant's assertions, including evidence showing consistently normal blood pressure readings during service, at separation from service, and during an examination conducted in September 2003, as well as objective evidence of lumbar disc herniation to explain the Veteran's lower extremity symptoms, and noted that this evidence weighed against a finding of hypertension or atherosclerosis manifested during service or the first post-service year. The VA examiner also noted that the medications identified by the Appellant would not be used to treat hypertension. The Board acknowledges that the Appellant's statements regarding the Veteran's elevated blood pressure, medications, and other systems are based on her own recollections and, thus, are considered competent and credible evidence. However, her statements are outweighed by the medical opinion and evidence of record which, as a whole, do not indicate or suggest that the Veteran's hypertension or atherosclerosis were incurred during or as a result of his active service, to include during his first post-service year. In this regard, the Board notes that the evidence does not reflect, nor has the Appellant alleged, that she has any medical education, experience, or training; nor has she offered any basis in common lay knowledge to support her assertions attributing the Veteran's hypertension and atherosclerosis to active service. Instead, the Appellant's statements are based upon her own beliefs, which are not supported by any medical evidence. Indeed, the claims file does not contain, nor has the Appellant identified, any medical evidence that attributes any of the disabilities that caused or contributed substantially or materially to the Veteran's death to his period of active service. Therefore, the Board finds the preponderance of the evidence is against the award of service connection for the cause of the Veteran's death, as the disabilities that caused his death were not incurred in service, did not manifest to a compensable degree within a year of service separation, and may not otherwise be presumed to have been incurred therein. Accordingly, the Appellant's claim is denied, and he benefit of the doubt doctrine is not applicable. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Turnipseed, 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.