Citation Nr: 23014455 Decision Date: 03/09/23 Archive Date: 03/09/23 DOCKET NO. 18-51 068 DATE: March 9, 2023 REMANDED Entitlement to service connection for the cause of the Veteran's death, for the period prior to July 9, 2019, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1987 to August 1989. He died in September 2017. The appellant was his surviving spouse until her remarriage on July 9, 2019. This case comes to the Board of Veterans' Appeals (Board) from a December 2017 rating decision of the Department of Veterans' Affairs (VA) Regional Office. This case was previously remanded by the Board in July 2022. The Board remanded this issue in order to obtain a medical opinion on the etiology of the Veteran's hypertensive cardiovascular disease and cause of death. The examiner was asked to address whether the Veteran's PTSD substantially, or materially, combined with hypertension or heart disease to cause or assist in his death, or whether it caused any debilitating effects that rendered him materially less capable of resisting the effects of the primary cause of death. The examiner was asked to specifically address the appellant's contentions that the Veteran had severe, uncontrolled anxiety and panic attacks that contributed to his hypertension and sudden heart problems. A VA psychiatrist provided a medical opinion in August 2022. The examiner wrote that the Veteran's hypertensive cardiovascular disease was less likely than not caused by or permanently aggravated by PTSD, and as rationale, wrote that the Veteran's hypertensive cardiovascular disease was caused by smoking, hypertension. hyperlipidemia, and genetic disposition. Regarding whether the Veteran's PTSD caused debilitating effects that rendered him materially less capable of resisting the effects of the primary cause of death, she just wrote that the Veteran died from hypertensive cardiovascular disease, and that the Veteran had a history of drug use and other risk factors, including family history and smoking. She also wrote that PTSD less likely as not substantially or materially combined with hypertension to cause, aid, or assist in his death, and repeated the same rationale. These medical opinions are little more than listing out some of the risk factors for hypertensive cardiovascular disease that the Veteran had, but do not include any actual discussion of his PTSD and the impact that it had on his hypertension. The examiner did not acknowledge or discuss the appellant's assertions, as was instructed, and did not actually answer the questions of whether PTSD contributed to the Veteran's death in addition to any other factors. The examiner was also asked to discuss the July 2018 letter from Dr. P.E., in which P.E. wrote that the Veteran's "chronically untreated, severely uncontrolled, disabling PTSD ... is definitely a possible trigger for acute cardiovascular events." The VA examiner referenced this letter, but stated that she "basically indicated that she could not determine a nexus without resorting to speculation," and then provided her own, irrelevant opinion that private providers should not be asked to provide medical opinions because it was a conflict of interest. The Board finds that this greatly mischaracterizes the July 2018 letter, and the VA examiner did not actually consider it or discuss its contents at all. A Board remand confers a right on a claimant to compliance with the remand order, and in this case, the Board's remand instructions have not been acceptably followed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). This issue is therefore remanded so that a new medical opinion can be obtained that actually answers all of the Board's questions in an appropriate manner. The appellant has also submitted additional private treatment records regarding an emergency room treatment just a week before the Veteran's death, and these records, as well as all of his other medical records, should be reviewed by the examiner before providing an opinion. The matters are REMANDED for the following action: Obtain a medical opinion on the etiology of the Veteran's hypertensive cardiovascular disease and cause of death, from an examiner other than the VA psychiatrist who provided the August 2022 medical opinion. The record and a copy of this remand must be made available to, and reviewed by, the examiner. The examiner should then address: a) Is it as likely as not that the Veteran's hypertensive cardiovascular disease was either i) caused or ii) aggravated by his service-connected PTSD? b) Is it as likely as not that the Veteran's PTSD substantially, or materially, combined with hypertension or heart disease to cause his death, or aided or assisted in the Veteran's death? c) Did the Veteran's PTSD cause debilitating effects that rendered the Veteran materially less capable of resisting the effects of the primary cause of death? d) The examiner must discuss i) the appellant's contentions that the Veteran had severe, uncontrolled anxiety and panic attacks that contributed to his hypertension and sudden heart problems and that he had been prescribed clonazepam just says before his death, ii) private treatment records showing that the Veteran had been treated for chest pain associated with panic attacks just a week before his death, and iii) the July 2018 letter from Dr. P.E. which indicates that PTSD could be a trigger for an acute cardiovascular event. The examiner is reminded that even if the Veteran has other primary risk factors for his death, he/she must specifically discuss the impact of the Veteran's PTSD and anxiety attacks. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.