Citation Nr: 1331747 Decision Date: 10/02/13 Archive Date: 10/07/13 DOCKET NO. 10-20 929 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for a psychiatric disorder, to include depression and anxiety, claimed as directly due to service and as secondary to hepatitis C. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD C. Bosely, Counsel INTRODUCTION The Veteran had active service from May 1975 to September 1977. This case is before the Board of Veterans' Appeals (Board) on appeal from a January 2009 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The case is currently under the jurisdiction of the VA RO in North Little Rock, Arkansas. In February 2011, the Veteran testified at a Board hearing before the undersigned. A transcript of this hearing is associated with the claims file. This matter was previously before the Board in August 2012, at which time it was remanded for further development. FINDINGS OF FACT 1. The weight of the credible and most probative evidence of record demonstrates that the Veteran's hepatitis C is not related to any event or circumstance of his active duty service, particularly air jet injector inoculations. 2. The weight of the more probative evidence demonstrates that a currently diagnosed psychiatric disorder, manifested by depression and anxiety, was not incurred coincident with or related to the Veteran's active duty service, to include his symptoms shown during service. CONCLUSIONS OF LAW 1. Service connection for hepatitis C is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. Service connection for a psychiatric disability, to include depression and anxiety, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As set forth in the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information on how a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, regarding the duty to notify, the Veteran was sent letters in June 2008, September 2008, and then again in September 2012 and February 2013, which provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Although complete notice was not provided prior to the January 2009 initial decision, the claims were readjudicated by a March 2013 supplemental statement of the case (SSOC) after compliant notice was provided, he and his representative responded to the notice, and further development was completed. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA timing defect may be cured by the issuance of fully compliant notification followed by readjudication of the claim). Next, as indicated, VA has a duty to assist a claimant in the development of a claim. This duty includes assisting in procuring service treatment records (STRs), all relevant pre-and post-service treatment records, and by providing an examination, when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. "Relevant records" in the context of VA's duty to assist "are those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the [] claim." Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010) (quoting Black's Law Dictionary 1316 (8th ed. 2004), "defining 'relevant' as '[l]ogically connected and tending to prove or disprove a matter in issue; having appreciable probative value-that is, rationally tending to persuade people of the probability or possibility of some alleged fact.'"). Not all of a claimant's medical records will be relevant to a VA disability claim. Id. The Board finds that all necessary development has been accomplished in this case, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In particular, the claims file contains the Veteran's STRs, as well as all relevant post-service medical records available from VA and private treatment providers. In this regard, a February 2005 administrative note shows that the Veteran was awarded SSDI benefits based on disability resulting from an incident in 1998, which is entirely unrelated to any disability now on appeal. At no time during the pendency of this appeal has the Veteran identified the Social Security records as relevant to either claim on appeal. Therefore, the Social Security records need not be obtained. See Golz, 590 F.3d at 1321. In addition to the documentary evidence, the Veteran's testimonial statements are of record, including testimony provided at a hearing before the undersigned Acting Veterans Law Judge. Importantly, the undersigned explained the issues on appeal. Notably, the Veteran and his representative thoroughly described his treatment history, including which records were available and submitted. Where necessary, the undersigned attempted to clarify and identify any additional favorable evidence for submission. The undersigned therefore satisfied all duties as presently directed by 38 C.F.R. § 3.103(c). Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010); see Procopio v. Shinseki, 26 Vet. App. 76, 80 (2012). Overall, the Board has carefully reviewed these medical records and testimonial statements. They disclose no additional evidence available, such as medical records, relevant to this appeal. In fact, more recently, the Veteran was provided a SSOC in March 2013. This SSOC listed the evidence used to decide the claim. The Veteran's representative responded later in March 2013 stating that there was no further information or evidence to submit. Also, the Veteran was afforded VA examinations, most recently in September 2012 and January 2013, respectively, to address the medical questions raised by the case. Although the Board below discusses an inadequacy in the factual premise relied on by the September 2012 VA examiner, the examiner's mistake is more favorable to the Veteran in this instance. Therefore, the Board finds that the September 2012 VA examination is nonetheless adequate to decide the claim. Otherwise, the Board finds that the VA examinations are adequate to decide the case because, as shown below, they were based upon consideration of the Veteran's pertinent medical history, including his lay assertions and his current complaints, and because they sufficiently inform the Board of the examiners' medical judgment on those medical questions and each examiner's essential rationale for the opinions. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). The Board accordingly finds no reason to remand for further examination. Finally, the Board also finds that there was substantial compliance with the August 2012 Board remand directives. Specifically, the Veteran was sent corrective notice letters upon remand in September 2012 and February 2013. Next, as directed, the Veteran's outstanding VA treatment records were obtained and associated with the claims file. He also underwent adequate VA examinations to address the complex medical questions raised by the case. Finally, the matter was readjudicated in a March 2013 SSOC, as directed by the Board. Accordingly, there was substantial compliance with the prior Board remand directives, and no further remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to the internal medicine specialist requested by the Board). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the appeal. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Analysis The Veteran is claiming entitlement to service connection for hepatitis C (HCV) and a psychiatric disorder. As he testified at his February 2011 Board hearing, he contends that he contracted HCV during service while receiving immunizations via an air jet injector. Hr'g Tr. 8-10. With regard to the claimed psychiatric disorder, he maintains that he first experienced symptoms during service. Hr'g Tr. 18. Alternatively, he contends that he now suffers from a psychiatric disorder secondary to his HCV. A. Law Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a), may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. However, if chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may nonetheless be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability, which includes the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Aggravation, for VA purposes, is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b). Accordingly, to prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (Fed. Cir. 2009); see also Walker v. Shinseki, 708 F.3d 1331, 1334 (Fed. Cir. 2013). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See 38 U.S.C.A. § 7104(d); Fagan, 573 F.3d at 1287-88; Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). In making its determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). B. Discussion The Veteran's two claims of service connection present different factual backgrounds and legal components. The Board will therefore address them separately. 1. HCV (a) Existence of a Present Disability The record on appeal confirms a present diagnosis of HCV. As the Veteran maintains, a September 1990 letter from the Red Cross shows that he tested positive for the disorder. Therefore, the first criterion to establish service connection is met. (b) In-Service Incurrence or Aggravation of a Disease or Injury Next, the Board finds that it is as likely as not that the Veteran received immunizations during service via an air jet injector. The evidence, including the STRs, neither confirm (nor rebut) the Veteran's assertions of such inoculations. However, he submitted buddy statements and other information indicating that immunizations via this method were commonplace at the time of his service. Although none of these statements are from first-hand witnesses who directly observed the Veteran receiving immunizations via an air jet injector, they establish that such a practice was common. Therefore, the evidence is in a state of relative equipoise in showing that the Veteran at least as likely as not received an injection via air jet injector. There is no question that HCV was not diagnosed during the Veteran's service. In fact, in support of his appeal, the Veteran submitted a brochure from hcvadvocate.org showing that a medical test for HCV did not exist in the medical community until the 1990s. Accordingly, the lack of a confirmed diagnosis during service is immaterial in this case and does not weigh against the appeal. (c) Nexus In light of the above findings, the central question remaining in this case concerns whether the Veteran's confirmed HCV is the result of receiving an immunization via air jet injector during service. The Board observes that HCV is not a chronic disease listed in 38 C.F.R. § 3.309(a). Thus, chronicity and continuity of symptomatology are not for consideration here. Otherwise, there is no intervening evidence between the Veteran's discharge in September 1977 and the confirmed diagnosis in September 1990. This absence of evidence is immaterial in this case. See Horn v. Shinseki, 25 Vet. App. 231, 239 (2012) (quoting Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011)) (an absence of evidence may generally not be considered substantive negative evidence)). Rather, the question of causation here involves whether the disease was incurred during service notwithstanding the absence of intervening evidence of such. In other words, the Veteran contends that HCV was present, but undiagnosed, during service and thereafter until the confirmed diagnosis in 1990. On this issue, the record before the Board contains some evidence favorable to the claim and some evidence unfavorable to the claim. Under such circumstances, the Board's duty is to assess the probative value of the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69 (1993). Where there is conflicting medical evidence, the Board may favor one medical opinion over another if it offers an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Although all opinions by a medical professional constitute medical conclusions that the Board cannot ignore or disregard, the Board is not obligated to accept any physician's opinion. See Willis v. Derwinski, 1 Vet. App. 66, 70 (1991); Hayes, 5 Vet. App. at 69. Accordingly, in determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history/background) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a veteran for a long period of time or through a factually accurate medical history reported by a veteran. See id. at 303-04. A VA examiner, however, need not discuss each piece of favorable evidence in the record. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012). The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Bostain v. West, 11 Vet. App. 124, 127-28 (1998); Obert v. Brown, 5 Vet. App. 30, 33 (1993). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative weight of a medical opinion comes from its reasoning, and the lack of discussion as to how the medical conclusions were arrived at prevents a proper assessment of whether those conclusions were based on a sufficient evidentiary basis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Horn v. Shinseki, 25 Vet. App. 231, 241-42 (2012). In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304. However, a VA examination is not nonprobative simply because the opinion does not "explicitly lay out the examiner's journey from the facts to a conclusion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Rather, the VA examination report "must be read as a whole" to determine the examiner's rationale. Id. Consequently, if the opinion is merely lacking in detail, then it may be given some weight based upon the amount of information and analysis it contains. Id. In short, a medical opinion will be considered probative if it includes clear conclusions and supporting data with a reasoned analysis connecting the data and conclusions. A medical opinion that is factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez, 22 Vet. App. at 304. In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012). If credible, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King, 700 F.3d at 1345. Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence or common knowledge of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438 (J. Lance concurring). Here, weighing against the claim, the Veteran sought treatment at VA in December 2004 and gave a history of risk factors involving chronic alcohol use and nasal cocaine in the 1970s. A December 2004 gastroenterological consultation record also includes an assessment of "[p]rior drug use 'quit 30 years ago'." This evidence, particularly the December 2004 admission of intranasal cocaine use, is highly believable for two reasons. First, intranasal cocaine use is a recognized risk factor for HCV as demonstrated by a VA risk factors questionnaire. The Veteran's December 2004 admission, as it could have subjected him to criminal liability, is a statement against his interest, which tends to heighten the trustworthiness of the statement. See, e.g., Fed. R. Evid. 804(b)(3); Bielby v. Brown, 7 Vet. App. 260 (1994). Second, and more persuasively, the statements were made during outpatient treatment, which indicates that they are candid statements made for purposes of seeking medical care for his HCV. Statements made in this context have long been held to have special guarantees of credibility. See White v. Illinois, 502 U.S. 346, 356 (1992); Rucker v. Brown, 10 Vet. App. 67, 73 (1997); see also Fed. R. Evid. 803(4). Regardless of whether the Veteran's intranasal cocaine use occurred during service, it establishes a known alternative risk factor. See 38 C.F.R. § 3.301(d) (stating that an injury or disease incurred during active service shall not be deemed to have been incurred in the line of duty if such injury or disease was a result of the abuse of drugs). Therefore, these statements are especially probative evidence tending to weigh against the claim. Also weighing against the claim, the Veteran underwent a VA examination in connection with the instant appeal in September 2012. The VA examiner concluded that the Veteran's HCV is less likely than not related to service. The Board finds that this opinion is highly persuasive as it is fully articulated with clear conclusions, based on an adequate factual foundation, and supported by sound reasoning. In addition to being clear and unequivocal, the examiner based this conclusion on an adequate medical history, including the Veteran's risk factor being air jet injector inoculations during service. Additionally, the examiner completed a clinical evaluation, including review of diagnostic testing. Finally, the examiner reasoned that there are no reputable medical studies showing that inoculations with air jet injectors cause HCV. The Board recognizes that the VA examiner reached his opinion based on an incomplete factual premise. That is, the examiner noted that the only HCV risk factor was the air jet injector inoculation. Thus, it does not appear the examiner accounted for the Veteran's past history of intranasal cocaine use. Nonetheless, the examiner's incomplete factual premise is more favorable to the Veteran's claim. Accordingly, the inaccurate assumption does not materially diminish the otherwise highly persuasive opinion. See, e.g., Kahana v. Shinseki, 24 Vet. App. 428, 439 n. 8 (2011) (Lance, J., concurring) (distinguishing an incorrect factual premise, which has no probative value, from an incomplete factual premise). In short, the September 2012 VA examiner provided an opinion that is factually adequate, fully articulated, and based on sound reasoning. It therefore carries significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Also unfavorable, the September 1990 Red Cross letter, which confirms the diagnosis, explains that although HCV has been shown to be spread by blood transfusion and I.V. needles, in the majority of cases, the source of infection is not known. This statement, as a medical fact, is important as it informs the Board of this general medical principle concerning sources of HCV infection. In summary, the evidence weighing against the claim consists of the Veteran's adverse admission during VA treatment, an unfavorable VA medical opinion, and a Red Cross letter. This evidence collectively makes it less likely that his HCV is the result of the claimed air jet injector immunizations. In fact, the Red Cross letter shows that the source of most HCV infections is unknown. The September 2012 VA opinion establishes that air jet injectors are not a known HCV risk factor. Finally, the VA treatment record affirmatively establishes a known risk factor in the Veteran's case. Although this evidence does not conclusively establish the source of the Veteran's HCV, it provides another factor that weighs against the Veteran's claim. In contrast to the highly persuasive evidence unfavorable to the claim, the record on appeal also includes considerable evidence supporting his claim. For numerous reasons, however, this favorable evidence holds little probative weight. First, the Veteran himself has offered his own opinion relating his HCV to service. Although lay persons are competent to provide opinions on some medical issues, the specific issue in this case, the causal relationship between jet gun inoculations and the Veteran's HCV, falls outside the realm of common knowledge of a lay person. In fact, this question of specific causation is not subject to lay observation. To the contrary, it is the subject of advanced medical knowledge concerning complex biological processes, pathologic relationships, and physiological functioning within the human body. Thus, it is not within the competence of a lay person. Otherwise, the Veteran has not shown that he possesses the requisite medical training or credentials needed to support a competent medical opinion on this question. As such, his lay opinion is not competent evidence supporting the claim. See Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007). Also important, the Veteran completed a VA risk factors questionnaire in connection with the instant appeal, denying all risk factors. He has made similar statements throughout his appeal. Of note, he testified at his Board hearing that he had been married to his current wife since June 1975, and he specifically denied using drugs, needles, or getting tattoos. Hr'g Tr. 3, 6. However, his statements are directly contradicted by the December 2004 VA outpatient treatment record showing his admission of intranasal cocaine use. When compared with the December 2004 VA outpatient record, his statements denying such a risk factor appear much less reliable. Notably, his statements made in direct support of his instant claim cast his history in a light more favorable to this end. This conflict compels a finding that his statements denying any intervening risk are less reliable and accurate. They are therefore noncredible and unpersuasive evidence. In an April 2009 letter, a private physician, Dr. D.R.O., confirmed that the Veteran has HCV. He noted that the Veteran had no previous history of surgery, blood transfusion, intravenous drug abuse, or high-risk sexual behavior to explain a possible exposure to HCV. The Veteran told Dr. D.R.O. that he had received immunizations in the military using the multi-dose compressed air injection devices, and he and other inductees had blood oozing from their injection sites. Dr. D.R.O. stated that given that the transmission of HCV occurs by exposure to infected blood or other body fluids, "it is as likely as not that this may possibly have been the exposure for [the Veteran]." The Board finds that this April 2009 opinion, while entirely favorable to the claim, is of little evidentiary value for two reasons. First, it is based on the incorrect factual premise that the Veteran had no potential risk factor other than the air jet gun inoculations during service. More importantly, the opinion itself is phrased in speculative terms. In other words, the central question here is not whether the Veteran "may possibly" have HCV due to service, but rather whether it is at least as likely as not that HCV is actually due to service. Such equivocation and speculativeness limits the probative value of the April 2009 opinion. See Nieves-Rodriguez, 22 Vet. App. at 304; Obert v. Brown, 5 Vet. App. 30, 33 (1993). Next, in an April 2009 letter, Dr. R.G.W., a VA psychiatrist, noted that the Veteran had depression which was exacerbated by HCV that was as likely as not contracted by his military immunizations. This opinion, as with the April 2009 physician's letter entirely supports the claim. But, it likewise has little probative value. First, the letter does not make clear whether the psychiatrist is simply transcribing the Veteran's own allegations establishing etiology or, by contrast, whether the psychiatrist is offering an independent opinion relating the Veteran's HCV to his inoculations during service. Such a lack of clarity reduces the probative value of the opinion. Moreover, no rationale or explanation is given to justify this opinion, which further limits the probative weight assignable. See Nieves-Rodriguez, 22 Vet. App. at 300-01. The Veteran himself wrote in a July 2008 statement that he has been told by "many doctors" that his inoculations during service are the source of his HCV. The Board observes that the record on appeal does not contain "many" medical opinions. In fact, apart from the two opinions from April 2009, the record contains none, though the evidentiary record is, in this regard, complete. Even assuming the credibility of the Veteran's statements relaying the opinions, however, the Board is unable to assess the evidentiary value of such medical opinions. More specifically, the Board cannot determine the factual premise and reasoning underpinning such favorable medical opinions. See Nieves-Rodriguez, 22 Vet. App. at 304. Therefore, these medical opinions have little probative value and are not sufficiently probative or persuasive to controvert the unfavorable evidence discussed immediately above. Similarly, the record on appeal includes VA treatment records, such as in September 2008, documenting the Veteran's allegation that he contracted HCV during service. These records, which transcribe the Veteran's allegation, provide no further evidentiary support for his claim than his own statements as they do not contain a medical opinion either confirming (or rebutting) the Veteran's allegations. They are therefore no more probative than the Veteran's own noncompeting lay opinions. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Finally, the Veteran has offered into evidence various prior Board decisions, service member statements, brochures, an Army regulation amendment, and other general information concerning HCV and air jet injectors. This evidence, however, provides little support for his claim either individually or collectively. As a threshold matter, it is important to understand that previously issued Board decisions are nonprecedential. See 38 C.F.R. § 20.1303. In other words, those cases were decided on the basis of the individual and distinct facts presented. Thus, although service connection may have been found due to jet gun inoculations in those cases, they do not otherwise inform the Board's instant determination based on the distinct facts of this Veteran's case. See id. Next, the "buddy" statements are best summarized in a June 2010 statement where it is written that "Many veterans found out that they at that time as likely as not were exposed to bloodborne [sic] diseases such as hepatitis C (HCV) and are not having to fight for life . . . . These people are deserving and I believe should be granted [service connection]." Importantly, these lay statements are not from individuals who have known the Veteran. Rather, they are simply aspirational statements setting forth the personal beliefs of the declarants. More importantly, as with the Veteran's own lay statements, these buddy statements are lay statements, which are not competent evidence establishing a causal relationship. See Nieves-Rodriguez, 22 Vet. App. at 304. As such, they are assigned correspondingly limited probative weight. Similarly, the remaining evidence cited is not highly probative. For instance, an undated brochure from HCVets.com (received into evidence in April 2008) is representative of such submissions. This brochure proclaims that service members have a higher rate of HCV infection, citing four doctors who indicated that jet guns were contaminated with bodily fluids. Such statements of general information are not material in this case. Importantly, they assert a degree of correlation, but not causation, between rates of HCV infection amongst service members. More significantly, this evidence does not address or inform the central question of causation specific to the facts of the instant Veteran's case. Also significant, a predominant feature in this brochure is a headline declaring "make hepatitis C a presumed service connected disease." This headline establishes that the purpose of the brochure is to promote a political cause; thus it is not consistent with a disinterested statement relaying objective medical information. It is therefore less persuasive. Overall, the Veteran has submitted considerable non-specific evidence indicating that there may be an increased risk or correlation between veterans who received inoculations via air jet injector and HCV. However, this evidence is too general and inconclusive, even when considered in combination with the remaining evidence, to be of more than minimal probative weight. See Sacks v. West, 11 Vet. App. 314, 317 (1998); Mattern v. West, 12 Vet. App. 222, 228 (1999). The Board also takes notice of an April 2007 VA Gastroenterology treatment record, which documents that the Veteran presented for a "second opinion" on an outpatient basis. At that time, the Veteran informed the gastroenterologist that the only possible place of HCV contraction was the vaccination guns in 1975-77 while in the service; he denied intravenous drug use, transfusions, or sexual exposure. The physician, after reviewing the Veteran's biopsy history, "discussed at length" with the Veteran the natural history of HCV, including the percent of patients that will progress to cirrhosis. The physician noted that if indeed the Veteran contracted HCV in 1975-77, and his biopsy showed no fibrosis 30 years later, he is likely in the 80 percent category of patients that will not develop cirrhosis. The Board observes that this April 2007 statement is not an opinion as to etiology of HCV. Rather, when read in context, it is more consistent with an opinion as to the likelihood that the Veteran will develop cirrhosis as a result of his HCV. Although the clinician stated "If indeed he contracted Hepatitis C in 1975-77," this statement is simply a tentative premise to show the likelihood that the Veteran will develop cirrhosis. Accordingly, an overall reading of the treatment record shows that this is not a statement either confirming or rebutting the Veteran's allegation that he contracted HCV during service. Thus, it neither supports nor weighs against the claim. In summary, the record on appeal contains considerable evidence supporting the appeal. However, for the reasons discussed, this favorable evidence has little to no probative weight. Overall, when comparing the probative value of the unfavorable evidence, which is substantial, with that of the favorable evidence, which is minimal, a preponderance of the evidence is against a finding that HCV is due to any event during service, including the air jet gun inoculations during service. In reaching this conclusion the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. A Psychiatric Disorder The Veteran has broadly defined the scope of his claim of service connection for a psychiatric disorder. In his April 2008 original claim, he wrote that he was seeking service connection for depression and anxiety. The medical evidence of record submitted in support of the claim shows a similar range of conditions. The Board will therefore assume that the Veteran intends to seek service connection for all diagnosed psychiatric disorders. See Brokowski, 23 Vet. App. at 86-87; see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). By contrast, the record on appeal also includes evidence of headaches, variously diagnosed as tension headaches and migraines. Of note, the Veteran wrote in his October 2009 notice of disagreement (NOD) received in November 2009 that his symptoms of depression and anxiety included severe headaches, chest pain, gastrointestinal problems, and irritability. Notwithstanding his NOD, headaches are shown to be a distinct diagnosis that can be expressed without recourse to complex medical terminology. And, importantly, the agency of original jurisdiction (AOJ) has not separately developed or adjudicated the scope of the instant claim to include headaches. As such, and to the extent the Veteran wishes to seek service connection for headaches, the Board finds that he would be substantially prejudiced by including headaches within the scope of the instant claim. Doing so would deprive him of his full due process rights regarding headaches, including his right to one review on appeal. Therefore, the Board will exclude headaches from the scope of the instant appeal. 38 U.S.C.A. § 7104; Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Headaches will be discussed below only to the extent necessary for context and clarity. With this background in mind, the Board notes that the Veteran raises alternative theories of entitlement. First, he maintains that a psychiatric condition first started during service. Second, he contends that a psychiatric condition is secondary to HCV. Because service connection has been denied for HCV, service connection for a psychiatric disorder secondary to HCV is precluded as a matter of law. See 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448. The Board will, therefore, proceed with discussion of the direct theory of entitlement. (a) Existence of a Present Disability The record on appeal establishes the existence of a present disability. Most recently, the Veteran underwent a VA examination in January 2013, which resulted in a diagnosis of depressive disorder, not otherwise specified (NOS) and generalized anxiety disorder (GAD). (b) In-Service Incurrence or Aggravation of a Disease or Injury The record on appeal also establishes that the Veteran experienced psychiatric symptoms during service. Specifically, the STRs show a sick call visit in March 1977 for "nerves." At that time, he was noted to be upset, nervous, irritable, and very hostile toward coworkers in duty station. He was complaining of his work conditions, and he stated he could not cope with his working conditions and fellow workers. He was seeking ways to be relieved of flight line duty, feeling that he was being worked excessively and having to do more than his share. A diagnosis was deferred at that time, but he was referred for consultation with the mental health clinic. (The STRs show that he failed to report to the appointment at the mental health clinic.) The Veteran's current statements, including his February 2011 Board hearing testimony, are consistent with the STRs. Accordingly, the record on appeal shows in-service incurrence of psychiatric symptomatology. (c) Nexus Because the Veteran's disability is not a chronic disease listed in 38 C.F.R. § 3.309, service connection is not available on the basis of chronicity shown during service or continuity of symptoms after discharge, pursuant to 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Rather, in light of the above two findings, the remaining question before the Board concerns whether the evidence establishes a nexus between the current psychiatric condition and in-service symptomatology. On this question, the evidence establishes that it is less likely than not that a nexus exists between the Veteran's current psychiatric condition and the symptoms shown during service. First, the STRs include a September 1977 separation examination showing that a clinical psychiatric evaluation was "normal," and the Veteran denied all pertinent symptoms, including depression or excessive worry and nervous trouble of any sort. This is persuasive evidence against the claim because it affirmatively shows the absence of a psychiatric disorder when tested at discharge. See Horn v. Shinseki, 25 Vet. App. 231, 239 (2012) (quoting Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011)); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The post-service evidence does not then contain affirmative, contemporaneous records showing either the absence or existence of ongoing symptoms after service. However, in his April 2008 claim, the Veteran identified October 1983 as the date his depression and anxiety began. Consistent with this assertion, the record on appeal includes several treatment records from 1983 showing onset of symptoms proximate in time to that date. First, in October 1983, he was hospitalized at a private facility. The hospitalization records show a history involving prior treatment by his private doctor for headaches one and a half years previously. He then had no more treatment until April 1983, when he was unemployed with a series of financial burdens, which continued. Immediately prior to his hospitalization, he had a poor appetite for 3 weeks, had not been sleeping well, and had other symptoms including irritability and suicidal thoughts. The Veteran stated that "he has not had any previous involvement with the Mental Health Center." The Veteran also underwent a complete psychiatric evaluation in October 1983. Again noting difficulty sleeping for the past 3 weeks, with depression, it was also noted that he had been laid off from work for 2 months prior to the onset of these symptoms. Then, it is noted that "There is no previous history of psychiatric illness. His birth and developmental histories are normal. There is no pertinent medical or surgical history." The summary likewise reflects symptoms of depression manifested by insomnia, loss of appetite, and anxiety for the past 3 weeks. He was then seen again in December 1983, where it was noted that his last treatment in October was for "a rather typical dysthymic disorder which had been precipitated by unemployment." At the time of the December 1983 evaluation, the Veteran was noted to have improved on medication, but recently had automobile trouble and his depression had returned with similar symptomatology. The assessment was relapse of dysthymic disorder precipitated by unfortunate events during the holidays. The record on appeal next includes treatment records from November 1984, June 1986, and a second hospitalization through April 1987 showing substantially similar symptomatology. For instance, in June 1986, a psychiatrist noted symptoms for 10 days, which were characterized as "sudden onset, which may be situational." Thereafter, the record on appeal consists of intermittent private and VA records, such as in June 1995 and October 1998, again characterizing symptoms that were "situational." Notably, in August 2003, it was observed that his life was "in shambles" since 1998 when something fell on him. These treatment records are highly persuasive evidence against the claim for several reasons. First, they are contemporaneous evidence showing that symptoms were precipitated by non-service related factors, such as losing a job, financial difficulties, and an accident. Second, they demonstrate his admissions that such symptoms began nearly contemporaneous to those events, rather than many years earlier during service. As explained herein above, statements such as these made for treatment purposes are considered especially reliable and, as such, highly probative. In fact, the only ambiguity arises in the June 1986 notation that the Veteran had treatment "several years ago." However, it is clear from this record that "several years ago" refers to 1983. Accordingly, this post-service medical evidence tends to weigh greatly against the claim. More recently, several pertinent treatment records continue to directly relate his symptoms to contemporary circumstances. For instance, a February 2005 mental health record affirmatively documents a history involving "2 previous bouts of depression in the last 20 years. This most recent problem started in 1998 when he was struck by a tree in the neck and upper back." The assessment was that he "has a history of depression and has been treated in the past with multiple antidepressants without effectiveness." The Board observes that 20 years prior to 2005 would be 1985, which is most consistent with the onset of symptoms shown in 1983. Likewise, an April 2005 VA mental health record shows "rage," which was "directed inward and is associated with his injury when the tree fell on him in 1998." It was found at that time that "[s]ituational stressors surrounding fears of loss of VA ben[e]fits are contributing to acuteness of anxiety today." Then, in July 2006, it was determined that the Veteran was experiencing anxiety related to being bothered by financial concerns and creditors scaring him. These outpatient treatment records, as with the earlier records, weigh against the claim as they persuasively indicate that the Veteran's symptoms are related to the post-service events described. In connection with his instant appeal, the Veteran was afforded a VA mental disorders examination in April 2010. After a review of the claims file and an interview with the Veteran, the examiner diagnosed depressive disorder, not otherwise specified. The examiner stated that there was no evidence that depression or anxiety began during service. The examiner reasoned that the Veteran was seen in service in 1977, which resulted in referral to mental health, but he did not get treatment and his records then "appear" silent until 1984. Therefore, the examiner found that he "do[es] not have any evidence that the Veteran's anxiety began during service." Later in the examination report, the examiner restated this opinion, then clarified that he "did not see any evidence that it had begun prior to 1984." As the Board previously explained in its August 2012 remand, this VA examiner's opinion does not fully address whether the Veteran has a current psychiatric disorder that is the result of his service. Instead, it only addresses whether a psychiatric disorder started during service. The April 2010 VA examiner's opinion is, therefore, assigned reduced probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. More recently, in January 2013, the Veteran underwent a second VA examination. The VA examiner concluded that based on the totality of the record, the Veteran's depression and anxiety "are both less likely as not related to his time in the military from 1975 to 1977." The Board finds that this VA examination is highly probative evidence. First, the examiner based this opinion on a review of the Veteran's pertinent medical history, including the STR entry in March 1977. The examiner also relied on the post-service reports of treatment from the Veteran's family practice physician and first psychiatric treatment in the early 1980s. The examiner also observed that the next documented mental health contact was in October 1983, explaining that this record shows complaints of symptoms for 3 weeks with no prior psychiatric treatment. Also, according to the examiner, a December 1983 treatment record shows precipitants as unemployment, financial, and family stressors. In short, the January 2013 VA examiner provided a clear opinion based on a complete and accurate factual foundation. Although the examiner did not specifically state why the cited facts support his opinion, an overall reading of the examination report makes clear that it is the examiner's opinion that the current diagnosis did not begin until many years after service, resulting from non-service related circumstances discussed. The VA examiner's opinion is assigned a correspondingly heightened degree of probative value consistent with the clarity of the opinion. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board further observes that the January 2013 VA examiner's opinion is uncontroverted by any other competent and probative evidence of record. In this regard, the Board takes notice of an April 2007 VA psychiatric record showing an assessment of major depressive disorder, recurrent, severe. Although the term "recurrent" could be representative of a nexus opinion, the Board finds that, when reading the term in the context of the treatment report overall, it is not reasonably consistent with a statement as to onset. However, even assuming that the term "recurrent" here was intended to indicate persistence over time, this statement does not show persistence since service. Any lack of clarify in this regard renders the assessment minimally probative. See id. Finally, the Veteran himself has offered his own opinion relating his psychiatric condition to service. For instance, he indicated at his Board hearing that he had continued symptoms after service, but had no health insurance, so did not seek treatment. Hr'g Tr. 22-23. He wrote in a July 2008 statement that he dealt with his symptoms after service by drinking alcohol. Again, as with his claimed HCV, these statements are contradicted by the contemporaneous statements in the 1980s, which were made during treatment and are more reliable. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997); see also Fed. R. Evid. 803(4). His current lay statements certainly portray his case in a light more favorable to his claim, but this calls into question the credibility of those assertions. Lacking credibility, they are of no probative weight. Several VA treatment records, such as in April 2007, similarly document the Veteran's allegation that his depression and anxiety existed while in the military. These records, which transcribe his statements, provide no additional support for his claim as they do not reflect a medical opinion by the transcriber either confirming (or rebutting) the Veteran's allegations. In other words, they are no more probative than his noncredible testimony. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Otherwise, the specific issue in this case, the causal relationship between symptoms during service and symptoms beginning many years later, falls outside the realm of common knowledge of a lay person. To the contrary, it is the subject of advanced medical knowledge as best demonstrated by the professional medical opinions obtained in this case. Thus, the question for causation in this case is not within the competence of a lay person. Otherwise, the Veteran has not shown that he possesses the requisite medical training or credentials needed to support a competent medical opinion on this question. As such, his lay opinion is not competent evidence supporting the claim. See Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007). In summary, the record on appeal consists of highly persuasive and probative evidence, including the January 2013 VA medical examiner's opinion showing that it is less likely that a current psychiatric condition was incurred coincident with service. Accordingly, the weight of the evidence is against the "nexus" element necessary to establish service connection. For these reasons, the Board finds that the weight of the evidence is against the Veteran's claim of service connection for a psychiatric disorder manifested by depression and anxiety. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for hepatitis C is denied. Service connection for a psychiatric disorder, to include depression and anxiety, is denied. ____________________________________________ M. Sorisio Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs