Citation Nr: 1301795 Decision Date: 01/16/13 Archive Date: 01/23/13 DOCKET NO. 03-34 788 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for hepatitis C. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1974 to January 1976; the service department has also certified that the Veteran served under an assumed name (David D. Darring) from May 1978 to December 1978. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2003 rating decision of the Muskogee, Oklahoma Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claims file is now in the jurisdiction of the Columbia, South Carolina RO. In June 2006, November 2008, and November 2010, the case was remanded for additional development. Thereafter, the Board sought an advisory medical opinion (received in June 2012) and a clarifying addendum (received in August 2012) from the Veterans Health Administration (VHA)). The Board observes that a January 2009 RO rating decision denied service connection for undiagnosed liver disorder. The Veteran did not file a notice of disagreement with this denial and the issue is not in appellate status. The issue currently on appeal contemplates whether service connection may be warranted for any current liver diagnosis shown during the pendency of this appeal; it does not include any theory of entitlement to service connection for an undiagnosed disability. FINDING OF FACT The Veteran is not shown to have hepatitis C (or to have had such disease at any time during the pendency of this claim). CONCLUSION OF LAW Service connection for hepatitis C is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of his claim prior to its initial adjudication. Notification letters sent in November 2002 explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. An August 2006 letter also informed the Veteran of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record and has not alleged that notice in this case was less than adequate. While fully complete and adequate notice was arguably not provided prior to the initial adjudication of the instant claim, the case was subsequently readjudicated in a December 2011 supplemental statement of the case (SSOC), curing any notice timing defects. Prickett v. Nicholson, 20 Vet. App. 370 (2006). Copies of the Veteran's available pertinent service treatment records (STRs) are associated with his claims file. The record (including the June 2006 Board remand) contains references to service treatment records (STRs) from both periods of service, suggesting that such records were previously associated with the record. The Board's close review of the record prior to previous remand found that the record includes service personnel records from the Veteran's first period of service (which includes some treatment records related to a significant knee disability that was the basis for his separation from the first period of service) and extensive treatment records (postservice prison treatment records) from the U.S. Department of Justice. Notably, some of the service department record envelopes that are labeled as, "STRs [or service medical records] copies of the original," are actually copies of the Veteran's postservice prison records, and are therefore incorrectly labeled. Prior to previous remand, the Board conducted an exhaustive search for the Veteran's STRs, to include contacting the Columbia, South Carolina RO; the Remand & Rating Development Team in Huntington, West Virginia; and the South Carolina VA Medical Center. Each of the aforementioned facilities responded that they are not in possession of the Veteran's STRs. As the Veteran's STRs have been lost or destroyed, or are otherwise unavailable, VA has a well-established heightened duty to assist him in developing his claim. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). This includes a search for alternate sources of service treatment records. See Cromer v. Nicholson, 19 Vet. App. 215 (2005). In this regard, the Board notes that with correspondence received in February 2009 and in January 2011, the Veteran enclosed copies of several treatment records from his second period of service (under the assumed name, David D. Darring) and indicated that there were no additional service treatment records in his possession. The January 2011 correspondence was in reply to the RO's November 2010 request for all service records in his possession (in accordance with the November 2010 Board remand). The Veteran's pertinent available postservice treatment records have been secured. He was afforded a VA examination and expert medical advisory opinions addressing the instant matter in October 2003 (VA medical advisory opinion), July 2008 (VA examination with medical opinion), June 2012 (VHA medical advisory opinion), and August 2012 (clarifying addendum to the VHA medical advisory opinion). As discussed below, the Board finds that (following the August 2012 clarifying addendum) the VHA medical advisory opinion is adequate for the purposes of this decision. The Board finds there has been compliance with the instructions of the November 2010 remand regarding the matter at hand (directing that the RO should advise the Veteran that his STRs from both periods of service that were associated with his claims file have been lost or destroyed and requesting that he submit any copies in his possession). The Veteran has submitted evidence and not identified any additional pertinent evidence that remains outstanding. Accordingly, the Board finds that VA's duty to assist is met and will address the merits of the claim. B. Legal Criteria, Factual Background, and Analysis Initially, the Board notes all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic database storage), with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection, there must be medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 381 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (e.g., a broken leg), (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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, competent medical evidence is necessary when the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). 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)(2). The Board finds that service connection is not warranted for hepatitis C in this case because, after significant development of the medical evidence on this question, the probative medical evidence indicates that the Veteran does not have hepatitis C and has not had hepatitis C during the pendency of this claim. Moreover, the Board finds that there is no diagnosis of any other manner of liver disability manifesting in the claimed symptoms during the pendency of this claim; there is no diagnosed chronic liver disability for which service connection is sought in this case. Service records from the Veteran's first period of service include some STRs related to a significant knee disability that was the basis for his separation from the first period of service. STRs from the Veteran's second period of service, in the U.S. Army, show that on pre-induction examination in January 1978 it was noted he had a tattoo near his right shoulder. In the associated report of medical history, he denied having or ever having had jaundice or hepatitis, or any stomach, liver, or intestinal troubles. In May 1978, he attempted to donate blood and was found to have an elevated total bilirubin of 1.7 mg/100ml. He was referred for evaluation of potential medical problems and, in June 1978, was given a provisional diagnosis of atypical hepatitis. In July 1978, he was referred for additional evaluation after it was felt he might have recurring hepatitis. After reviewing the Veteran's hospitalization records from earlier that month, the physician stated there was "no evidence that he ever had hepatitis," and instead opined that the Veteran had benign Gilbert's syndrome. On August 25, 1978, the Veteran presented with complaints of malaise, fatigue, early satiety and right upper quadrant epigastric discomfort with prior history of abnormal liver function tests and abnormal liver/spleen scan. The physician stated that the "most likely possibility" for these symptoms was a viral syndrome, which included a mild hepatitis. Included in this category were EB virus, CMV, toxoplasmosis, adenovirus, herpes simplex, and Type A and Type C hepatitis (although the Veteran was noted as having a negative surface antigen). The physician also stated that in light of the Veteran's history of night sweats and bilateral axillary adenopathy, Hodgkins and non-Hodgkins lymphoma needed to be considered. The physician stated, "In light of the myriad of diagnoses with which the patient has been labeled in the past, to include acute hepatitis, Gilbert's syndrome and Dubin-Johnson's, I have done my best to avoid giving him a specific diagnosis at this point." Five days later, on August 30, 1978, the Veteran was seen by the same physician again. For reasons more fully explained in his consultation report (which is included in the record), he stated, "I am convinced that this patient does not suffer from EB, MV, toxoplasmosis, adenovirus, Type A Hepatitis, Dubin Johnson's or Gilbert's syndrome. My tentative diagnoses for this patient is atypical hepatitis, though this does not account for the repeat episodes [he] is experiencing." In November 1978, the Veteran was afforded a service separation physical examination. Clinical evaluations of all physical systems were normal; it was noted that he had tattoos on both arms. It was also noted that he had a history of Dubin-Johnson's syndrome. In the associated report of medical history, he indicated that he had a history of jaundice or hepatitis, and of stomach, liver, or intestinal trouble. The Veteran's extensive postservice treatment records show that hepatitis C was diagnosed by laboratory findings in 1999 (prior to the pendency of this appeal). In various statements, he asserts that he was misdiagnosed in service as having Dubin-Johnson's syndrome, Gilbert's syndrome, and the Epstein Barr virus, pointing out that they are hereditary diseases for which he does not have a family history, and which subsequent testing has shown he does not have. It continues to be his contention that he experienced a hepatic episode in May 1978, and that he currently suffers from hepatitis C related to that incident in service. In October 2003, the Veteran's claims file was forwarded to an examiner for review (because the Veteran was in prison and not available for a physical examination) and an opinion as to whether he had hepatitis C that was incurred in service. In reviewing the Veteran's extensive records, the examiner noted that he had "multiple social problems." This included a marriage and divorce within one year of his separation from service, a history of crime, and a potential for multiple sexual partners, which was a risk factor for hepatitis C. He also noted that there was "no administrative nor definite diagnosis of hepatitis entertained when [the Veteran] left the service." The examiner further observed that, in service, the Veteran complained of yellow sclera and dark urine with unchanged stools; this suggested he had some disease that was felt to be Johnson's syndrome or Gilbert's syndrome, and was treated with Phenobarbital. The examiner then noted that the Veteran was currently on Phenobarbital in the prison system; therefore, it was his opinion that the Veteran did not have hepatitis A, B, or C, when he was in service but instead had some viral syndrome. In July 2008, the Veteran was afforded another VA evaluation (this time with a physical examination). He indicated that his risk factors for hepatitis C included one tattoo in between his two periods of service, a second and final tattoo during his second period of service, 60 plus female partners in his lifetime, one homosexual sex encounter in which he was the dominant player, and multiple needle sticks as a paramedic between 1989 and 1991. After reviewing the Veteran's extensive treatment records (from his two periods of active duty service and after service), the examiner noted: In 06/1978 [during the veteran's second period of service], there was a palpable liver edge but an otherwise normal examination with an impression of atypical hepatitis. In 07/1978, it was noted to be an increased unconjugated bilirubin, possible [Gilbert syndrome], although this diagnosis has come and gone over the years. He then reviewed the Veteran's extensive postservice treatment records, and stated: It would appear as if [the Veteran] has hepatitis C viral infection, although it is likely that the pattern we are seeing is that he has cleared the viral titers from his system, which is why it has never been able to genotype the virus. This would also be consistent with repeated normal liver function studies. In addition, it is certainly conceivable that he does, in fact, have Gilbert syndrome. This is a condition of elevated unconjugated bilirubin, also referred to as the indirect bilirubin. He then went on to opine that it was "less likely than yes" that the Veteran had hepatitis C that was incurred in service. He explained that even though it was not clear to him at what point the Veteran developed hepatitis C, the fact that he had an elevated bilirubin during his Army enlistment was "not sufficient evidence that he had the hepatitis C at that point as that could, in fact, have been the Gilbert syndrome." He also weighed the Veteran's multiple risk factors and found that his multiple female sexual partners and multiple needle sticks during his years as a paramedic were more significant than his tattoos or one homosexual contact; therefore, it was more likely that his hepatitis C was derived from these (postservice) events. Although the physician providing the July 2008 opinion did offer the nexus opinion sought, based on the comments given, it appears the examiner felt there was uncertainty regarding the correct diagnosis for the Veteran's disability, and the opinion leaves unclear whether the opinion would be any different if the uncertainty were removed. A January 2009 VA examination report (not prepared in direct connection with this appeal) discusses the Veteran's account of medical history pertinent to the claimed hepatitis C. The examiner makes no diagnosis of hepatitis C. After indicating that confirmation of hepatitis C was pending laboratory testing results, an addendum to the report shows that the examiner interpreted the laboratory results as "within normal limits." In July 2009, the Veteran's representative sought a private medical opinion from Dr. A.M.G. She reviewed the Veteran's claims file and pertinent medical records and noted the following: Hepatitis was diagnosed in June 1978. Clinical records associated with that diagnosis show that the Veteran had, one month earlier, presented with symptoms consistent with a viral infection and an enlarged and tender liver. His bilirubin was also noted to be abnormal at 1.7. He complained of dark urine and generalized myalgias. Blood tests in June 1979 were significant for mild unconjugated hyperbilirubinema with normal transaminases. After service, the Veteran had multiple blood tests during his incarcerations (from 1978 to 1984, from 1985 to 1989, and from 1992 to 2006), and most of them revealed elevated total bilirubin that was essentially mild unconjugated hyperbilirubinema. He was found to be positive for hepatitis C in May 1999, and he was also considered to have Gilbert's syndrome. Dr. A.M.G. then reviewed the July 2008 VA examiner's report and stated that she disagreed with his opinion that the Veteran's acute presentation of liver disease in service was most likely Gilbert's syndrome. She noted that Gilbert's syndrome was an asymptomatic condition whereas the Veteran had manifestations of symptoms suggestive of acute liver disease in service. In the absence of blood tests performed to assess for hepatitis at that time, Dr. A.M.G. stated "it would be difficult to conclude with any degree of medical certainty that the acute liver disease was due to Hepatitis C. It would also be difficult to conclude that it was not Hepatitis C since the tests performed were inadequate to refute this." Regarding the Veteran's risk factors, Dr. A.M.G. concurred with the July 2008 VA examiner's observation that the Veteran had numerous risk factors; however, she also felt it "important to note that there [were] data indicating that a significant predictor of positivity for hepatitis C among veteran populations was a history of tattoos (78% of subjects)." Therefore, given the diagnosis of infectious hepatitis during service, the presence of risk factors that preceded this diagnosis, and the epidemiology of hepatitis C, it was her opinion that it was "at least as likely as not that the acute liver disease that manifested during service was an early manifestation of Hepatitis C." The threshold question that must be addressed here, as in any claim seeking service connection, is whether the Veteran actually has (during the pendency of his claim has had) the disability for which service connection is sought, i.e., hepatitis c. Most recently in March 2012 and in June 2012 requests for a VHA medical advisory opinion, the Board sought to develop medical evidence specifically addressing questions that included this threshold matter. In an opinion dated in June 2012, a VA medical doctor (Dr. R.T.) stated that the Veteran: does not have a chronic hepatitis C infection; he spontaneously cleared the virus after infection (and if his RIBA test is negative, he never really had hepatitis C to begin with, but it is likely that he spontaneously cleared the virus as the specificity of the standard hepatitis C antibody test is close to 98-99%). Dr. R.T. explained that "it is impossible that any of his current health problems are a consequence of hepatitis C- there are no precedents in the medical literature of long term complications from individuals who spontaneously clear hepatitis C" (emphasis in original). Dr. R.T. cited that "on multiple occasions his HCV RNA (the viral load) is undetectable" and "I could not find a documented positive RIBA test in the record" in finding that the Veteran "does not have chronic hepatitis C infection." The VA expert explained that "if and only if his hepatitis C RIBA test is truly positive" then the Veteran's episode of jaundice in 1978 was more likely than not related to an episode of "acute hepatitis C, which spontaneously resolved." The opinion concludes by explaining: this process was self limited ..., it is highly [] unlikely (less than a 0.1% chance based on my review of the natural history of spontaneous resolved hepatitis C infection, for which there are no known complications reported in the medical literature) that he has had any type of disabling symptoms or complications from hepatitis C. In essence, the June 2012 medical expert advisory opinion indicates that even assuming that the Veteran had hepatitis C during service, such infection was acute, and the Veteran does not have any related residual chronic disability. Clearly, the alternative assumption, that the Veteran did not have hepatitis C during service, would likewise weigh against finding any basis for an award of service connection for hepatitis C. Upon reviewing the June 2012 VHA advisory opinion, however, the Board sought to clarify whether the expert opinion contemplates the laboratory report from Bio-Cypher Laboratories, dated May 14, 1999, which indicates that the Veteran's HCV Qualitative RNA (explained as designed to detect hepatitis C infections) was positive. Such information tends to suggest that the Veteran did, in fact, have a diagnosis of hepatitis C at least as recently as May 1999; it was not clear from Dr. R.T.'s June 2012 advisory opinion whether such records were reviewed when he opined that the Veteran did not have a current chronic hepatitis C infection. Notably, the May 14, 1999 lab report follows several copies of a May 10, 1999 lab report in which it was noted that the Veteran's Hepatitis C RNA, PCR was "not detected," and that an improper specimen had been submitted and should be resubmitted. In light of the foregoing, the Board found that clarification of the June 2012 VHA medical advisory opinion was necessary. The Board requested that Dr. R.T. again review the Veteran's claims file and specifically the May 14, 1999 lab report and clarify for the record why the findings reported in that lab report do not reflect a current diagnosis of hepatitis C. In August 2012, Dr. R.T. provided a clarifying addendum to his expert medical advisory opinion. The addendum explained that the finding of a positive qualitative hepatitis C virus PCR from May 14, 1999 did not change his opinion in any way. The opinion reiterates "the claimant does not have chronic hepatitis C," and explains that "[t]he basis for this response is that all follow up hepatitis C quantitative viral loads (which have a sensitivity of over 99%- i.e. le[ss] than 1% false negative rates) have consistently been negative." Dr. R.T. cites: "Specifically, he had a negative hepatitis C viral quantitative viral load on January 30, 2009 and July 8, 2008 (these are just 2 specific dates but there are no other positive viral loads in the records that I reviewed)." Dr. R.T. states clearly and unequivocally "I can state with 100% certainty that the claimant does not have chronic hepatitis C - regardless of the 1999 qualitative viral loads." This conclusion is supported by an accurate citation of the evidence of record and a thorough technical discussion of the applicable medical principles; Dr. R.T. clearly explains that in cases of hepatitis C: "when the virus is cleared either spontaneously ... or after successful treatment, it does not lay dormant in the host's cells - like other viruses can. This concept has been confirmed in numerous natural history studies and post treatment summaries." The opinion emphasizes that "once hepatitis C virus is cleared, it does not exist in dormant or latent state - it is completely gone and purged from a host and absolutely cannot cause any type of liver damage or hepatitis." Dr. R.T. discussed that the positive qualitative PCR from May 1999 was either (1) a false positive test or (2) represented an active infection at that time which was subsequently spontaneously cleared. The discussion explains that in either event, it is clear that the Veteran does not currently have hepatitis C; the discussion also notes that "[a]lmost all cases of spontaneous[] clearance of HCV occur within 1 year of infection." The Board observes that that this suggests that the May 1999 laboratory report is unlikely to reflect a hepatitis C infection that was incurred more than a year prior to May 1999. It also suggests that, in light of the fact that any hepatitis C infection that may have been present in May 1999 has spontaneously cleared, that such clearance would have most likely occurred prior to the pendency of this claim on appeal. The claim on appeal was filed in October 2002, and there is otherwise no evidence of a confirmed diagnosis of hepatitis C diagnosis during the pendency of this claim. The VHA expert medical advisory opinion, as amended in August 2012, clearly and persuasively explains that the evidence of record shows that the Veteran does not have any chronic residuals of any past hepatitis C infection, and has not had any hepatitis C infection during the pendency of this appeal. The VHA opinion discusses the pertinent evidence of record thoroughly, addresses the information that might support the Veteran's claim, and explains the relevant medical principles. The Board finds the examination report to be adequate and probative medical evidence regarding whether or not the Veteran has/has had chronic hepatitis C. Notably, the examiner's finding that the Veteran has not had chronic hepatitis C during the pendency of this appeal is not firmly contradicted by any other competent medical evidence of record. In this regard, the Board notes that the July 2009 private medical opinion from Dr. A.M.G. discusses the question of whether the Veteran may have had hepatitis C during service; the opinion does not present any analysis or opinion concerning whether the Veteran has a confirmed diagnosis of hepatitis C during the pendency of this claim. The October 2003 VA medical opinion was unable to medically confirm a current diagnosis of hepatitis C as the Veteran was not available for physical examination at that time. The July 2008 VA examination report did not provide any statement adequately confirming a medical diagnosis of hepatitis C during the pendency of the claim; the report merely states: "It would appear as if [the Veteran] has hepatitis C viral infection, although it is likely that the pattern we are seeing is that he has cleared the viral titers from his system." The Board sought the June 2012/August 2012 VHA medical advisory opinion to address and clarify the significance of the unclear esoteric medical statements, laboratory data, and other indications of record; the June 2012/August 2012 VHA medical advisory opinion thoroughly explains that the medical evidence of record shows that the Veteran has not had hepatitis C during the pendency of the claim. The Board finds no clear medical statement or indication to the contrary, and the Board is not otherwise competent to draw any contrary medical conclusion from the laboratory testing data and other medical information of record. The Veteran is not competent to establish a diagnosis of hepatitis C, as such a diagnosis requires specialized medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans' Court). In Jandreau, the Federal Circuit specifically determined that a lay person is not considered competent to testify when the issue was medically complex, as is the question of a hepatitis C diagnosis in this case. The Veteran has not provided any competent evidence supporting his belief that he has chronic hepatitis C (or has had hepatitis C during the pendency of this appeal); he has not submitted a supporting medical opinion on this point, nor does he cite to supporting factual data or medical literature. He is a layperson with no medical training. Consequently, his own opinion is not competent evidence in the matter. He otherwise offers no explanation of rationale for the assertion that he has hepatitis C which may otherwise identify other avenues of development or consideration in this appeal. The Board also notes that there is no other clear medical diagnosis raised by the record associated with the disability manifestations claimed in this appeal, and thus no other diagnosis for consideration of service connection in this case. The Veteran has been very clear in repeatedly asserting that he has hepatitis rather than any alternative suggested diagnosis, and the evidence does not show a confirmed diagnosis of any form of hepatitis during the pendency of this appeal (there is no suggestion of a diagnosis of any form of hepatitis other than hepatitis C). In the absence of any competent evidence that the Veteran had chronic hepatitis C during the pendency of this claim, he has not presented a valid claim of service connection for such disability. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the appeal in the matter must be denied. ORDER Service connection for hepatitis C is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs