Citation Nr: 1302892 Decision Date: 01/25/13 Archive Date: 01/31/13 DOCKET NO. 04-39 391 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for hepatitis C. REPRESENTATION Appellant represented by: Dennis L. Peterson, Attorney ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from February 1970 to September 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2004 rating decision of the St. Paul, Minnesota Department of Veterans Affairs (VA) Regional Office (RO). In the January 2004 rating decision, the RO denied service connection for hepatitis C, finding that no new and material evidence had been received. The Veteran filed a notice of disagreement (NOD) in March 2004 with respect to the RO decision on this claim and was issued a statement of the case (SOC) in June 2004. He perfected an appeal with respect to this issue by filing a timely substantive appeal in October 2004. The claim for service connection for hepatitis C was reopened and remanded for further development by the Board in April 2007. Thereafter, the Board denied the claim for service connection for hepatitis C in June 2010. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). By a July 2011 Order, the Court granted a July 2011 Joint Motion for Remand (Joint Motion), vacating the Board's June 2010 decision and remanding the Veteran's claim for consideration by the Board. In the Joint Motion, the parties found a December 2009 VA examination which the Board relied upon in its decision to be inadequate. The parties found that a July 7, 2004 Hepatitis C Clinic report referred to by the December 2009 VA examiner was not of record, and therefore, the examiner and the Board's reliance on such report in denying the Veteran's claim to be unclear. The Board was instructed to consider the effect of this lack of evidence in its analysis with respect to service connection, and specifically, whether further medical examination or opinion was required pursuant to VA's duty to assist. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) Thus, in March 2012, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, D.C. to afford the Veteran a VA medical examination and ensure that all of the Veteran's VA treatment records were associated with the Veteran's claims folder. The action specified in the March 2012 Remand completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The Veteran's hepatitis C did not have its onset in service and was not caused by or otherwise related to the Veteran's active military service. CONCLUSION OF LAW The criteria for entitlement to service connection for hepatitis C have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease 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) (2012). Risk factors for hepatitis C include intravenous (IV) drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, shared toothbrushes or razor blades. See Veterans Benefits Administration (VBA) letter 211B (98- 110), November 30, 1998. A VA "Fast Letter" issued in June 2004 (Veterans Benefits Administration (VBA) Fast Letter 04-13, June 29, 2004) identified "key points" that included the fact that hepatitis C is spread primarily by contact with blood and blood products, with the highest prevalence of hepatitis C infection among those with repeated, direct percutaneous (through the skin) exposure to blood (i.e., intravenous drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and hemophiliacs treated with clotting factor before 1987). Another "key point" was the fact that hepatitis C can potentially be transmitted with the re-use of needles for tattoos, body piercing, and acupuncture. In addition, VBA Fast Letter 04-13 states: Population studies suggest hepatitis C can be sexually transmitted. However, the chance for sexual transmission of [hepatitis C] is well below comparable rates for HIV/AIDS or hepatitis B infection. . . . The hepatitis B virus is heartier and more readily transmitted than [hepatitis C]. While there is at least one case report of hepatitis B being transmitted by an air gun injection, thus far, there have been no case reports of hepatitis C being transmitted by an air gun transmission. The source of infection is unknown in about 10 percent of acute hepatitis C cases and in 30 percent of chronic hepatitis C cases. These infections may have come from blood-contaminated cuts or wounds, contaminated medical equipment or multi-dose vials of medications. The large majority of hepatitis C infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992, and injection drug use. Despite the lack of any scientific evidence to document transmission of hepatitis C with air gun injectors, it is biologically plausible. . . . VBA Fast Letter 04-13 (June 29, 2004). Service treatment records are silent as to any complaints, diagnosis, or treatment for hepatitis C. On separation from active duty, in August 1970, the examination was absent of any findings of hepatitis or any chronic liver disorder. Post-service medical records, including private and VA medical records reflect that the Veteran initially tested positive for hepatitis C in February 2000. At this time, he reported that his spouse had been in a long extramarital affair for many years and that her partner was hepatitis positive, although he was not sure if it was hepatitis B or C. Also at this time, the private physician discussed with the Veteran that there was a possibility that he got the hepatitis C from a possible blood transfusion or blood product transfusion when he was injured 13 years earlier before testing was done regularly for hepatitis C. The Board notes that the record indicates that the Veteran was involved in a motor vehicle accident in 1985 wherein he sustained severe and extensive burns over both legs, arms, hands, and torso, and subsequently underwent an above the knee amputation on the left reportedly due to gangrene. The record indicates that one of the treating facilities was Brook Army Medical Center in San Antonio, Texas. However, a response from this facility, received in April 2008, indicated that no records were available. The Veteran filed his original claim for hepatitis C in January 2002. At that time, he did not report any in-service risk factors, including air gun inoculations. Private treatment reports from December 2002 to October 2003 reflect that, in an undated report, the Veteran reported his hepatitis C risk factors included multiple sexual partners or a history of sexually transmitted diseases, including gonorrhea. He also checked "No" to blood transfusion prior to 1992, using needles to inject recreational drugs, snorting drugs, exposure to other people's blood, tattoos or body piercing, hemodialysis, excessive alcohol use, and unexplained liver disease. At a September 2003 VA examination, the examiner noted that the claims file was not available for review. The Veteran reported that he suffered a serious motorcycle accident in July 1985 which resulted in a brain injury and amputation of the left leg below the knee. The Veteran further reported that hepatitis C was diagnosed in 2001, and that he was asymptomatic at the time of the original diagnosis. Neither a liver biopsy, nor any other treatment, was received at that time. He denied that he underwent a blood transfusion following the 1985 accident. The Veteran stated that he did not use needles to inject drugs, he did not snort drugs, he was not exposed to anyone else's blood, he did not have a tattoo or piercing, and he never received hemodialysis. He did relate that he had multiple sexual partners in service, and that he was diagnosed once with gonorrhea. The examiner found that the Veteran's multiple sexual partners and history of sexually-transmitted disease (gonorrhea times one) was the source of his infection with hepatitis C. However, the examiner provided no rationale for this conclusion and a medical opinion that contains only data and conclusions is accorded no weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A June 7, 2004 VA Hepatitis C Clinic Note initial evaluation was obtained and added to the record following the Board's March 2012 remand. In this Clinic Note, the Veteran's risk factors for acquiring hepatitis C were noted to be exposure to other people's blood through skin/mucous membrane between 1980 and 2001. Although as noted in the Introduction, the Joint Motion, a July 7, 2004 VA Hepatitis C Clinic note appeared not to be of record, it appears that the June 7, 2004 record is the one reviewed by the VA examiner as it includes the same information that was reported by the VA examiner to have been in a July record. The Veteran submitted a statement in October 2004 in which he stated that he received immunizations along with many other men in service, and that he believed he was exposed to hepatitis C at the time of inoculation in 1970. In November 2004, a VA nurse practitioner issued a statement which noted that the Veteran was diagnosed with hepatitis in 2001, and that he most likely acquired the virus many years prior. It was further noted that risk factors for hepatitis C included a possible blood transfusion in 1986, even though the Veteran denied that he received a transfusion following his accident during his September 2003 VA examination. The nurse practitioner noted that the Veteran could not recall for sure if he had had a blood transfusion then. The Veteran also reported in-service air gun inoculations. The practitioner stated that it was difficult to ascertain exactly how the Veteran was infected with hepatitis C, but was likely infected from one of the risk factors noted above. The Veteran submitted a risk factor questionnaire in April 2008. He affirmed that he had never used intravenous drugs, intranasal cocaine, engaged in high-risk sexual activity, had hemodialysis, received a tattoo or body piercing, shared toothbrushes or razor blades, had acupuncture with non-sterile needles, had a blood transfusion, or been exposed to any contaminated blood or fluids. At an October 2009 VA examination, the examiner noted that he reviewed the Veteran's claims file and medical records and the Veteran's CPRS (Computerized Patient Records System) electronic records. At that time, it was noted that the Veteran was diagnosed with hepatitis in 2001, and that his spouse was involved in a relationship with someone else, and that her partner was infected with hepatitis C. The Veteran reported that his wife tested negative for hepatitis at that time and that recently, his girlfriend had been treated for hepatitis C, and that she currently tested positive for the disorder. He maintained that he never received an in-service blood transfusion. The Veteran reported only one in-service sexual partner, although the VA examiner noted that in the past the Veteran had repeatedly attested to multiple sexual partners in service. The Veteran was diagnosed with chronic, active hepatitis C, however an etiological opinion was not provided. A supplemental VA opinion was obtained in December 2009. Following a review of the Veteran's claims file, to include a review of the October 2009 VA examination, it was noted that the Veteran did not report any hepatitis C risk factors during his period of active duty, with the exception of "multiple sexual partners," which he later recanted. The examiner noted that in a July 7, 2004 Hepatitis C Clinic evaluation, the Veteran reported that between 1980 and 2001, he had been exposed to other people's blood or mucous membranes. As noted, this appears to have been error in the reporting of the date by the examiner as the exact language is utilized in a June 7, 2004 note. The examiner opined that the most likely cause of the Veteran's current diagnosis was exposure to blood between 1980 and 2001. In support of the opinion, the examiner noted that there was no obvious exposure to hepatitis during the Veteran's period of active duty. It was noted that the most important risk factors for hepatitis C are injectable drug use and persons with hemophilia treated with blood products prior to 1987. In contrast, the examiner stated that other common behaviors, to include immunizations with air guns, carry risk factors which are very small or minimal compared to the risk from blood transfusions prior to 1987. As such, the examiner opined that it was more likely than not that hepatitis C is not related to the Veteran's period of active service. In May 2012, the Veteran was afforded a new VA examination. The examiner stated that he was unable to determine whether it is at least as likely as not that the Veteran's hepatitis C was incurred during his period of active service without resorting to speculation. He explained that the Veteran has multiple medical problems, including substance abuse, alcohol dependence, personality disorder, etc, and is unable to provide essential information allowing the examiner to determine the source of the Veteran's hepatitis C infection. Unfortunately, the examiner failed to clarify what evidence would be required for him to render an opinion. In August 2012, the Veteran was afforded yet another VA examination. The VA examiner opined that it is less likely than not that the Veteran's hepatitis C was incurred during his period of active service. Instead, the examiner concluded that the Veteran's hepatitis C is most likely the result either of exposure to blood or bodily fluids via skin or mucous membranes as a result of sexual activity between 1980 and 2000 (noting in the report the June 7, 2004 Hepatitis C Clinic note) or a transfusion of blood products at the time of his above the knee amputation and care of extensive burns following a post-service motorcycle accident (noting in the report that given the magnitude of the Veteran's 1986 motorcycle accident, blood product administration was likely although no medical records were available). The examiner explained that the possibility of contracting hepatitis C through sexual activity with multiple partners or blood product administration prior to 1987 is substantially greater than the possibility of blood exposure by air gun injection. In December 2011, the Veteran submitted a letter from a physician's assistant, C.R., in support of his claim. C.R. reported that he had seen the Veteran for the first time in December 2012 for hepatitis C and at that time, the Veteran reported only one risk factor for exposure- air gun inoculations during his military service. C.R. stated that hepatitis C infection from air gun inoculations is biologically plausible and that as it was the Veteran's only reported risk factor, it is as least as likely as not that this was the cause of his infection. Based on all the above evidence, the Board finds that the preponderance of the evidence is against the Veteran's claim. The Veteran served on active duty for seven months as a supply clerk; his service treatment records are negative as to any complaints, diagnosis, or treatment for hepatitis C. On separation from active duty, in August 1970, the examination was absent of any findings of hepatitis or any chronic liver disorder. Post-service, the Veteran had multiple non-service related risk factors for hepatitis C, including reported sexual activity with multiple sexual partners, and a probable blood transfusion. Notably, VA primary care notes dated between 2004 and 2007 indicate that the Veteran had been married for 19 years, had five children with his spouse, was divorced in 2001 reportedly due to his spouse's infidelity, and had four additional children each with a different female partner. While the Veteran has claimed that he was exposed to hepatitis C as a result of air gun inoculations in service, the Board does not find the Veteran's testimony to be competent, credible or probative in this case. As an initial matter, the Board notes the Veteran has been inconsistent in describing his alleged hepatitis C risk factors. When he filed his original claim in January 2002, the Veteran did not report air gun inoculations as a possible risk factor for hepatitis C exposure. Several years later, he submitted a statement describing it as a probable risk factor. Additionally, the Veteran has provided conflicting accounts regarding the number of sexual partners he had in service. The Veteran has also provided conflicting information as to whether he received a blood transfusion following his 1986 motorcycle accident and this remains unclear from the record although the most recent VA examiner opined that it was likely given the magnitude of the accident. The Board notes that credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995). Here, the Veteran's inconsistencies undermine the probative value of his testimony. Overall, the Board finds that there is considerable evidence to conclude that the Veteran is not reliable historian. Furthermore, the Veteran has not demonstrated that he has any knowledge or training in determining the etiology of his hepatitis C condition. In other words, he is a layman, not a medical expert. The Board recognizes that there is no bright line rule that laypersons are not competent to offer etiology opinions. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (rejecting the view that competent medical evidence is necessarily required when the determinative issue is medical diagnosis or etiology). Evidence, however, must be competent evidence in order to be weighed by the Board. Whether a layperson is competent to provide an opinion as to the etiology of a condition depends on the facts of the particular case. In Davidson, the Federal Circuit drew support from Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) for support for its holding. Id. In a footnote in Jandreau, the Federal Circuit addressed whether a layperson could provide evidence regarding a diagnosis of a condition and explained that "[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran seeks to offer etiology opinions rather than provide diagnoses, the reasoning expressed in Jandreau is applicable. The Board finds that the question of whether the Veteran currently has hepatitis C due to his alleged exposure in service is too complex to be addressed by a layperson. This connection or etiology is not amenable to observation alone. Rather it is common knowledge that such relationships are the subject of extensive research by scientific and medical professionals. Hence, the Veteran's opinion of the etiology of his current disability is not competent evidence and is entitled to low probative weight. Additionally, as the December 2011 opinion by C.R. was based solely on the Veteran's inaccurate medical history and did not include a review of the record, the Board finds that this opinion has a low probative value. In Kowalski v. Nicholson, 19 Vet. App. 171 (2005), the Court indicated the Board may not disregard a favorable medical opinion solely on the rationale it was based on a history given by the Veteran. Rather, as the Court further explained in Coburn v. Nicholson, 19 Vet. App. 427 (2006), reliance on a veteran's statements renders a medical report not credible only if the Board rejects the statements of the Veteran as lacking credibility. Here, the Board has found the Veteran's statements to be lacking in credibility, for the reasons discussed above, and notes that the Veteran failed to inform C.R. of many of the possible risk factors noted elsewhere in the records, such as a probable blood transfusion in 1985 and sexual relationships with potentially infected partners. If C.R. had had access to the full record, it is possible he may have reached a different conclusion regarding the etiology of the Veteran's disability. While the Veteran's private and VA treatment records contain numerous diagnoses of hepatitis C, the Veteran's record is silent as to medical evidence of a nexus between his hepatitis and his period of active service, save for a November 2004 statement from a VA nurse practitioner which echoed the Veteran's reports of blood exposure through in-service air gun inoculations, and which opined that it was "difficult to ascertain" how the Veteran was infected, but that infection was likely the result of one of the risk factors noted, presumably to include a possible 1986 blood transfusion and/or air gun inoculation. To the extent that the above statement could be construed as a positive etiological opinion, linking the Veteran's current diagnosis to an in-service inoculation, the Board notes that, when facing conflicting medical opinions, the Board must weigh the credibility and probative value of each opinion, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In this case, the Board attaches limited probative value to the VA statement of November 2004. In Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), the Court discusses, in great detail, how to assess the probative weight of medical opinions and the value of reviewing the claims folder. The Court held that claims file review, as it pertains to obtaining an overview of the claimant's medical history, is not a requirement for medical opinions. The Court added, "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." In the Nieves-Rodriguez decision, the Court vacated the Board's decision because the Board had dismissed one of the two favorable private medical opinions solely on the basis that the physician had not reviewed the claims folder, without an explanation of why that failure compromised the value of the medical opinion. By contrast, the Court held that, in rejecting the other private medical opinion, the Board had offered adequate reasons and bases for doing so (the doctor had overlooked pertinent reports regarding the Veteran's medical history), and thus, the Board's rejection was not based solely on the failure to completely review the claims file. The Board finds that the November 2004 nurse practitioner did not provide a sufficient rationale to support her opinion that the Veteran's hepatitis could be related to an in-service inoculation. Instead, it was simply pointed out that the Veteran provided a history of several risk factors, and that any could be the cause, without sufficiently weighing each risk factor as to the relative probability of infection. Further, her statement was entirely speculative in nature. The Board notes that service connection may not be predicated on a resort to speculation or remote possibility. 38 C.F.R. § 3.102 (1996); see also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (service connection claim not well grounded where only evidence supporting the claim was a letter from a physician indicating that veteran's death "may or may not" have been averted if medical personnel could have effectively intubated the Veteran; such evidence held to be speculative); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that the Veteran may have been having some symptoms of multiple sclerosis for many years prior to the date of diagnosis deemed speculative). Further, the Court has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). It is therefore unclear whether this opinion was formed primarily based on the Veteran's self-reported history, an independent review of the file, or a combination of both. Compare LeShore v. Brown, 8 Vet. App. 406, 409 (1995) with Nieves-Rodriguez v. Peake; see also, Kowalski v. Nicholson, 19 Vet. App. 171 (2005) and Coburn v. Nicholson, 19 Vet. App. 427 (2006). Instead, the Board attaches the most probative value to the VA opinion dated in August 2012. The August 2012 VA examiner based his conclusions on an extensive review of the record, including past medical opinions, as well as epidemiological data from the Centers for Disease Control concerning the most significant risk factors for hepatitis C transmission. He concluded that the Veteran's hepatitis C was more likely than not caused by a post-service risk factor such as multiple sexual partners or a blood transfusion as the possibility of contracting hepatitis C through these activities is substantially greater than the likelihood of contracting hepatitis C through an air gun inoculation. The examiner's rationale is logical, clearly explained, and consistent with the evidence of record. For all the above reasons, entitlement to service connection for hepatitis C is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and 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. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, VA has met all statutory and regulatory notice provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Letters dated in May 2007 and April 2008 informed the Veteran of the information necessary to substantiate the claims for service connection for hepatitis C. He was also informed of the evidence VA would seek on his behalf and the evidence he was expected to provide. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2009); Quartuccio, at 187. These letters also included information with regard to the assignment of a disability rating and effective date. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Although complete and proper notice was received after the initial denial of the Veteran's claim, the Court and the United States Court of Appeals for the Federal Circuit (Federal Circuit) have clarified that the VA can provide additional necessary notice subsequent to the initial AOJ adjudication, and then readjudicate the claim, such that the essential fairness of the adjudication - as a whole - is unaffected because the appellant is still provided a meaningful opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (where the Federal Circuit Court held that a SOC or supplemental SOC (SSOC) can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, as well as VA treatment records. The Veteran submitted private treatment records. The appellant was afforded a VA medical examination in May 2003, October 2009, May 2012, and August 2012. The August 2012 examination is adequate and probative for VA purposes because the examiner relied on sufficient facts and data, provided a rationale for the opinion rendered, and there is no reason to believe that the examiner did not reliably apply reliable scientific principles to the facts and data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. 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). ORDER Entitlement to service connection for hepatitis C is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs