Citation Nr: 1615641 Decision Date: 04/18/16 Archive Date: 04/26/16 DOCKET NO. 09-32 673 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for cirrhosis of the liver, including as due to herbicide exposure or as secondary to service-connected type II diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from October 1966 to June 1970. This case comes to the Board of Veterans' Appeals (Board) on appeal of an August 2002 rating decision of the Houston, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2010, the Veteran testified at a videoconference hearing at the RO before a Veterans Law Judge (VLJ). A transcript of that hearing is of record. In a February 2014 letter, the Board advised the Veteran that the VLJ from the April 2010 hearing was no longer employed at the Board and offered him the opportunity for a new Board hearing. In March 2014, the Veteran responded that he did not want a new Board hearing. The case was remanded by the Board in December 2011 and March 2014 for further development of the evidence. This was accomplished and the case has been returned for further appellate consideration. The Board notes that the Veteran has submitted a Notice of Disagreement (NOD) with the initial evaluation and effective date awarded for service-connected hypertension. This matter is being separately developed and addressed by the RO and is not currently ripe for appellate consideration. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam (RVN) during service. 2. No injury, disease, or chronic symptoms of cirrhosis of the liver were manifested during service. 3. The Veteran did not continuously manifest symptoms of cirrhosis of the liver in the years after service. 4. Cirrhosis of the liver was not manifested to a degree of ten percent or more within one year of service separation. 5. Cirrhosis of the liver is not caused by any in-service event, including defoliant exposure, during service. 6. Cirrhosis of the liver is not caused by, or increased in severity beyond the natural progress of the disease by, a service-connected disability. CONCLUSION OF LAW Cirrhosis of the liver was neither incurred in nor aggravated by service, nor may it be presumed to have been, and is not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). 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). 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 a 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 the claim. While he did not receive complete notice prior to the initial rating decision, several letters, including in August 2007 and November 2014, explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. These letters as well as a March 2006 letter also informed the Veteran of disability rating and effective date criteria. A supplemental statement of the case (SSOC) readjudicated the matter after the Veteran and his representative responded and further development was completed. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (a VCAA timing defect is cured by the issuance of fully compliant notification followed by readjudication of the claim). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. A letter was received from the Social Security Administration (SSA) indicating that there are no records available from any disability claim submitted by the Veteran. The Veteran was afforded VA medical examinations, with a most recent medical opinion obtained in August 2014. The Board finds that, taken together, the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). While the Veteran has objected to the statements of one VA examiner, neither he nor his representative has challenged the adequacy of the most recent medical opinions, except as to disagreement with the conclusions reached. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2015). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also 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). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as cirrhosis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In order to prevail on the issue of service connection, there must be medical evidence of 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 (1990). 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 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. 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). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. 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) (West 2014); 38 C.F.R. § 3.102 (2015). 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). The statutory provision specifically covering Agent Orange is 38 U.S.C.A. § 1116. Under 38 U.S.C.A. § 1116(f), a claimant, who, during active service, served in the Republic of Vietnam during the Vietnam era, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that he was not exposed to any such agent during that service. Disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309, will be considered to have been incurred in service under the circumstances outlined in that section even though there is no evidence of such disease during the period of service. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; type 2 diabetes, non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; multiple myeloma, respiratory cancers (cancers of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma, ischemic heart disease, "all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia)," and Parkinson's disease. 38 C.F.R. § 3.309(e) (2015). Aside from these presumptive provisions, service connection might be established by satisfactory proof of direct service connection. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In accordance with VA regulations, the National Academy of Science (NAS) issued "Veterans and Agent Orange: Update 2012" (Update 2012). The attached notice explains a determination made by the Secretary, based upon Update 2012 and prior NAS reports, that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for the following health outcomes: Hypertension; Stroke; Cancers of the oral cavity (including lips and tongue), pharynx (including tonsils), and nasal cavity (including ears and sinuses); Cancers of the pleura, mediastinum, and other unspecified sites within the respiratory system and intrathoracic organs; Cancers of the digestive organs (esophageal cancer; stomach cancer; colorectal cancer (including small intestine and anus); hepatobiliary cancers (liver, gallbladder and bile ducts); and pancreatic cancer); Bone and joint cancer; Melanoma; Nonmelanoma skin cancer (basal cell and squamous cell); Breast cancer; Cancers of reproductive organs (cervix, uterus, ovary, testes, and penis; excluding prostate); Urinary bladder cancer; Renal cancer (kidney and renal pelvis); Cancers of brain and nervous system (including eye); Endocrine cancers (including thyroid and thymus); Leukemia (other than all chronic B-cell leukemias including chronic lymphocytic leukemia and hairy cell leukemia); Cancers at other and unspecified sites (other than those as to which the Secretary has already established a presumption); Reproductive effects (including infertility, spontaneous abortion other than after paternal exposure to TCDD; and - in offspring of exposed people - neonatal death, infant death, stillborn, low birth weight, birth defects (other than spina bifida), and childhood cancer (including acute myeloid leukemia)); Neurobehavioral disorders (cognitive and neuropsychiatric); Neurodegenerative diseases (excluding Parkinson's disease); Chronic peripheral nervous system disorders (other than early-onset peripheral neuropathy); Respiratory disorders (wheeze or asthma, chronic obstructive pulmonary disease, and farmer's lung); Gastrointestinal, metabolic, and digestive disorders (including changes in liver enzymes, lipid abnormalities, and ulcers); Immune system disorders (immune suppression, allergy, and autoimmunity); Circulatory disorders (other than ischemic heart disease); Endometriosis; Effects on thyroid homeostasis; Hearing loss; Eye problems; and Bone conditions. See Notice, 77 Fed. Reg. 47,924 (Aug. 10, 2012). Cirrhosis of the Liver The Veteran contends that service connection should be established for cirrhosis of the liver and associated liver diseases, which he believes are the result of service. During the appeal, he has pointed out that he was treated for fatigue while on active duty and that he served in the RVN where he was exposed to herbicides, including Agent Orange. He has also contended that his liver cirrhosis is caused or aggravated by his service-connected diabetes mellitus. It is initially noted that the Veteran did have service in the RVN and, as such, is presumed to have been exposed to defoliants during that time. Service connection for type II diabetes mellitus is based upon such exposure. After review of the record, the Board finds that no injury, disease, or chronic symptoms of cirrhosis of the liver were manifested during service, in the years after service, or to a degree of 10 percent within one year of service separation. In this regard, it is noted that review of the Veteran's STRs shows no complaints or manifestations of liver disease while the Veteran was on active duty. While the STRs do show complaints of backaches and general malaise in January and February 1968, on examination for separation from service no abnormality of the liver was described. The first demonstration of cirrhosis of the liver of record is shown in a July 1989 report of private treatment. At that time, the Veteran presented with swollen feet, abdominal discomfort, and shortness of breath. He had a history of chronic alcoholism for several years. After examination, the diagnosis was cirrhosis of the liver (alcoholic). An examination was conducted by VA in February 2012. At that time, the examiner reviewed the Veteran's STRs and opined that the malaise and backache were not manifestations of early liver disability. The rationale for this opinion was that these symptoms occurred on one occasion and review of the records shows that no other complaints were noted and these were not documented in his records again. Moreover, there were no ongoing symptoms documented or reported by the Veteran that would make any medical professional consider ongoing liver disease for over 20 years without more medical manifestations. Given the fact that there are no findings of chronic liver disease, including cirrhosis, until almost 20 years after separation from active duty, the Board can find no basis for service connection based strictly on the Veteran's period of active duty. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). In a November 1996 statement, a private physician who had treated the Veteran intermittently since March 1991 noted the Veteran's past history of alcohol abuse, dioxin exposure and diabetes mellitus. It was stated that "I have no way of knowing how important his exposure to dioxin was to his ongoing metabolic problems, particularly in light of his ethanol consumption and diabetes mellitus." After review of the record, the Board finds that cirrhosis of the liver is not caused by any in-service event, including defoliant exposure, during service. As noted, as the Veteran has been certified as having served in the RVN he is presumed to have been exposed to herbicides during service. The record contains several medical opinions in support of, and against, a finding that the cirrhosis is the result of herbicide exposure. It is initially noted that cirrhosis is not among the disabilities for which regulations presume service connection on the basis of herbicide exposure. Moreover, as noted above, gastrointestinal, metabolic, and digestive disorders including changes in liver enzymes, lipid abnormalities, and ulcers are not disabilities for which the presumption is applicable. In a February 1993 statement, a private physician noted that, after receiving information from the Veteran, the Veteran had significant exposure to Agent Orange that may have made the liver more susceptible to damage from alcohol, which the Veteran reportedly stopped using from 1989 or 1990. The examiner went on to state was that, even though the Veteran's medical problems seemed to have a multifactorial etiology, the initial insult for the liver disease was probably related to service exposure to Agent Orange. In a March 1999 statement, the Veteran's private physician indicated that the Veteran had some significant exposure to various chemicals while in the military and, while he gave some history of alcohol in the past, the abdominal studies that had been reported to the physician from other doctors who had treated the Veteran show some significant problems with cirrhosis inconsistent with the amount of alcohol that the Veteran had consumed. The physician stated that there was a significant effective exposure of chemicals to his system and cirrhosis was otherwise idiopathic. His cirrhosis may come in a significant degree from his chemical exposure. This opinion was reiterated in a November 2012 statement from this physician, who, in an August 2015 statement reported that a recent toxicology screen showed a significant elevation of exposure to Agent Orange. The physician went on to state that the Veteran has liver disease "that is not explained completely by alcohol misuse or any sort of hepatitis." The examiner stated that it was strongly suspected that Agent Orange more likely than not had some effect on his developing liver cirrhosis. The February 2012 VA examiner indicated that the Veteran's cirrhosis was not the result of exposure to Agent Orange during service. The rationale given was that the Veteran's reported level of dioxin exposure had not specifically been associated with cirrhosis of the liver. The examiner noted that while the literature presented by the Veteran indicated liver disease probabilities, it did not confirm specifically cirrhosis. Other literature presented by the Veteran noted serum dioxin and hepatic abnormalities in veterans of operation ranch hand, this study was of the Air Force personnel in charge of handling Agent Orange for spraying by the Air Force. While the study concluded some liver enzyme changes, it did not conclude a specific liver disease (cirrhosis). The examiner further noted that the conflicting medical evidence was due to the history provided by the Veteran. If alcohol were to be taken out of the diagnostic picture then doctors must consider other elements in the history to achieve a diagnosis of cirrhosis and the diagnosis provided by the other doctors was considered differential diagnosis because those are also possible causes, but not in this case. The strong history of alcohol use could only point to alcohol being the cause of this Veteran's cirrhosis. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140, 146 (1993); Guerrieri, 4 Vet. App. at 470-71. While the Board may not ignore a medical opinion, it is certainly free to discount the relevance of a physician's statement, as it has done in this case. See Sanden v. Derwinski, 2 Vet. App. 97 (1992). In this case, the medical opinions that support the Veteran's contention that his liver disease is the result of Agent Orange exposure are predicated on a history, given by the Veteran, of "some history of alcohol in the past." The contemporaneous medical evidence noted at the time that the cirrhosis was diagnosed, however, shows that the Veteran gave a history of alcoholism at that time. Therefore, the opinions are based upon on inaccurate factual premise. Moreover, the 1993 opinion is phrased as there "may" be a relationship between herbicide exposure and the development of liver disease. The Board finds such an opinion to be speculative at best, of little evidentiary value, and amounts to what in essence is "nonevidence" of an etiological relationship to a service-connected disability. See Perman v. Brown, 5 Vet. App. 237, 241 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Obert v. Brown, 5 Vet. App. 30 (1993) (a medical opinion expressed in terms of "may," also implies "may or may not" and is too speculative to establish a plausible claim). The VA examiner in 2012 noted a "strong history of alcohol use" in the medical records, which, as noted, is supported by the medical evidence from the Veteran's initial diagnosis in 1989. Finally, as previously noted, liver disease, is not among those disabilities for which service connection may be presumed as a result of herbicide exposure and credible, persuasive evidence has not been submitted which otherwise establishes such a causal relationship. For these reasons, the Board does not find that service connection based on herbicide exposure is warranted. The Veteran's final contention is that his liver disease is related to his service-connected diabetes mellitus. After review of the record, the Board finds that cirrhosis of the liver is not caused by, or increased in severity beyond the natural progress of the disease by, a service-connected disability. In this regard, it is noted that, as with herbicide exposure discussed above, there are several medical opinions that are in conflict as to whether the service-connected diabetes caused or aggravated the cirrhosis. For example, in a November 2002 statement, the Veteran's private physician indicated that there was no obvious reason for the Veteran's liver disease. It remained somewhat idiopathic and it was believed to be as likely related to diabetes "as diabetics have more idiopathic liver cirrhosis than do other people." This same physician submitted a subsequent statement dated in July 2006 wherein he noted that the Veteran was service connected for diabetes and had been treated for quite some number of years for idiopathic liver cirrhosis. He went on to state that there is a direct correlation with idiopathic liver cirrhosis and steat hepatitis caused by diabetes, which could be a positive or aggravating factor in this case. The examiner did not give a rationale for these opinions. A medical records review was conducted by a VA examiner in November 2004. At that time, the examiner noted the November 2002 statement of the Veteran's private physician and the Veteran's STRs. In addition, the examiner noted that although the VA chief of gastroenterology had stated that if the Veteran's history of "no consumption of alcohol," is confirmed, then the cirrhosis would have to be considered "cryptogenic," then the fact that the diabetes mellitus would have to be considered one possible contributing factor. The November 2004 reviewing physician opined that it would be as likely as not that the diabetes mellitus being diagnosed two years later would cause the cirrhosis to become worse. In a March 2006 addendum, the examiner who rendered the November 2004 opinion was requested to clarify the opinion. He stated that the baseline manifestations of the Veteran's disabilities were those of cirrhosis of the liver, portal hypertension, and hepatic encephalopathy. There were no specific manifestations that were related to the service-connected diabetes mellitus, noting that the statements made concerning possible aggravation of his cirrhosis by his diabetes were relevant to his discussion with a VA Chief of GI Medicine. This discussion was that the VA Chief of GI Medicine had stated that, if the Veteran's claim of "no alcohol intake history of significance" was considered to be true and correct, then the cirrhosis would be considered cryptogenic cirrhosis, meaning that the cause was unknown. This would include not being sure whether Agent Orange had played any role in hepatitis. Finally, the examiner stated that he tried to explain that if one were to accept the fact that no alcoholic intake took place, then the resulting consequences of the effects of one disease on the other would be that the disease of diabetes mellitus would likely have a deleterious effect on cirrhosis. No specific level of effect and no specific identification of any specific manifestation was suggested or discussed. Finally, the examiner explained that, if one were willing to accept the contention that the patient was actually a nondrinker, although this was contradicted in his medical records, then one must consider what the cause of the cirrhosis was. When this case was discussed in detail with the Chief of GI Medicine and presented with the patient's statement that he had never been a drinker, was not now a drinker, and never would be a drinker, the answer was that a diagnosis then of cirrhosis without chemical insult, without disease insult of hepatitis, without any other thing that might affect the liver, would have to be a cryptogenic cirrhosis; that is cirrhosis of unknown etiology. It was further indicated that if the patient had cryptogenic cirrhosis and then had diabetes mellitus on top of it, it would be reasonable to suppose that the diabetes might have some deleterious effect on the course of the cirrhotic disease. This does not posit a causal effect relationship. It does not posit any specific manifestations that could be elicited and therefore identified as specific worsening of his cirrhosis condition based on his diabetes. It instead posits that if one is to accept one premise then one must consider the second premise. That is, if there were no alcohol intake this would lead to cryptogenic cirrhosis; if this exists, then diabetes mellitus is likely to have a deleterious effect on the course of that disease. Finally, the examiner stated that it was mere supposition and speculation that if supposition one is true, then supposition two might also be true. It does not lead to the irrefutable connection between the two premises, but that it seemed reasonable. A VA medical opinion following review of the available medical records was obtained in August 2014. At that time, the examiner was to offer opinions regarding whether it was at least as likely as not that the current liver cirrhosis was permanently worsened in severity beyond a normal progression by the service-connected diabetes mellitus disability. After extensive review of the medical record, it was the examiner's opinion that, although some of the Veteran's physicians have stated that his diabetes could theoretically worsen his cirrhosis, the Veteran's clinical course over the past decade and a half did not support this theory. In 1990, the Veteran was critically ill with liver failure, ascites and hepatic encephalopathy. He was then diagnosed with diabetes mellitus in November 1991 when he was admitted for an inguinal abscess. At that time, his liver disease was noted to have been stabilized for the past two years. In 1992, his private doctor noted that the Veteran had been hospitalized for liver disease in 1991 and that he had "stopped" drinking in July 1989, but still "has had an occasional one," referring to his beer drinking habit. If the diabetic condition were to have caused permanent aggravation of the cirrhosis, objective measure of liver function would be expected to worsen over time since the diagnosis of diabetes and that this disease continued to be relatively poorly controlled. After extensive review of laboratory results over the years, the examiner stated that there was clearly no worsening trend over time regarding the liver function tests that would support the contention that diabetes had permanently worsened beyond a normal progression of the Veteran's current liver cirrhosis. This was because it would be expected to have progressive liver failure with worsening lab results and clinical symptoms over time, which has not been the case. Therefore, it was less likely as not that the current liver cirrhosis was permanently worsened in severity beyond a normal progression by the service-connected diabetes mellitus disability. As noted, the Board has a responsibility to weigh the probative value of medical opinions in the record. In this case, the Board finds that the medical opinions that relate the diabetes mellitus to the Veteran's cirrhosis are less persuasive than those that do not. There are several factors for this finding. First, the Veteran's cirrhosis diagnosis predates the diagnosis of diabetes mellitus by several years. Second, the opinions in support of the Veteran's contention are all predicated on the Veteran's statements that his alcohol consumption was not excessive. The Board finds that these statements are not credible in that they are in direct contrast to those made at the time cirrhosis was first diagnosed and the findings of the private examiner who rendered the diagnosis of alcoholic cirrhosis prior to the time that the Veteran submitted his initial claim for compensation benefits. Finally, as pointed out by the VA examiner in 2014, laboratory findings show no worsening of liver function over time. Therefore, there is no demonstration of worsening of cirrhosis over the years so there can be no aggravation by the service-connected diabetes mellitus. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for cirrhosis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER Service connection for cirrhosis of the liver, including as a result of herbicide exposure or secondary to service-connected type II diabetes mellitus, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs