Citation Nr: 18153346 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-34 094 DATE: November 27, 2018 ORDER The appeal to reopen a claim for entitlement to compensation under the provisions of 38 U.S.C. § 1151 for optic neuropathy is granted. The appeal to reopen a claim for entitlement to compensation under the provisions of 38 U.S.C. § 1151 for headaches is granted. The appeal to reopen a claim for entitlement to compensation under the provisions of 38 U.S.C. § 1151 for tremors is granted. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for optic neuropathy or vision loss is denied. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for headaches is denied. Entitlement to service connection or compensation under the provision of 38 U.S.C. § 1151 for head tremors is denied. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for neck tremors is denied. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for bilateral hand tremors is denied. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for brain damage is denied. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for memory loss is denied. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for an autoimmune disorder is denied. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for dermatitis and skin rash is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. Entitlement to service connection for memory loss is remanded. Entitlement to a total disability rating based upon individual unemployability as a result of service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. An unappealed February 2007 rating decision denied entitlement to compensation under the provisions of 38 U.S.C. § 1151 for optic neuropathy, headaches, and tremors. 2. Evidence added to the record since the February 2007 rating decision raises a reasonable possibility of substantiating the previously denied claims for optic neuropathy, headaches, and tremors. 3. The Veteran’s VA medical care providers are shown to have substantially complied with the informed consent requirements prior to providing Peginterferon Alpha-2a and Ribavirin treatment for his hepatitis C in October 2005. 4. The persuasive medical evidence demonstrates the adverse effects of Peginterferon Alpha-2a and Ribavirin treatment for hepatitis C provided from October 2005 to January 2006 that the Veteran experienced were rare but known reactions to the treatment and were not reasonably foreseeable by his VA medical care providers. 5. The evidence demonstrates that optic neuropathy or vision loss, chronic headache, head tremors, neck tremors, bilateral hand tremors, acquired psychiatric disorder, including PTSD, brain damage, memory loss, autoimmune disorder, and dermatitis and skin rash disabilities did not develop as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the medical treatment; any such additional disabilities that may have developed as a result of VA treatment for hepatitis C during the period from October 2005 to January 2006 are shown to have been due to an event not reasonably foreseeable. 6. The evidence demonstrates that optic neuropathy or vision loss, chronic headache, head tremors, neck tremors, bilateral hand tremors, brain damage, autoimmune disorder, and dermatitis and skin rash disabilities were not manifest during active service and the preponderance of the evidence fails to establish that any such current disorders are etiologically related to service. CONCLUSIONS OF LAW 1. The February 2007 rating decision that denied 1151 claims for optic neuropathy, headaches, and tremors is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2018). 2. New and material evidence was received, and the 1151 claims for optic neuropathy, headaches, and tremors are reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. The criteria for entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for optic neuropathy or vision loss have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). 4. The criteria for entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for headaches have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). 5. The criteria for entitlement to service connection or compensation under the provision of 38 U.S.C. § 1151 for head tremors have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). 6. The criteria for entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for neck tremors have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). 7. The criteria for entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for bilateral hand tremors have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). 8. The criteria for entitlement to compensation under the provisions of 38 U.S.C. § 1151 for an acquired psychiatric disorder, including PTSD, have not been met. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 3.361 (2018). 9. The criteria for entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for brain damage have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). 10. The criteria for entitlement to compensation under the provisions of 38 U.S.C. § 1151 for memory loss have not been met. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 3.361 (2018). 11. The criteria for entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for an autoimmune disorder have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). 12. The criteria for entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for dermatitis and skin rash have not been met. 38 U.S.C. §§ 1110, 1151 (2012); 38 C.F.R. §§ 3.303, 3.361 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from March 1970 to May 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in April 2010 and June 2012 by the Portland, Oregon, Regional Office (RO) of the Department of Veterans Affairs (VA). The April 2010 decision denied entitlement to compensation under the provisions of 38 U.S.C. § 1151 (1151 claims) including for optic neuropathy, headaches, and tremors; denied 1151 claims for PTSD, memory loss, and depression; and denied entitlement to a TDIU. VA obtained new and material evidence as to the 1151 claims within one year of the April 2010 decision and in a June 2012 rating decision the RO denied 1151 claims for low vision, headaches, neck tremor, head tremor, left and right-hand tremor, PTSD, brain damage, memory loss, autoimmune disorder, and dermatitis. The Board notes that in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Appeals for Veterans Claims (hereinafter “the Court”) held that an initial claim for PTSD should also be read as including other psychiatric disorder diagnoses reasonably raised by the symptoms described and all information obtained in support of the claim. Therefore, the issues on appeal as to this matter have been revised to include consideration of the other applicable diagnoses of record in this case. The RO addressed the 1151 claims for optic neuropathy, headaches, and tremors on the merits in its July 2016 statement of the case; however, the Board is required to determine whether new and material evidence has been presented when a claim has been previously disallowed based upon the same factual basis. Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996). These issues were initially denied in a February 2007 rating decision. The Veteran was notified of the determination, but did not timely appeal. For this reason, the Board has included issues as to whether new and material evidence has been submitted to reopen the claims on the title page for administrative purposes. Although the Veteran did not submit a timely notice of disagreement from any specific increased rating service-connected disability decision, he provided a timely substantive appeal from a July 2016 statement of the case addressing entitlement to a TDIU and the RO has certified the issue as a matter on appeal. The June 2012 decision also considered and denied entitlement to service connection for. The RO combined the 1151 and service connection matters as single issues for review in its July 2016 statement of the case. The Board finds these matters involve distinct facts and law and are not inextricably intertwined issues. For administrative purposes explained in the reasons for remand section; however, the Board finds that the acquired psychiatric disorder/PTSD and memory loss issues are more appropriately addressed as separate service connection and 1151 claims. The Veteran submitted additional evidence in support of his appeal in June 2017 and waived Agency of Original Jurisdiction (AOJ) consideration. As such, the Board finds the matters addressed herein are appropriately developed for appellate review. New and Material Evidence VA law provides that a claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2018). The United States Court of Appeals for Veterans Claims (hereinafter “the Court”) has held that the credibility of evidence must be presumed for the purpose of deciding whether it is new and material. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The United States Court of Appeals for the Federal Circuit has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (Fed. Cir. 2000). When making a determination as to whether received evidence meets the definition of new and material evidence, the Board should take cognizance of whether that evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). A February 2007 rating decision denied 1151 claims for optic neuropathy, headaches, and tremors. The basis of the denial was the absence of evidence demonstrating carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA staff in treating his hepatitis C. The Veteran did not appeal and new and material evidence was not added to the file within a year of that decision. Accordingly, the decision became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2018). The evidence added to the record since the rating decision includes additional information as to the matter. In statements provided in support of his claim the Veteran asserted that he provided medical literature and asserted that his VA medical care providers had failed to timely discontinue treatment after he reported having vision problems. This evidence was not previously considered and it raises a reasonable possibility of substantiating the claims for optic neuropathy, headaches, and tremors. The previously denied claims as to these matters is reopened. 1151 Eligibility Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110 (2012). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases, including organic diseases of the nervous system, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from 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. 38 U.S.C. §§ 1112, 1113 (2012); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2018). VA law provides that for claims received by VA on or after October 1, 1997, compensation shall be awarded for a qualifying additional disability or a qualifying death of a Veteran in the same manner as if that additional disability or death were service-connected. A disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the Veteran’s willful misconduct and the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by VA, and the proximate cause of the disability or death was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C. § 1151 (2012). To obtain compensation, a claimant must show: (1) a qualifying additional disability, (2) actually caused by the treatment furnished by VA, and (3) a proximate or direct cause that is either a fault on the part of VA or an event not reasonably foreseeable. To establish VA fault, it must be shown that VA failed to exercise the degree of care that would normally be expected of a reasonable health care provider or that VA furnished care without the Veteran’s informed consent. 38 U.S.C. § 1151(a) (2012); 38 C.F.R. § 3.361(c)(1), (d)(1) (2018). To determine whether a Veteran has an additional disability, VA compares the Veteran’s condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy (CWT) program upon which the claim is based to the Veteran’s condition after the care, treatment, examination, services, or program has stopped. VA considers each involved body part or system separately. 38 C.F.R. § 3.361(b). Claims based on additional disability or death due to hospital care, medical or surgical treatment, or examination must meet the applicable causation requirements. Actual causation is required. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the additional disability or death. Merely showing that a Veteran received care, treatment, or examination and that the Veteran has an additional disability or died does not establish cause. Additional disability or death caused by a Veteran’s failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c). With regard to carelessness or negligence, to establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing hospital care, medical or surgical treatment, or examination was the proximate cause of a veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran’s additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran’s informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(1). With regard to reasonable foreseeability, whether the proximate cause of a veteran’s additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have foreseen or disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(2). Informed consent is the freely given consent that follows a careful explanation by the practitioner to the patient or the patient's surrogate of the proposed diagnostic or therapeutic procedure or course of treatment. The practitioner, who has primary responsibility for the patient or who will perform the particular procedure or provide the treatment, must explain in language understandable to the patient or surrogate the nature of a proposed procedure or treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and anticipated results if nothing is done. The patient or surrogate must be given the opportunity to ask questions, to indicate comprehension of the information provided, and to grant permission freely without coercion. The practitioner must advise the patient or surrogate if the proposed treatment is novel or unorthodox. The patient or surrogate may withhold or revoke his or her consent at any time. 38 C.F.R. § 17.32(c) (2018). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2018). Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for: optic neuropathy or vision loss; headaches; head tremors; neck tremors; bilateral hand tremors; an acquired psychiatric disorder, to include PTSD; brain damage; memory loss; an autoimmune disorder; and dermatitis and skin rash. Factual Background The pertinent evidence of record includes service treatment records and a May 1971 separation examination report noting normal clinical evaluations of the eyes, head, skin, and neurologic system. Records are negative for complaint, treatment, or diagnosis associated with optic neuropathy or vision loss, chronic headache, head tremors, neck tremors, bilateral hand tremors, brain damage, autoimmune disorder, or dermatitis and skin rash. VA treatment records show the Veteran was first diagnosed with hepatitis C in 2001 and that a liver biopsy in 2003 revealed stage 1-2 fibrosis. Records dated in October 7, 2005, noted his hepatitis C care provider found that he appeared to be a good candidate for anti-viral therapy, that he felt well, and that he was ready to begin therapy. Treatment with Peginterferon and Ribavirin was scheduled to begin on October 14, 2005. The physician noted that half of the time spent in the 30-minute session was spent in counseling and care coordination. In a separate October 7, 2005, report the physician provided the following: INTERFERON RELATED SIDE-EFFECTS Common Physical Complaints: Flu-like symptoms (e.g., fever, muscle aches, and chills), fatigue, loss of appetite, nausea, vomiting, abdominal pain, diarrhea, hair loss, weight loss, sexual problems, discomfort at the injection site, and rashes. Neuropsychiatric Side-Effects: Depression, irritability, poor concentration, sleep disturbance, relapse on substance abuse, poor impulse control, and suicide ideation. CAUTION: Patient suicides have been reported in rare instances. Changes in Laboratory Tests: Neutropenia, thrombocytopenia, hyperglycemia, and altered thyroid function. RIBAVIRIN RELATED SIDE-EFFECTS: Hemolytic anemia, elevated uric acid levels, gastrointestinal complaints, paresthesia, and skin disorders. Ribavirin can also cause serious birth defects and harm to a fetus. All side-effects, with the possible exception of altered thyroid function, will generally resolve upon stopping treatment. An October 7, 2005, pharmacy counseling note provided the following: The patient or the patient's caregiver received counseling on drug dose, schedule, storage, potential side effects, and significant drug interactions, and the procedure for obtaining refill prescriptions. The patient or the patient's caregiver expressed satisfactory understanding of the medication regimen and is expected to be compliant with the following regimen. A November 4, 2005, report noted the Veteran had a rash on his face, but that he had a history of rosacea and had experienced similar rashes prior to treatment. A November 4, 2005, optometry consult noted he complained of blur and that he had a history of distance vision blur, with the right eye worse recently. He had a history of left eye solar retinopathy since childhood. The examiner’s assessment included mild astigmatism, presbyopia, and probable mild latent hyperopia; mildly reduced left eye vision and solar retinopathy by history; and trace cataracts. A November 4, 2005, hepatitis C clinic report noted the Veteran had not developed the typical flu-like symptoms, but had developed marked nausea that was treated with good result. He also had some mild fatigue and positional vertigo. An examination revealed the sclera were nonicteric. It was noted he was in his fourth week of therapy and was tolerating the treatment well. A January 9, 2006, VA telephone encounter report noted that the Veteran complained of a two-day history of vision impairment. He reported having had a piece of metal in his eye a few weeks earlier that he had removed two days earlier. He stated that since then he had developed a blackening curtain over half of one eye. A January 9, 2005, ophthalmology clinic report noted he complained of a blacked-out area that began three days earlier and that one week earlier a piece of metal had fallen in his eye which he removed himself. He also complained of headaches, of pain associated with recently having a tooth pulled, and of fatigue which he had felt since starting interferon. The examiner’s assessment included optic nerve edema of the right eye of unknown etiology. It was noted that differential diagnoses included anterior ischemic optic neuropathy (AION) which a literature search revealed could be associated with interferon. A January 10, 2005, report noted optic nerve edema of the right eye and likely AION (from interferon). It was noted that the matter had been discussed with the Veteran’s hepatitic C care provider who had approved stopping interferon and ribavirin and starting 325 milligrams of acetylsalicylic acid (ASA). A January 18, 2006, VA ophthalmology report noted the Veteran was seen for follow-up, that he reported he had not taken interferon since his last visit, and that he felt there was no change in his vision. A diagnosis of optic nerve edema RE with hemifield defect respecting a horizontal midline was provided. It was noted interferon was stopped. A January 13, 2006, magnetic resonance imaging (MRI) scan was noted to have revealed a normal examination of the orbits, without evidence to suggest optic neuritis or mass. A February 10, 2005, ophthalmology report noted a diagnosis of optic nerve edema to the left eye with resolving optic nerve edema to the right eye of unknown etiology. Differential diagnoses included vasculitis (associated with hepatitis C), AION (associated with interferon), and optic neuritis. It was noted that interferon had been stopped one month earlier and that the case had been discussed with the Veteran’s hepatitis C care provider who felt his hepatitis C status was not a contraindication at that time to high dose steroids. A February 10, 2006, VA neurology service report noted the Veteran had a second episode of optic neuritis within one month. The first episode was thought to be a side effect of interferon which was a documented, but rare side effect. It was noted, however, the second episode raised a concern for MS or other demyelinating disease. There were no neurologic symptoms or signs (other than those associated with vision) to suggest MS at that time. The examiner stated that it was possible that given that peg-interferon is a depot form of the drug that this was a delayed side effect due to its slow clearance. An April 2006 VA neurology service report noted that on January 7, 2006, the Veteran had awoken and suddenly noticed a black spot in the lower quadrant of the right eye without pain associated with mild weakness in the upper extremities. He denied having any other neurological symptoms. He reported his right eye vision had become fuzzy and the black spot became grey. It was noted he had discontinued usage of Peginterferon Alpha-2a and Ribavirin as of January 9, 2006. On February 8, 2006, he had awoken with similar symptoms over the left eye without pain or any other associated neurological symptoms. The examiner’s assessment was acute onset of loss of vision in both eyes, which was likely related to the use of Peginterferon Alpha-2a. It was further noted that at that time there was no conclusive evidence the symptoms were due to multiple sclerosis. An October 2006 VA report noted that if vision was due to a primary bilateral optic neuritis, there should be consideration as to whether it was due to an “MS-like” disease caused by interferon alpha. It was noted there were case reports in the literature of similar patients who developed bilateral optic neuritis and an abnormal MRI while on interferon alpha. After interferon was discontinued they improved and did not develop clinically definite MS. The mechanism of this seemingly paradoxical response to interferon was noted to be unclear. A February 2008 VA ophthalmology consult noted an MRI revealed a single Dawson’s finger-like lesion in the left parietal lobe and many non-specific T2 hyperintensities scattered throughout the remainder of the white matter. The examiner stated that, in review all the evidence, it was felt in was most likely that the interferon alpha had resulted in an “MS-like” syndrome. It was noted that, though this was most likely, there were some atypical features of the Veteran’s presentation, including altitudinal visual. In a November 2009 statement the Veteran requested entitlement to service connection for eye, brain, memory loss, and tremors, but subsequently described injuries that developed as a result of his VA treatment for hepatitis C beginning in October 2005. He reported that he had complained of vision loss and blurred vision at a November 2005 appointment with a VA optometrist and was told by his hepatitis C medical care provider to continue the treatment. He stated he had been instructed to discontinue the treatment in January 2006 after he lost sight in his right eye, but that he was not put on immediate steroids at that time as he believed should have been prescribed. He stated he was never informed that he could have permanent vision loss, brain damage, memory loss, or other permanent disabilities resulting from the drug. He asserted that had action been taken in January 2005 it would have prevented the cascading effects he experienced. He subsequently provided a chronology of the events he believed were pertinent to his claims. A January 2010 VA ophthalmology report noted diagnoses including probable toxic optic neuritis with optic atrophy, bilaterally, likely associated with Interferon alpha use, and macular scarring and pigment change, left greater than right, attributed to solar retinopathy obtained during viewing of a solar eclipse. In an August 2010 statement the Veteran’s former spouse stated that he had been started on hepatitis C treatment in October 2005 and that in November 2005 he had complained of blurred vision and was seen by an optometrist. She stated he had been told to continue taking interferon and in January 2006 he lost sight in his right eye. She noted he had been diagnosed with PTSD and had over 15 lesions on his brain. A February 2011 report noted a diagnosis of depression with loss of sight and income. A March 2011 report noted he presented with a prior clinically isolated syndrome of sudden bilateral vision loss secondary to optic neuritis versus acute ischemic optic neuropathy versus highly probable interferon-associated demyelination in a setting of ongoing interferon alpha therapy. Interferon-associated demyelinating reaction was most suspected. There remained some suspicion for a clinically isolated syndrome (CIS) with a high risk of MS given an abnormal MRI. It was noted, however, that the most suspicion for demyelinating disease was based on whether the etiology of the vision loss was primarily demyelinating versus ischemic versus interferon-associated. A diagnosis of possible CIS was provided if vision loss was due to primary idiopathic bilateral optic neuritis and MS risk was as high as 60 to 70 percent given abnormal MRI findings. It was noted the Veteran had been stable clinically and radiographically since the initial event and that ongoing stable clinical and imaging followup continued to be reassuring. The examiner stated that suspicion was highest that his demyelinating reaction was related to the use of interferon alpha, noting there were case reports in the literature of similar patients who developed bilateral optic neuritis and abnormal MRI while on interferon alpha. After interferon was discontinued, the reported subjects did not develop clinically definite MS. A December 2011 VA medical opinion based upon the examiner’s review of the record found the Veteran’s decreased vision was at least as likely as not (greater than 50 percent probability) a result of his treatment with interferon for chronic Hepatitis C. This was noted to be a rare but previously reported adverse side effect of this treatment. The examiner found, however, that there was no evidence on a detailed review of the records that decreased vision, headaches, right hand tremors, memory loss, dermatitis/skin rashes, PTSD (due to loss of vision), brain damage, or autoimmune disorder was caused by or became worse as a result of VA treatment because the additional disability resulted from either carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. The examiner further found that the additional disability resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider. It was noted that the treatment plan and possible side effects were disclosed and discussed with the Veteran prior to beginning treatment. Decreased vision was noted to be a rare but previously reported adverse side effect of this treatment. The examiner also found that there was no evidence that VA failed to timely diagnose and/or properly treat the additional disabilities, allowing the disease to continue to progress. Multiple examinations by a neurologist noted there had been no progression of the Veteran’s symptoms. A March 2012 VA report noted the Veteran’s chronic symptoms included severe visual impairment disability that limited his daily activities and employment as well as chronic but stable mild cognitive difficulty with some short-term memory difficulty. He was noted to have been very stable clinically and radiographically since his initial event. Upon present examination, he reported a significant increase in a chronic right greater than left upper extremity tremor over the last three to four months, with no clear aggravating factors. He denied any change in gait or balance and denied any new weakness or numbness. He stated his tremor had been present since his initial demyelinating event in 2003, but that symptoms had clearly progressed over the past three to four months. He had also noticed some mild short-term memory difficulties over the past several months. Based upon the available record, the Board finds the Veteran’s VA medical care providers are shown to have substantially complied with the informed consent requirements prior to providing Peginterferon Alpha-2a and Ribavirin treatment for his hepatitis C in October 2005. The persuasive medical evidence also demonstrates that the adverse effects of Peginterferon Alpha-2a and Ribavirin treatment for hepatitis C provided during the period from October 2005 to January 2006 that the Veteran experienced were rare but known reactions to the treatment and were not reasonably foreseeable by his VA medical care providers. The evidence demonstrates that optic neuropathy or vision loss, chronic headache, head tremors, neck tremors, bilateral hand tremors, acquired psychiatric disorder, including PTSD, brain damage, memory loss, autoimmune disorder, and dermatitis and skin rash disabilities did not develop as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the medical treatment; any such additional disabilities that may have developed as a result of VA treatment for hepatitis C during the period from October 2005 to January 2006 are shown to have been due to an event not reasonably foreseeable. The opinions of the December 2011 VA examiner are found to be persuasive. The examiner is shown to have reviewed the evidence of record and to have adequately considered the lay statements and reported symptom manifestations history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). There are no contrary medical opinions as to the pertinent matters at issue. Although VA medical opinions and treatment reports attribute the Veteran’s adverse reaction residuals to Peginterferon Alpha-2a and Ribavirin treatment, there are no medical opinions indicating that any such residuals developed as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the medical treatment nor medical opinion asserting that the event was reasonably foreseeable by the medical care providers. The Board also finds that the evidence demonstrates that optic neuropathy or vision loss, chronic headache, head tremors, neck tremors, bilateral hand tremors, brain damage, autoimmune disorder, and dermatitis and skin rash disabilities were not manifest during active service and that the preponderance of the evidence fails to establish that any such current disorders are etiologically related to service. Although the Veteran raised service connection as part of his claims, he provided no specific comments relating any active service injury, disease, or event to these disorders. In fact, his statements address his claims that these disorders developed as a result of VA treatment for hepatitis C. Consideration must be given to the Veteran’s personal assertion that he has such additional disabilities a result of improper VA care. The Board notes that lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The specific issues in this case, however, fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The claimed disabilities at issue are not conditions that are readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board acknowledges that the Veteran is competent to report observable symptoms, but there is no indication that he is competent to assess the propriety of the care provided. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the Veteran’s claims. REASONS FOR REMAND 1. Entitlement to service connection or compensation under the provisions of 38 U.S.C. § 1151 for an acquired psychiatric disorder, to include PTSD, and memory loss, is remanded. 2. Entitlement to a TDIU is remanded. The Veteran contends, in essence, that he has an acquired psychiatric disorder as a result of adverse side-effects of VA medical treatment for hepatitis C or which was caused or permanently aggravated as result of events in service or proximately due to a service-connected disability. He also contends that he is unemployable as a result of his only service-connected disability, involving the left knee and currently rated 10 percent disabling. In correspondence received in June 2017 he asserted that service connection was warranted for depression as secondary to his left knee disability and for hepatitis C and residuals of treatment for that disorder. A copy of a June 2017 private medical opinion was provided noting the examiner’s findings that the Veteran was unable to engage in gainful employment due to a depressive disorder and the holistic effect of medical and psychiatric disturbance. It was further opined that his left knee was permanently debilitating and had caused his depression. Service treatment records include a February 1971 report noting the Veteran had asked to see a psychiatrist due to frequent memory loss and that he admitted he had been taken off tranquilizers due to an overdose. Records are negative for subsequent treatment, complaints, or diagnoses. The Veteran’s May 1971 separation examination revealed normal neurologic and psychiatric systems. A July 2010 report included a diagnosis of PTSD noted to be associated with childhood experiences and to have been aggravated by military experiences and depression/anxiety due to medical condition. It was noted the Veteran reported having had an abusive childhood and that he indicated he had had been hit and physically beaten as a recruit by an officer. The Board notes that a March 2016 VA examiner provided a diagnosis of adjustment disorder and found it was less likely that the Veteran had a mental health disorder incurred in or caused by active service. No specific opinion was provided, however, as to proximate causation due to his service-connected left knee disability. The Board finds that the service connection acquired psychiatric disorder and TDIU issues on appeal are inextricably intertwined with the service connection hepatitis C, secondary service connection for depression, and increased left knee disability rating claims raised by the Veteran. There is also no indication that the Veteran was notified that other evidentiary sources might assist him in substantiating his PTSD claim, to the extent he asserts it was aggravated by events in service. Such notice is required. See 38 C.F.R. § 3.304(f)(5) (2018). Therefore, further development is required prior to appellate review. The matter is REMANDED for the following action: 1. Develop and adjudicate the inextricably intertwined service connection hepatitis C issue and the increased left knee disability rating issue. If the benefits sought are not granted to the Veteran’s satisfaction, send the Veteran and his representative a statement of the case and provide an opportunity to respond. 2. Send the Veteran notice as required for PTSD claims based on personal assaults, and allow time for a response. Then, attempt to corroborate any identified in-service stressor based on a personal assault. If more details are needed, contact the Veteran to request the information. 3. Schedule the Veteran for a VA PTSD examination for an opinion that addresses the following: a. Identify/diagnose any acquired psychiatric disorder or memory loss disability that presently exists or that has existed during the appeal period. A specific finding should be made as to whether the Veteran has a diagnosis of PTSD under the DSM-IV or V. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to an in-service stressor. The stressor(s) must be identified. If the evidence does not support a PTSD diagnosis, a detailed explanation should be provided, which included reconciling that finding with those records and reports that list PTSD as a diagnosis. b. For each diagnosed psychiatric disability or memory loss disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that had its onset in service or was incurred or permanently aggravated as a result of a service-connected disability. c. For each diagnosed psychiatric disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that had it is etiologically related to his active service, to include as a result of credible evidence of a personal assault. The examiner must address whether any evidence of behavior change indicates that a personal assault occurred. All necessary tests and studies should be conducted. A complete rationale for any opinion given must be provided. Rationale for the requested opinion shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, provide an explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or the limits of current medical knowledge with respect to the question. 4. After the requested development has been completed, together with any additional development as may become necessary, readjudicate the Veteran’s claims. If the benefits sought on appeal remain denied, issue to the Veteran and his representative a supplemental statement of the case and give an opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. K. A. KENNERLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Douglas, Counsel