Citation Nr: 18115672 Decision Date: 07/02/18 Archive Date: 07/02/18 DOCKET NO. 07-33 392 DATE: July 2, 2018 ORDER Service connection for hepatitis C, based on substitution of the appellant, is granted. REMANDED Entitlement to service connection for the cause of the Veteran’s death is remanded. FINDINGS OF FACT Resolving reasonable doubt in the Veteran’s favor, his hepatitis C was at least as likely as not related to service. CONCLUSIONS OF LAW The criteria for service connection for hepatitis C are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1970 to February 1971. The appellant, the Veteran’s surviving spouse, has been substituted in the instant case. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. As such, the analysis below will focus specifically on what evidence is needed to substantiate the Veteran’s claim, and what the evidence in the claims file shows, or fails to show, with respect to this claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. Entitlement to service connection for hepatitis C. This matter was previously before the Board in February 2010, June 2011, and January 2012, at which time it was remanded for further development. The Board acknowledges that appellant’s representative raised the issue of substantial compliance with the Board’s January 2012 remand directives. However, in light of the favorable disposition below granting service connection for hepatitis C, the Board need not further consider whether the AOJ has substantially complied with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran contended that he contracted hepatitis C in service by two possible events. The Board finds that the Veteran had a current diagnosis of hepatitis C, during the pendency of the appeal, which was related to service. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.303(a); see also Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). By a July 2011 VA examination, the examiner thoroughly reviewed the Veteran’s claims file, which include his service treatment and post-service medical records, and considered the Veteran’s lay testimony regarding his claimed in-service events that exposed him to hepatitis C. She explored potential risk factors for exposure to the virus before, during, and after military service. She stated: “it is my opinion that it is more likely than not that his chronic hepatitis C was contracted during his military service and the majority of his medical history, specifically decompensated cirrhosis requiring liver transplantation and chronic immunosuppression (the latter leading to interstitial lung disease), is due to hepatitis C.” She went on to state that she found no evidence or reports of any other potential exposure to hepatitis C in the Veteran’s medical records other than his alleged events of exposure in service. She ultimately concluded that in her medical opinion it was more likely than not that the Veteran contracted hepatitis C during his time in the military. The Board finds that the VA examiner’s conclusion was based on her review of the file, consideration of the medical literature, and medical expertise and training. She set forth, at length, detailed reasons and analysis supporting her opinions. The Board finds her examination report is adequate and dispositive to the matter at hand. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board further notes that there is a private positive nexus opinion from one of the Veteran’s treating providers. This private provider also indicated that the Veteran had no other known risk factors for hepatitis C, beyond that in the military. Accordingly, resolving all reasonable doubt in favor of the Veteran, the Board finds entitlement to service connection for hepatitis C is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 2. Entitlement to service connection for the cause of the Veteran’s death. The appellant seeks service connection for the cause of the Veteran’s death. She contends that the Veteran’s hepatitis C caused his death. To establish service connection for the cause of the Veteran’s death, the evidence must show that a disability incurred in or aggravated by active service was either the principal or contributory cause of death. To constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. To be a contributory cause of death, the evidence must show that the service-connected disability contributed substantially or materially to the cause of death, or that there was a causal relationship between the service-connected disability and the Veteran’s death. To be a contributory cause of death, the service-connected disability must be shown to have combined with the principal cause of death, that it aided or lent assistance to the cause of death. It is not sufficient to show that it casually shared in producing death. A causal relationship must be shown. 38 C.F.R. § 3.312. Medical evidence is required to establish a causal connection between service or a disability of service origin and a veteran’s death. Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). The Veteran’s death certificate listed respiratory failure and pulmonary fibrosis as the causes of death, and hepatitis C as a significant condition contributing to death. Accordingly, given the Board’s grant of service connection for hepatitis C, a medical opinion is required on remand to address the Veteran’s cause of death. Of note, in a February 2012 notation, the Veteran’s pulmonologist opined that he was dissuaded from putting on the death certificate “respiratory failure secondary to pulmonary fibrosis secondary to chemotherapy as an immuno suppressant agent.” Moreover, other medical records indicate that the Veteran’s interstitial lung disease was potentially secondary to immunosuppression. Notably, an October 2010 VA medical opinion (for an unrelated matter to the issue at hand), states that “it appears that the interstitial lung disease is due in part to an adverse reaction to the sirolimus.” The 2011 VA examiner, as discussed above, found that the Veteran’s chronic immunosuppression led to interstitial lung disease, which was due to hepatitis C. A remand is needed in order to obtain a medical opinion that considers this evidence. Finally, as the matter is being remanded, updated VA and private treatment records documenting treatment for the disorders causing and contributing to the Veteran’s death should be obtained and associated with the claims file. See 38 C.F.R. § 3.159(c)(2). The matter is REMANDED for the following action: 1. Obtain and associate any outstanding VA treatment records with the claims file. 2. Ask the appellant to identify any private medical care providers who treated the Veteran for hepatitis C, respiratory failure, and/or pulmonary fibrosis; and make reasonable efforts to secure the necessary releases and to associate any such identified records with the claims file. 3. After completion of the above, obtain a VA medical opinion by an appropriately qualified examiner to address whether a relationship exists between the Veteran’s causes of death and his service connected disabilities. The claim file and a copy of this REMAND should be provided to the examiner and he or she must indicate review of this in the examination report. After a review of the claim file, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s respiratory failure and/or pulmonary fibrosis were etiologically related to his service-connected disabilities? (b.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s now service-connected hepatitis C caused or materially contributed to the cause of his death? In providing the above opinions, the VA examiner is asked to address the medical evidence of record regarding a relationship between the Veteran’s immunosuppression, interstitial lung disease, and hepatitis C. (Continued on the next page)   If a requested opinion cannot be rendered without resorting to speculation, the examiner must be clear that such an opinion is not procurable based on a lack of knowledge among the “medical community at large” and not merely on a lack of expertise, insufficient information, or unprocured testing on the part of the specific examiner. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved should be provided. DELYVONNE M. WHITEHEAD Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Dellarco, Associate Counsel