Citation Nr: 19192490 Decision Date: 12/10/19 Archive Date: 12/10/19 DOCKET NO. 16-40 587A DATE: December 10, 2019 REMANDED Entitlement to service connection for cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1962 to April 1968 and from April 1978 to May 1992. The Veteran died in March 2014 and the Appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Appellant testified before the undersigned Veterans Law Judge at a travel Board hearing. A transcript is of record. Entitlement to service connection for cause of death is remanded. The Appellant contends her husband’s death is related to his active service. Specifically, she asserts his hepatitis C infection was caused by an air gun used for inoculations during his active service and the hepatitis C led to his carcinoma. The Board finds further development is necessary. The Veteran died in March 2014. His immediate cause of death is listed as cervical quadriplegia, cervical abscess, intra-abdominal abscess, and hepatocellular carcinoma. The Veteran’s death certificate further notes his hepatitis C condition as a significant condition contributing to death but not resulting in the underlying causes given as cause of death. However, his post-service treatment records attribute his hepatocellular carcinoma to his hepatitis C. The Veteran’s service treatment records indicate he received inoculations therein. Post-service treatment records indicate a diagnosis of acute or unspecified hepatitis C in January 2004. An April 2004 treatment record notes the Veteran reported last using intravenous drugs 20 years ago. An October 2004 treatment record notes likely exposure through intravenous drug use from 1971 to 1973 and denial of all other risk factors. The Veteran was diagnosed with hepatocellular carcinoma in November 2012. A June 2015 correspondence from the Veteran’s treating physician, Dr. D.B., indicates the Veteran had a history of hepatitis C, which is most likely the cause of hepatoma. An August 2017 private opinion indicates it is as likely as not that the Veteran’s cause of death was service-connected due to the Veteran suffering from hepatitis C, which he as likely as not contracted from jet-gun immunizations early in his military service. The August 2017 private opinion further indicates that a secondary nexus as likely as not exist between the Veteran’s hepatitis C and his subsequent development of hepatocellular carcinoma. The Board notes that the June 2015 opinion indicates the Veteran’s hepatocellular carcinoma and conditions are related, but does not indicate the Veteran’s hepatitis C is related to service. Similarly, the August 2017 private opinion indicates that there are no other indicators or factors of record that would have provided a mechanism for transmittal of hepatitis C, to include intravenous drug usage. However, the Board reiterates that the Veteran’s post-service treatment records indicate the Veteran reported intravenous drug usage from 1971 to 1973. Thus, while the private opinions are insufficient to decide the claim, the Board finds the “low threshold” necessary to establish entitlement to a VA medical examination has been satisfied. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see VBA Fast Letter 04-13 (June 29, 2004) (recognizing as a “biologically plausible” transmitter of hepatitis C in-service air gun inoculations). Accordingly, on remand, a VA examination considering the nature and etiology of the Veteran’s hepatitis C should be obtained. The matters are REMANDED for the following action: Obtain a medical opinion from an appropriate clinician to determine the nature and etiology of the Veteran’s hepatitis C. The clinician must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including any in-service jet-gun immunizations he may have received. (Continued on the next page)   If the clinician finds the Veteran’s hepatitis C is related to service, the clinician should also opine whether it is at least as likely as not his hepatitis C (1) was the immediate or underlying cause of death or was etiologically related thereto or (2) contributed substantially or materially, combined to cause, or aided or lent assistance to the production of the Veteran’s death. The examiner must provide a complete rationale for all proffered opinions. If the requested opinions cannot be provided without resorting to speculation, the examiner should provide an explanation as to why speculation is required. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.Aoughsten, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.