Citation Nr: 19137645 Decision Date: 05/15/19 Archive Date: 05/15/19 DOCKET NO. 09-44 268 DATE: May 15, 2019 ORDER Entitlement to service connection for hepatitis C is denied. FINDING OF FACT The most probative evidence indicates the Veteran’s hepatitis C was not present until many years after his discharge from service, and is not etiologically related to service. CONCLUSION OF LAW The criteria for service connection for hepatitis C have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION Introduction The Veteran served on active duty from December 1978 to December 1981. The case was most recently before the Board in September 2017, at which time the above issue was remanded for additional development. The case has now been returned to the Board for further appellate review. Duty to Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C. §§ 5103, 5103A (2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2018), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The record reflects that all pertinent available service treatment records (STRs) and post-service medical evidence identified by the Veteran have been obtained. The Veteran was afforded an appropriate VA examination in November 2015, and additional comprehensive medical opinions were obtained in January 2016 and February 2018. The Veteran was also afforded an opportunity for a hearing before a Decision Review Officer or before the Board, but declined to do so. The Veteran has not identified any outstanding evidence that could be obtained to substantiate the claim; the Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the Veteran’s claim. Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2018); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background and Analysis The Veteran has claimed service connection is warranted for hepatitis C, as he avers the condition was incurred in service, to include as a result of “air gun” inoculations, sharing of food rations, or the self-administration of a tattoo. The Board acknowledges at the outset that the Veteran was diagnosed with hepatitis C in the course of his November 2015 VA examination. A review of the Veteran’s STRs fails to show he was ever treated for or diagnosed with hepatitis C in service. However, the Board does find the Veteran competent to report certain potential risk factor exposures in service, including his inoculations by way of an air gun, sharing of food rations, and self-administration of a tattoo. Therefore, the central issue is whether the Veteran’s hepatitis C was caused by his above-noted risk factor exposures. Initially, the Board notes that to date the Veteran has not provided a statement from a medical professional linking his hepatitis C to his military service. However, the Veteran has undergone a VA examination, and two addendum medical opinions have been obtained to determine whether a relationship exists between his hepatitis C and his reported risk factor exposures in service. In November 2015, the Veteran underwent a VA hepatitis examination. At that time the examiner diagnosed the Veteran with hepatitis C. However, the examiner found the Veteran’s disability was less likely than not related to service. In support of her conclusion, the examiner noted the Veteran was not diagnosed until many years after service, and his acknowledged prior alcohol use would have likely accelerated the progression of his hepatitis C. In January 2016, a second opinion was obtained from an examiner that did not perform the Veteran’s November 2015 VA examination. This examiner also concluded the Veteran’s hepatitis C was less likely as not incurred in service, as a result of air gun injections or the sharing of food cans, and more likely the result of other high-risk behaviors that occurred after service. The case was recently remanded in September 2017 in order to obtain another addendum medical opinion, which acknowledged and addressed the Veteran’s reports of self-administering a tattoo in service. In February 2018 the examiner that performed the Veteran’s November 2015 VA examination again reviewed the file. The examiner acknowledged numerous inconsistencies in the Veteran’s reports relative to his tattoo. In particular, the Veteran initially stated he administered his tattoo after his service in Germany, but then reported that he administered his tattoo while he was in advanced infantry training (AIT) school in Virginia, before his service in Germany. The Veteran also initially reported in a March 2009 statement that he received a tattoo on his “body” in 1979, which the examiner found an odd wording for a tattoo on one’s hand. Notwithstanding the above-noted inconsistencies, the examiner acknowledged the Veteran may have indeed self-administered a tattoo on his hand in service. However, the examiner again found the Veteran’s current hepatitis C disability was less likely than not related to his military service. In this respect, the examiner again noted the Veteran’s heavy use of alcohol would have likely hastened the progression of his hepatitis C and liver damage. In this regard, the examiner noted that scientific evidence shows the mean time to develop cirrhosis (liver damage) following hepatitis C infection was found to be 20.6 years. The examiner also noted the majority of patients who develop cirrhosis following infection with hepatitic C will do so within 20-30 years. The examiner then noted the Veteran’s clinical records show that as of 2014 he had no radiological evidence of cirrhosis, and was only shown to have early signs of cirrhosis in 2016. The examiner found that since the Veteran only showed early signs of cirrhosis in 2016, roughly 34 years after his discharge from active duty, his acquisition of hepatitis C likely occurred after service. The examiner found this was even more likely given the Veteran’s past history of alcohol abuse, which again, would have likely expedited the onset of his liver damage. The Board finds this opinion to be highly probative, as the examiner cited to numerous scientific studies analyzing the progression of hepatitis C and consequentially related cirrhosis. Further, the examiner applied those studies to reach a well-reasoned medical conclusion in this matter, given the particular facts associated with the Veteran’s case. As discussed above, all of the medical opinions addressing the Veteran’s claim are against the claim. Further, as also noted above, VA has reviewed several comprehensive medical studies, but these studies provide probative evidence indicating the Veteran’s hepatitis C was more likely contracted after service. To date, neither the Veteran nor his representative has provided a single medical opinion linking the Veteran’s claimed disability to his claimed risk factor exposures in service. Although the Veteran may sincerely believe his disability was incurred in military service, his lay opinion concerning these matters requiring medical expertise is clearly of less probative value than the medical opinions against the claim. (Continued on the next page)   Based on the foregoing, service connection for hepatitis C must be denied. In reaching this decision the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is significantly against the claim. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Fraser, 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.