Citation Nr: 20021855 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 12-20 752A DATE: March 27, 2020 REMANDED Entitlement to service connection for cirrhosis of the liver as secondary to service-connected posttraumatic stress disorder (PTSD) with depression is remanded. REASONS FOR REMAND The Veteran had active duty for training in the United States Navy Reserve from January 1966 to July 1966, and he served on active duty in the United States Navy from October 1966 to September 1968. He also served on active duty in the United States Coast Guard from January 1973 to July 1981. The Veteran died in December 2011, and the appellant is his surviving spouse. In July 2012, the Agency of Original Jurisdiction (AOJ) recognized the appellant as a valid substitute claimant. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2011 rating decision. The appellant testified at a hearing before the undersigned Veterans Law Judge in June 2014. A transcript of that proceeding is associated with the record. In April 2018, the Board denied entitlement to service connection for cirrhosis of the liver as secondary to service-connected PTSD with depression. The appellant appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In an August 2019 Order, the Court granted a Joint Motion for Remand (Joint Motion) filed by the parties to vacate and remand the April 2018 Board decision. In the August 2019 Joint Motion, the parties agreed that the Board erred by relying on a November 2017 advisory medical opinion from the Veterans Health Administration (VHA) that addressed “permanent aggravation.” In February 2020, the appellant submitted a private medical opinion in which Dr. C.M. (initials used to protect privacy) opined that it was at least as likely as not that the Veteran’s alcohol use developed secondary to his service-connected PTSD as an effort to self-medicate for his symptoms and eventually led to his death in 2011. In so finding, Dr. C.M. referenced the appellant’s lay statements regarding the Veteran’s alcohol use as a teenager. However, she did not fully address the numerous medical evidence and lay statements of record that suggest that the Veteran had a long history of alcohol abuse prior to his reported onset of PTSD symptoms. In particular, in a March 2010 VA medical record, the Veteran reported that he drank a fifth of vodka daily at starting at the age of 14 and that he continued to drink at that level for six to eight years. In a September 2005 VA medical record, the appellant acknowledged that the Veteran was deceptive about his drinking. An April 2005 private medical record also noted that the Veteran had elevated levels of alanine transaminase and aspartate transferase in 2002. Moreover, Dr. C.M.’s opinion did not clearly address the issue of whether the Veteran’s service-connected PTSD and any resulting increase in alcohol consumption aggravated his cirrhosis of the liver. In particular, she did not provide supporting rationale for her conclusion that any alcohol use that developed secondary to the Veteran’s service-connected PTSD led to his death in 2011. For these reasons, a remand is necessary to obtain a VA medical opinion. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the appellant provide the names and addresses of any and all health care providers who have provided treatment for the Veteran’s cirrhosis of the liver. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran’s claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of the Veteran’s cirrhosis of the liver. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay statements. He or she should specifically consider the September 2017 VHA medical opinion request that provides a summary of relevant evidence. It should be noted that the Veteran and the appellant are competent to attest to factual matters of which they have first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran or the appellant, the examiner should state this with a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran’s cirrhosis of the liver was caused or aggravated by his service-connected PTSD with depression, including any resulting increase in the consumption of alcohol. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) 3. The AOJ should review the medical opinion to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Wulff, 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.