Citation Nr: 20060591 Decision Date: 09/15/20 Archive Date: 09/15/20 DOCKET NO. 15-27 004 DATE: September 15, 2020 ORDER Service connection for a liver disorder, claimed as due to exposure to contaminated water at Camp Lejeune, is denied. FINDING OF FACT A liver disorder is not shown to be is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include exposure to contaminated water at Camp Lejeune. CONCLUSION OF LAW The criteria for service connection for a liver disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1966 to February 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in September 2014 by a Department of Veterans Affairs (VA) Regional Office. In October 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In February 2019, the Board remanded the matter for additional development and it now returns for further appellate review. Entitlement to service connection for a liver disorder, claimed as due to exposure to contaminated water at Camp Lejeune. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). VA acknowledges that persons residing or working at the U.S. Marine Corps Base Camp Lejeune from August 1, 1953, through December 31, 1987, were potentially exposed to drinking contaminated water with volatile organic compounds. See Veterans Benefits Administration Fast Letter 11-03 (January 11, 2011). In this regard, VA has established a presumption of service connection for certain diseases for veterans, former reservists, and former National Guard members who were exposed to contaminants in the water supply while serving at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953, to December 31, 1987. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Specifically, there is a presumption of service connection for kidney cancer, liver cancer, Non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer, which have become manifest to a degree of 10 percent or more at any time after service if the veteran was stationed at Camp Lejeune between August 1, 1953, and December 31, 1987. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As an initial matter, the Board notes that the Veteran does not allege, nor does the record show, that his liver disorder, currently diagnosed as hepatic steatosis, manifested during service or is related to any instance of his military service other than his exposure to contaminated water while he was stationed at Camp Lejeune. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008). However, after a review of the record, the Board finds that service connection for a liver disorder is not warranted. In this regard, while liver cancer is acknowledged to be presumptively related to exposure to contaminated water at Camp Lejeune, such presumption does not apply to hepatic steatosis, or any liver disorder other than cancer. Consequently, presumptive service connection for the Veteran’s liver disorder is not warranted. Nonetheless, he is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In this regard, in a July 2014 VA opinion, an examiner reviewed the record and noted that the Veteran had a diagnosis of cirrhosis of the liver. She then opined that such disorder was less likely as not caused by or a result of his exposure to contaminated water at Camp Lejeune. In support thereof, the examiner explained that the Committee on Contaminated Drinking Water at Camp Lejeune indicated that there was inadequate/insufficient evidence of an association between chronic exposure to solvents and the development of cirrhosis. She also noted that the Veteran’s records indicated a history of alcohol use. Thus, she concluded that it was likely that the use of alcoholic beverages was the cause of his liver cirrhosis. However, in the February 2019 Remand, the Board found that such opinion was inadequate to decide the claim. In this regard, it was noted that the Veteran’s VA treatment records indicated that he had hepatic steatosis, which is one of the diseases placed into the category of limited/suggestive evidence of an association between certain diseases and exposure to the chemical contaminants at Camp Lejeune by the National Research Council (NRC). Further, a September 2016 VA treatment record noted that the Veteran’s hepatic steatosis may have a connection to his reported exposure to Camp Lejeune. Additionally, in November 2018, the Veteran’s VA provider noted that he had an assessment of non-alcoholic steatohepatitis (NASH), and it was his opinion that his clinical picture was not consistent with alcoholic-induced liver injury or alcoholic-induced chronic liver disease. He also opined that the Veteran’s NASH could be related to his reported chemical exposure at Camp Lejeune as at least one of the chemicals he described was related to direct liver injury, which could lead to acute and/or chronic liver disease, cirrhosis, hepatitis, steatohepatitis, etc. While such opinions were couched in speculative terms and thus are afforded no probative weight in such regard, the Board found that, in light of the issues raised therein, an addendum opinion was needed to decide the claim. While on remand, May 2019 and June 2019 notes from VA clinicians were received. In this regard, the May 2019 clinician opined that the Veteran’s clinical picture was not consistent with alcoholic induced liver injury or alcoholic induced chronic liver disease, and he seemed to have non-alcoholic fatty liver disease (NAFLD) with some fibrosis. She also noted that the Veteran was stationed at Camp Lejeune and that certain chemicals are associated with hepatic steatosis. She then stated that there was a definite possibility that the Veteran’s steatosis could be related to the reported chemical exposure to Camp Lejeune. However, as such statement is couched in speculative terms and does not include a rationale, it is afforded no probative weight. Additionally, the June 2019 VA clinician noted that she had not seen the Veteran, but was asked to comment on his situation. In this regard, she addressed the 3 most common etiologies of hepatic steatosis, which were obesity, diabetes, and excess alcohol consumption. She found that the Veteran was not obese by body mass index (BMI) criteria, was not diabetic, and did not have a clear history of alcohol abuse or misuse. The clinician also noted that she was aware that there was more evidence for other types of health effects of Camp Lejeune water contamination than there was for hepatic steatosis as she had read many pages of the governmental epidemiologic and occupational health studies on the topic. Nonetheless, she determined that hepatic steatosis was a covered entity and indicated that she believed that the Veteran’s exposure was as likely the cause of hepatic steatosis as any other condition or exposure he had. However, she acknowledged that her opinion was limited as she noted that the issue of the strength of epidemiologic evidence for Camp Lejeune water contamination causing hepatic steatosis was not for her to decide and did not bear on this case. Rather, the clinician indicated that, if the government decided that it was a covered entity, she saw no other definite cause in the Veteran, and the probable link should be regarded as sufficient. Consequently, as the clinician’s opinion was acknowledged to be limited in light of the strength of epidemiologic evidence for Camp Lejeune water contamination causing hepatic steatosis and misstated the current category into which hepatic steatosis had been placed (as it is not a “covered entity;” rather, there is only limited limited/suggestive evidence of an association between such and exposure to contaminated water at Camp Lejeune as determined by the NRC), it is likewise afforded limited probative weight. Additionally, pursuant to the February 2019 Remand, an addendum opinion was obtained in January 2020. At such time, the examiner noted that hepatic steatosis had been placed into the category of limited/suggestive evidence of an association between certain diseases and exposure to the chemical contaminants at Camp Lejeune by the NRC, but found that, in the Veteran’s specific case, his liver disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include such in-service exposure to contaminated water at Camp Lejeune. In support thereof, she considered the aforementioned May 2019 and June 2019 notes from VA clinicians and noted that both indicated that alcohol use was not the cause of hepatic steatosis. The examiner also explained that, per Up to Date, the top causes of hepatic steatosis were male sex, increasing age, dyslipidemia, and obesity. In this regard, she explained that the Veteran’s records indicated he had hyperlipidemia/dyslipidemia and was on cholesterol lowering medications several years before his liver abnormality was initially diagnosed in 2013. The examiner also noted that the Veteran was in his 60s at the time of his diagnosis and his BMI had been 27.5 for several years prior to the diagnosis. In this regard, she explained that, while the Veteran was not obese per his BMI, a cited study indicated that elevated BMI above 22.5 increased the risk of hepatic steatosis with 9 fold increase for BMI of 30 to 32.5. Thus, the examiner concluded that the Veteran’s liver abnormality, which was first diagnosed in 2013 and resulted in a final diagnosis of hepatic steatosis in 2019, was due to his well-documented and established dyslipidemia/hyperlipidemia, elevated BMI, male sex, and age 60s and was less likely than not incurred in or caused by his exposure to contaminated water at Camp Lejeune. The Board affords great probative weight to the opinion offered by the January 2020 VA examiner as such considered all of the pertinent evidence of record, to include the Veteran’s medical history and relevant medical literature, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Further, as noted previously, the other opinions offered in connection with the Veteran’s claim are speculative, lacked a rationale, or were limited in nature, and, thus, are entitled little to no probative weight. In reaching its decision, the Board has considered the Veteran’s belief that his liver disorder is related to his exposure to contaminated water at Camp Lejeune; however, as he is a lay person, he does not possess the requisite training and experience necessary to address such a complex medical matter. Specifically, the etiology of a liver disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of a liver disorder, to include its relationship to exposure contaminated water at Camp Lejeune, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran’s opinion as to the etiology of his liver disorder is not competent evidence and, consequently, is afforded no probative weight. Consequently, the Board finds that the Veteran’s liver disorder is not shown to be is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include exposure to contaminated water at Camp Lejeune. Therefore, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a liver disorder. As such, that doctrine is not applicable in the instant appeal and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Clark, 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.