Citation Nr: 20029556 Decision Date: 04/28/20 Archive Date: 04/28/20 DOCKET NO. 13-05 911 DATE: April 28, 2020 REMANDED Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for renal insufficiency and kidney stones, claimed as secondary to hepatitis C is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to June 1969. These matters initially came before the Board of Veteran’s Appeal (Board) on appeal from a January 2012 rating decision of the Department of Veteran’s Affairs (VA) Regional Office (RO). In February 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In March 2018, the Board remanded the claims. 1. Service Connection for Hepatitis C is remanded The Board regrets the additional delay, but for following reasons finds that another remand is warranted. During the Veteran’s February 2018 Board hearing, the Veteran stated that he had a private medical opinion from Dr. Kam, who treated the Veteran during his liver transplant. The Veteran stated that Dr. Kam’s medical opinion suggested that the Veteran’s hepatitis C was longstanding based on the condition of the Veteran’s liver. The Board’s March 2018 remand noted that Dr. Kam’s medical opinion was not currently of record and instructed the AOJ to obtain outstanding private medical records and Dr. Kam’s medical opinion. In May 2018, the Veteran’s representative submitted a letter notifying VA of Dr. Kam’s retirement and that Dr. Kam referred the Veteran’s request for a medical opinion to Dr. Jackson, the current private surgeon overseeing the Veteran’s treatment following his liver transplant. On May 4, 2018, Dr. Jackson rendered a medical opinion that it is possible that the Veteran contracted hepatitis C during his military service in Vietnam. In October 2018, January 2019 and November 2019 the RO contacted the Veteran to obtain Dr. Kam’s medical opinion. However, Dr. Kam’s medical opinion is not in the record of evidence and Dr. Kam has indicated that no such opinion is forthcoming. Dr. Jackson’s May 4, 2018 opinion is the relevant private medical opinion regarding the etiology of the Veteran’s hepatitis C and his liver transplant. In October 2019 a VA physician rendered a medical opinion that it is less likely than not that the Veteran’s hepatitis C incurred in or was caused by an in-injury, event or illness. The VA doctor’s medical opinion does not mention or reference Dr. Jackson’s May 4, 2018 medical opinion. The VA medical examiner indicates that she reviewed all of the evidence contained in the claims file. In February 2020 the RO provided the Veteran with a supplemental statement of the case (SSOC) explaining the continued denial of the Veteran’s clam. The list of evidence does not mention Dr. Jackson’s May 4, 2018 medical opinion. Although VA is presumed to have reviewed all evidence in the record when making a determination as to service connection, Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000), in this case given the importance of this evidence and lack of indication that it was reviewed by either the physician or the AOJ, a remand is warranted for the AOJ to obtain a new medical opinion that specifically considers Dr. Jackson’s medical opinion regarding the etiology of the Veteran’s hepatitis C and for the AOJ to review this evidence in the first instance. See Sprinkle v. Shinseki, 733 F.3d 1180, 1183-84 (Fed. Cir. 2013) (noting that veterans’ claims are initially developed and adjudicated by the RO and reviewed on appeal by the Board, and that, “[t]o ensure that claimants receive the benefit of this two-tiered review within the agency, all evidence relevant to a claim generally must be considered by the Regional Office in the first instance”). In addition, the Veteran indicated that he received two tattoos during service, one on his right shoulder and one on the left calf. As noted by the AOJ, the entrance and separation examination reports indicate a single tattoo on the right forearm. However, given that the forearm would generally be a part of the body visible to an examiner while the calf and shoulder would not, the inference that the lack of mention of the other two tattoos by the entrance and separation examiners reflects that there were no such tattoos is not warranted. Consequently, the new medical opinion should consider whether the Veteran’s hepatitis C is due to receiving tattoos during service, as tattoos are a recognized risk factor for hepatitis C. 2. Service Connection for Renal Insufficiency and Kidney Stones as Secondary to Hepatitis C. The Veteran’s claim of entitlement to service connection for renal insufficiency and kidney stones as secondary to hepatitis C is inextricably intertwined with the Veteran’s claim of service connection for hepatitis C, because the renal insufficiency and kidney stones issue may be affected by the grant of service connection for hepatitis C. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a Veteran’s claim for the second issue). Consequently, the claim for service connection for renal insufficiency and kidney stones must be remanded as well. The matters are REMANDED for the following action: 1. Obtain a new VA medical opinion regarding the etiology of the Veteran’s hepatitis C that specifically considers both (1) the Veteran’s lay statements regarding his possible exposure to hepatitis C during his military service in Vietnam to include tattoos; and (2) Dr. Jackson’s May 4, 2018 medical opinion regarding the etiology of the Veteran’s hepatitis C. 2. If the Veteran’s hepatitis C is found related to service, obtain an opinion as to whether the renal insufficiency and kidney stones are either (a) caused or (b) aggravated by the hepatitis C. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Henderson, 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.