Citation Nr: 21001063 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 11-27 413 DATE: January 6, 2021 REMANDED Entitlement to service connection for a seizure disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), to include as secondary to in-service personal assault, is remanded. Entitlement to service connection for a liver disability, to include infectious hepatitis, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1974 to January 1977 and from December 1977 to November 1978. In August 2016, the Veteran testified via videoconference before the undersigned Veterans Law Judge (VLJ) of the Department of Veterans Affairs (VA) Board of Veterans’ Appeals (Board), seated at the Board’s Central Office in Washington, D.C. A transcript of the hearing has been associated with the claims file. Most recently, in September 2019, the Board remanded the issues on appeal for additional development; the claims file has been returned to the Board for adjudication. 1. Entitlement to service connection for a seizure disorder is remanded. As discussed in the Board’s December 2016 and September 2019 Remands and discussed again here for clarity, despite its repetitive nature, the Veteran, during his August 2016 Board hearing, asserted that his seizure disorder was related to service on the basis that he incurred seizures during service. He reported that while he was lying in his barracks, he had seizures, but did not know what they were and did not seek treatment. He also asserted that he was assaulted during service, hit between the eyes with a baseball bat, and was found unconscious. He reported his post-service treatment for seizures and noted that he was taking two medications to treat such. The Veteran’s service treatment records are silent for complaint, treatment, or diagnosis of any seizures. Service treatment records dated in February 1978, associated with the claims file resultant to the Board’s December 2016 Remand, indicate that the Veteran was hospitalized after being assaulted. He was initially unresponsive, without focal neurological findings, and physical examination revealed a laceration over the bridge of the nose and abrasions and contusions about the right eye, without other evidence of trauma. There was no acute injury to the jaw, and all findings were within normal limits save for swelling about the lateral malleolus of the right ankle with intact neurology. He was diagnosed with a right ankle disability and concussion. In February 1988, the Veteran was admitted for VA treatment for alcohol dependence, he had been beaten up and had a blackout, and complained of nervousness and headaches. VA treatment records dated in December 2004 indicate that the Veteran was treated for the onset of seizures, thought to be related to withdrawal from prescription medication. In March 2008, a VA treatment provider noted that VA neurology consultation revealed what was most likely a complex partial seizure, the last one occurring in November 2005. VA treatment records dated in August 2010 indicate that the Veteran reported an assault, by nine men, three days prior; he presented with multiple contusions and abrasions; computed tomography (CT) was negative. During VA treatment in June 2011, a VA treatment provider noted that although it would be difficult to prove, he felt that the Veteran had an underlying seizure disorder, likely idiopathic complex partial seizures with secondary generalization, despite non-paroxysmal electroencephalograms (EEGs). During VA psychiatric treatment in September 2013, the treatment provider diagnosed the Veteran, as an Axis III diagnosis, with seizure disorder. Based on such, the Board, in its December 2016 Remand, directed the VA Regional Office (RO) to afford the Veteran a VA examination to determine the presence of any seizure disorder during the appellate period and the etiology of the same. Report of an April 2017 Disability Benefits Questionnaire (DBQ) indicates that the Veteran was diagnosed with psychomotor epilepsy, onset May 2006. The Veteran reported that he thought his seizures began in service when he was jumped and hit between the eyes with a bat, with loss of consciousness. He reported that he was lying in bed and shaking. He reported that when he gets stressed out, he will “go out” and not remember anything. The examiner noted that the Veteran had been diagnosed with seizures resultant to VA mental health treatment. The examiner cited service treatment records dated in February 1976 indicating that the Veteran had fear from auditory and visual hallucinations, without a psychiatric diagnosis or notation as to seizures. The examiner cited the Veteran’s August 2003 report during VA treatment that he had been assaulted three times, once in service, with loss of consciousness on each occasion, and hospitalization for the first two assaults. The examiner cited the Veteran’s December 2004 VA treatment records indicating new-onset seizures, likely secondary to withdrawal from medication, his January 2005 VA diagnosis of conversion disorder, and his hallucinations secondary to his general medical condition, that being possible seizures and sleep apnea, his May 2002 VA diagnosis of doubtful seizure disorder, his May 2005 VA diagnosis of chronic organic brain syndrome, probably multifactorial, including head trauma, and drug use, and diagnoses of brain syndrome and posttraumatic post-concussion syndrome, his November 2005 VA diagnosis of possible syncopal disorder versus epilepsy, his December 2005 VA diagnosis of possible seizure disorder, his May 2006 and July 2011 VA treatment records noted neurology suggestive of underlying seizure disorder, his March 2008 VA diagnosis of likely complex partial seizure, and his October 2010 VA diagnosis of seizure disorder. The examiner opined that the Veteran’s diagnosed disability was less likely than not related to service and opined that the Veteran’s first documented seizure disorder was in December 2004, twenty-five years after service, and his in-service hallucinations were attributed to a psychiatric condition. The examiner cited medical literature that discussed the many causes for visual hallucinations. The examiner reported that there was no evidence of chronic progressive complaints of symptoms referable to seizure disorder from separation from service in 1978 until 2004, and that the Veteran provided a subjective report of an in-service head injury with loss of consciousness, not substantiated in the service treatment records. The examiner reported that the Veteran’s VA treatment records showed multiple instances where he claimed two or three other post-service head injuries associated with a loss of consciousness, and it would be purely speculative to attribute a seizure disorder diagnosis from 2004 to a remote head injury prior to 1978 rather than to one of the more recent head injuries claimed by the Veteran. As noted, the February 1978 service treatment records demonstrating the Veteran’s in-service assault and resultant hospitalization, with diagnosed concussion, were associated with the claims file after the April 2017 DBQ. The examiner based the negative etiological opinion on the fact that there was no clinical evidence to support the Veteran’s lay report of being assaulted during service with loss of consciousness. The Board, in September 2019, directed the RO to afford the Veteran a new VA examination and obtain an adequate etiological opinion that considered the relevant February 1978 service treatment records as well as report of a January 2018 DBQ related to the Veteran’s separate claim of entitlement to service connection for traumatic brain injury, negative for a diagnosis of TBI. In a December 2019 DBQ, the examiner diagnosed the Veteran with idiopathic complex partial seizures with secondary generalization, and provided a reasoned opinion as to whether the Veteran has a current seizure disorder, managed by medication. The examiner opined that the Veteran’s seizure disorder is less likely than not related to service and examiner reasoned that as the post-service treatment records demonstrated multiple episodes of head trauma, beyond once in service, and the Veteran’s in-service head injury was in 1978 and his seizure disorder did not present itself until twenty-plus years later, it was more medically feasible that one of the more recent head trauma events would be the cause of his seizure disorder. The examiner also reported that it was even more medically likely that the Veteran’s seizure disorder is idiopathic, of an unknown cause. The examiner opined that the Veteran’s seizure disorder is less likely than not proximately due to or aggravated by any service-connected disability including hearing loss, tinnitus, a low back disability, a right ankle disability, or an acquired psychiatric disorder including PTSD, reasoning that there was no medical evidence that the cited disabilities caused or aggravated his seizure disorder. The December 2019 opinion is inadequate. The examiner did not provide rationale for her conclusion that the Veteran’s seizure disorder is less likely than not proximately due to or aggravated by any service-connected disability including hearing loss, tinnitus, a low back disability, a right ankle disability, or an acquired psychiatric disorder including PTSD. Also, she did not adequately consider the Veteran’s February 1978 service treatment records, the basis for the Board’s September 2019 Remand; it appears that she simply concluded that, based on time alone, that it was more appropriate to attribute the Veteran’s seizure disorder to his post-service head injuries. On remand, the RO should obtain an adequate etiological opinion that responds fully to the Board’s inquires. 2. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, to include as secondary to in-service personal assault, is remanded. As discussed in the Board’s December 2016 and September 2019 Remands and discussed again here for clarity, despite its repetitive nature, the Veteran asserts that his acquired psychiatric disorder, to include PTSD, to include as secondary to personal assault, was incurred during service. In a September 2007 statement, the Veteran reported that he was seen during service for hearing voices and seeing things and asserted that such was not an attempt to get out of service, that he wanted to stay in service and worked on his reading and writing skills in order to pass the test to stay. His service treatment records dated in May 1974 indicate that the Veteran complained of nerves and was diagnosed with nervous tension. In February 1976, the Veteran complained of fear from auditory and visual hallucinations and reported experiencing such just before entry into service. He asserted that as he became more frightened, his hallucinations were harder to control. The treatment provider noted the Veteran’s in-service discipline problems and decreased performance. No psychiatric diagnosis was recorded, and the treatment provider noted that the Veteran had child-like manipulation in an underlying anti-social personality. Subsequent in-service psychiatric evaluation in February 1976 indicates that the Veteran was diagnosed with situational adjustment reaction, in resolution, and the examiner noted that visions and voices were normal cultural expressions of fear and nervousness. The Veteran was discharged from service for unsuitability. In as early as February 1988, the Veteran complained of nervousness during VA treatment. In May 2006, during VA treatment, the Veteran was diagnosed with mood disorder, second to his general medical condition, specifically; sleep apnea, and personality disorder. VA treatment records dated in December 2008 indicate that the Veteran was diagnosed with dementia and mood disorder attributed to his general medical condition. During VA treatment in December 2010, he was diagnosed with depressed mood, and during VA treatment in April 2011, he was diagnosed with mood disorder. During VA treatment in December 2011, it appears that the Veteran was diagnosed with PTSD. An August 2011 DBQ indicates that the examiner reported that it was not possible to differentiate what symptoms reported were attributable to a specific diagnosis, including personality disorder and dementia, as well as other noted diagnoses, including posttraumatic brain syndrome and polysubstance abuse disorder. The Veteran reported, and the examiner considered, his pre-service and in-service history to include reported chaos, including both physical problems and psychosocial distress. The Veteran reported that during service he was “left for dead” and beat up and pistol-whipped and tied up to the ship. He reported that he impregnated both his girlfriend and wife at the same time, his marriage failed, and his father was ill. The examiner noted the Veteran’s in-service report of experiencing hallucinations prior to service. The Veteran reported that he was harassed and the target of disciplinary actions during service. The examiner reported that the Veteran’s behavior was inappropriate before, during, and after his military career resulting in school problems, legal problems, and expulsion from the military on the basis of his “defective attitudes.” The examiner opined that adjustment disorders occurred in response to stressful life events, and it is more likely than not that the Veteran’s current mental disorder is a separate and distinct condition and more likely than not began prior to his military service and would have persisted at a similar degree regardless of his involvement in the military. The August 2011 VA opinion was inadequate, as the examiner did not comment on the Veteran’s mood disorder or depression, diagnosed during the appellate period, or offer a sufficient opinion as to any pre-existing acquired psychiatric disorder. The Board, in its December 2016 Remand, directed the RO to afford the Veteran a new VA examination in order to determine the etiology of any acquired psychiatric disorder found present. Report of an April 2017 DBQ indicates that the Veteran was diagnosed with post-concussion syndrome. The examiner noted the August 2011 DBQ indicating diagnosed personality disorder, polysubstance dependence, and dementia, and noted that the Veteran complained of auditory and visual hallucinations while in service and also admitted that such was an effort to get out of service, and that testing in service was not valid due to the Veteran feigning symptoms. The examiner reported that there was no psychiatric disorder diagnosed on separation from service. The examiner noted the Veteran’s 1988 VA in-patient treatment for alcohol dependence and notations that brain injury and PTSD were diagnosed due to a gang-related fight, and that again, testing was invalid due to overreporting symptoms and exaggeration. The examiner noted that the list of VA-diagnosed disorders included anxiety, opiod dependence, organic mental disorder, substance induced, and post-concussion syndrome. The examiner reported that the Veteran was diagnosed with mental health disorders over time, typically on subjective self-reports, and that the objective data available did not support those diagnoses and prior psychiatric testing suggested the Veteran was feigning a mental disorder. The examiner reported that on the current examination, the Veteran did not endorse mental disorder symptoms and there was no objective sign of a mental disorder, and the prior VA examination with objective data did not determine a clinical diagnosis. The Board, in its September 2019 Remand, was unable to resolve this issue. The examiner, in April 2017, reported that the VA examiner in August 2011 did not provide a diagnosis, that “prior VA examination with objective data did not determine a clinical diagnosis.” Such appeared incorrect, review of the August 2011 DBQ indicates that the Veteran was diagnosed with personality disorder, with symptoms listed, polysubstance dependence in sustained full remission, and dementia. Also, the Board discussed that the VA examiner in April 2017 declined to diagnose the Veteran with a relevant disorder based on the Veteran’s current presentation, one without endorsing mental health symptoms, and has considered the examiner’s comments as to the lack of valid testing. The Board noted that the VA treatment records associated with the claims file detail the Veteran’s lack of cooperation and lack of reliability as a historian in the setting of his mental health treatment. However, it was not yet appropriate to deny the Veteran’s claim on the basis that there is no current acquired psychiatric disorder. The records dated over the entire appellate period indicate the Veteran’s significant VA mental health treatment, with medication, for such. The Board, in its September 2019 Remand, directed the RO to afford the Veteran a new examination with an examiner other than the examiner who conducted the April 2017 DBQ to attempt to determine the prior psychiatric diagnoses over the course of the appeal and the etiology thereof. In a December 2019 DBQ, the examiner diagnosed the Veteran with diagnosed the Veteran with other specified personality disorder, mild neurocognitive disorder, and other specified trauma and stressor-related disorder. When asked if there was clear and unmistakable evidence that the Veteran’s acquired psychiatric disorder preexisted his entry into service, the examiner responded that it was more likely than not that it did; she did not consider the appropriate standard or provide adequate rationale, only citing pre-service functioning. When asked if there was clear and unmistakable evidence that the Veteran’s preexisting acquired psychiatric disorder was not aggravated during service, she responded that it did not appear that the Veteran’s personality disorder was aggravated due to service based on his pre-service and post-service functioning, and that his other specified trauma and stressor-related disorder was aggravated therein due to the cumulative effect of emotional trauma. However, as she did not render an adequate opinion as to whether the Veteran’s other specified trauma and stressor-related disorder preexisted service, the Board cannot extrapolate an adequate opinion as to aggravation of the same. The examiner did not respond to the inquiry as to whether there was any superimposed injury resulting in additional disability on the Veteran’s personality disorder during service and she only opined that there was no relationship between the Veteran’s diagnosed disorders and his service-connected hearing loss, tinnitus, low back disability, and right ankle disability when asked if such was proximately due to or aggravated by the disabilities. The examiner also opined that the Veteran’s mild neurocognitive disorder more likely than not was incurred during service if a traumatic brain injury did occur and depending on the nature and severity of the same. The examiner did not provide rationale for the opinion, which is based on evidence not cited and only appears to muse that if there was evidence of a traumatic brain injury of an unspecified nature or severity, the Veteran’s mild neurocognitive disorder could be attributed to such. The examiner did not discuss the nature of the Veteran’s February 1978 service treatment records indicating that the Veteran was hospitalized after being assaulted. He was initially unresponsive, without focal neurological findings, and physical examination revealed a laceration over the bridge of the nose and abrasions and contusions about the right eye, without other evidence of trauma. There was no acute injury to the jaw, and all findings were within normal limits save for swelling about the lateral malleolus of the right ankle with intact neurology. He was diagnosed with a right ankle disability and concussion. The examiner did not discuss the Veteran’s in-service and post-service head injuries or the results of the January 2018 DBQ related to his separate claim of entitlement to service connection for traumatic brain injury, negative for a diagnosis of TBI. On remand, the RO should obtain an adequate etiological opinion that responds fully to the Board’s inquires. 3. Entitlement to service connection for a liver disability, to include infectious hepatitis, is remanded. As discussed in the Board’s December 2016 and September 2019 Remands and discussed again here for clarity, despite its repetitive nature, the Veteran asserts that his liver disability, to include infectious hepatitis, is related to service. In a September 2007 statement, the Veteran reported that he got hepatitis while serving overseas, but that he did not know how; and that he drank the water. He also reported that during service he had to give a lot of blood for blood tests. During his August 2016 Board hearing, the Veteran reported that he did not know if he had any form of hepatitis or residuals thereof. He asserted that he had been diagnosed with infectious hepatitis or a liver condition during service, but did not know which type, and denied any exposure to bodily fluids during service. The Veteran’s service treatment records are silent for any complaint, treatment, or diagnosis of a liver disability, to include infectious hepatitis, however, he underwent testing during service in approximately December 1976 to rule out mononucleosis hepatitis and/or hepatitis A, resultant to dark urine, tender nodes, and malaise, and results of such are not associated with the records. During a March 1997 DBQ to evaluate the Veteran’s low back disability, the examiner noted that the Veteran had a history of hepatitis B; laboratory results, which appear to be non-reactive, dated in March 1997, are attached to the DBQ. VA treatment records dated in April 2011, an annual comprehensive assessment, indicates that an Axis III diagnosis included “medical condition” and listed infectious hepatitis to include liver condition, without further comment or physical findings. The Board reviewed the VA treatment records associated with the claims file, which include results of numerous blood tests, however, the Board was unable to determine if such blood tests reveal residuals of any hepatitis or any liver disability, to include infectious hepatitis; and the Board, in its December 2016 Remand, directed the RO to afford the Veteran a VA examination in order to determine the etiology of any liver disability, to include infectious hepatitis, found present. Report of an April 2017 DBQ indicates that the Veteran had been diagnosed with mononucleosis-associated hepatitis, the year of such not indicated in the service treatment records. The Veteran reported that during service he began urinating dark orange and sought treatment. He reported that he was told that his urine was orange because he drank something orange, and that by the fourth attempt at treatment, he was checked and treated in isolation for hepatitis for some period of time which eventually cleared. He reported that he was advised to avoid certain foods, and that he did not seek treatment for such after separation from service and has not been told anything about his liver since separation from service. The examiner cited the in-service report of dark urine with enlarged nodes and admission with a provisional diagnosis of mononucleosis-associated hepatitis and reported that such is a known complication of mononucleosis, and that all records indicated the resolution of such without residual. The examiner cited VA treatment records dated in March 1997 including a history of hepatitis B and noted that results of any testing were not included. The examiner cited VA treatment records dated in August 2003 indicating possible chronic hepatitis B, with testing silent for the same and silent for any gastrointestinal symptoms or symptoms prompting the provider to indicate possible chronic hepatitis B. The examiner reported that August 2003 VA laboratory results were negative for antibodies for hepatitis A, B, or C, which indicates no prior infection and rules out a diagnosis of chronic hepatitis B. The examiner concluded that there was no clinical or laboratory evidence of a chronic liver condition, that testing in 2003 was negative for hepatitis A, B, or C, and rules out prior infections. The Board, in its September 2019 Remand, discussed that results of laboratory testing in 2003, dated many years ago and prior to the time during which a VA treatment provider, in April 2011, in the annual comprehensive assessment, indicated that an Axis III diagnosis included “medical condition” and listed infectious hepatitis to include liver condition, is not sufficient evidence to deny the claim on the basis that there is no such disability. The Board, in its September 2019 Remand, directed the RO to afford the Veteran a new VA examination to determine whether he has any liver disability, to include infectious hepatitis, and if so, the etiology of such. Significantly, the Board directed the examiner to conduct appropriate laboratory testing to determine of the Veteran has liver disability, to include infectious hepatitis, or any hepatitis. In a December 2019 DBQ, the examiner diagnosed the Veteran was mononucleosis with hepatitis, in service. The examiner opined that such was less likely than not related to service and reasoned that the Veteran’s service treatment records showed mononucleosis with hepatitis, or inflamed liver, a known complication of mononucleosis, which was treated and resolved. The examiner reported that there was no current liver condition and no chronic progressive complaints of a liver condition since that time, that his hepatitis A, B, and C antibodies have never been positive, that he has never had any exposure to any hepatitis viruses, and that he experienced a complication, inflamed liver, due to a normal young adulthood virus, mononucleosis. The December 2019 opinion is inadequate. The Board specifically directed the examiner to conduct appropriate laboratory testing to determine of the Veteran has liver disability, to include infectious hepatitis, or any hepatitis; she did not. The Board, in its September 2019 Remand, had determined that laboratory testing in 2003, dated many years ago and prior to the time during which a VA treatment provider, in April 2011, in the annual comprehensive assessment, indicated that an Axis III diagnosis included “medical condition” and listed infectious hepatitis to include liver condition, is not sufficient evidence to deny the claim on the basis that there is no such disability. Also, the examiner did not consider the Veteran’s in-service testing to rule out hepatitis A or his lay statements describing exposure to drinking water overseas and repeated in-service blood tests. On remand, the RO should obtain an adequate etiological opinion. As to each of the claims on appeal, the most recent VA treatment records associated with the claims file are dated in August 2020. On remand, the VA RO should obtain the Veteran’s updated VA treatment records. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from August 2020 to the present. 2. Forward the claims file to the VA examiner who conducted the December 2019 DBQ as to the Veteran’s seizure disorder, or a suitable substitute, and obtain an adequate etiological opinion that responds fully to the inquires below. If any examiner deems that additional physical examination of the Veteran is required, so schedule the Veteran. (a) The examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that any current seizure disorder began during active service, or is related to any incident during active service, specifically considering and discussing the Veteran’s lay statements of in-service seizure symptoms during service, as well as his recorded in-service psychiatric complaints that included auditory and visual hallucinations, his lay statements of an in-service personal assault wherein he was hit between the eyes with a baseball bat and lost unconscious, and his February 1978 in-service diagnosed concussion resultant to an assault and the January 2018 DBQ related to his separate claim of entitlement to service connection for traumatic brain injury, negative for a diagnosis of TBI. (b) The examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that any current seizure disorder is: (1) proximately due to any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability, or his acquired psychiatric disorder, to include PTSD; (2) aggravated beyond its natural progression by any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability, or his acquired psychiatric disorder, to include PTSD. 3. Forward the claims file to the VA examiner who conducted the December 2019 DBQ as to the Veteran’s acquired psychiatric disorder, or a suitable substitute, and obtain an adequate etiological opinion that responds fully to the inquires below. If any examiner deems that additional physical examination of the Veteran is required, so schedule the Veteran. (a) The examiner must opine as to whether it is clear and unmistakable (obvious or manifest) that any current psychiatric disorder pre-existed the Veteran’s active service. (b) If so, the examiner must opine as to whether it is also clear and unmistakable (obvious or manifest) that any current psychiatric disorder was not aggravated by active service beyond its natural progression, considering the Veteran’s in-service psychiatric complaints and lay statements describing in-service stress with his family life and disciplinary actions, as well as his lay statements describing a personal assault and February 1978 in-service diagnosed concussion resultant to an assault and the January 2018 DBQ related to his separate claim of entitlement to service connection for traumatic brain injury, negative for a diagnosis of TBI. (c) If not, the examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that any current acquired psychiatric disorder, including, but not limited to, adjustment disorder, personality disorder, dementia, depression, mood disorder, and/or PTSD had its clinical onset during service or is otherwise related to service, considering the Veteran’s in-service psychiatric complaints and lay statements describing in-service stress with his family life and disciplinary actions, as well as his lay statements describing a personal assault and February 1978 in-service diagnosed concussion resultant to an assault and the January 2018 DBQ related to his separate claim of entitlement to service connection for traumatic brain injury, negative for a diagnosis of TBI. (d) The examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that any current acquired psychiatric disorder, including, but not limited to, adjustment disorder, personality disorder, dementia, depression, mood disorder, and/or PTSD is: (1) proximately due to any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability; (2) aggravated beyond its natural progression by any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability. (e) For any personality disorder, the examiner must also opine as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran has an additional disability due to a disease or injury superimposed upon a personality disorder as a result of service, considering the Veteran’s in-service psychiatric complaints and lay statements describing in-service stress with his family life and disciplinary actions, as well as his lay statements describing a personal assault and February 1978 in-service diagnosed concussion resultant to an assault and the January 2018 DBQ related to his separate claim of entitlement to service connection for traumatic brain injury, negative for a diagnosis of TBI. 4. Afford the Veteran a VA examination with an appropriate examiner to determine the etiology of any liver disability, to include infectious hepatitis, present during the appellate period. (a) Conduct appropriate laboratory testing to determine of the Veteran has liver disability, to include infectious hepatitis, or any hepatitis. (b) If the Veteran is diagnosed with such, the examiner should opine as to whether it is at least as likely as not (at least a 50 percent probability) that such began during active service, or is related to any incident during active service, considering his in-service testing to rule out mononucleosis-associated hepatitis and/or hepatitis A, and his lay statements describing exposure to drinking water overseas and repeated in-service blood tests. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.