Citation Nr: 21001791
Decision Date: 01/11/21	Archive Date: 01/11/21

DOCKET NO. 16-36 895
DATE: January 11, 2021

REMANDED

Entitlement to service connection for hepatitis C is remanded.

REASONS FOR REMAND

The Veteran served on active duty from December 1972 to December 1975.  This matter comes before the Board of Veteran’s Appeals (Board) on appeal from an October 2012 decision.  The Veteran presented testimony before the Board in February 2020.  Thereafter, in February 2020, the Board remanded the matter to obtain outstanding service personnel records and any line of duty determinations involving the motor vehicle accident.

In light of the additional development and upon further review, the Board has determined it cannot make a fully-informed decision on the issue of service connection for hepatitis C.  In pertinent part, the Veteran maintains that he contracted hepatitis C as a result of surgeries performed in service.  The Veteran was afforded a VA examination in November 2018 wherein the examiner opined hepatitis C was less likely incurred as a result of “treatment for right toe fracture.”  The examiner then noted risk factors for hepatitis C to include cocaine 1975, possible transfusion 1960, tattoo 1972, and possible non combat blood exposure 1973/1974.  

The Board finds the rationale inadequate as the examiner failed to address service treatment records showing the Veteran sustained a laceration to the right great toe in September 1973 treated with sutures.  Records later reveal in October 1973 the wound became infected and sutures had to be removed with dressing changes and whirlpool baths over a 10 day period. A clinical record cover sheet dated in November 1973 showed the Veteran had postoperative wound infection of the right second toe, organism undetermined, and secondary closure of the wound.  The examiner also provided no explanation as to the risk factors listed, which other than the tattoo, have not been shown in the objective medical record and disputed by the Veteran during the hearing.  Consequently, the matter must be remanded to obtain an addendum opinion to determine the etiology of the Veteran’s hepatitis C based on an accurate medical history and supported by adequate rationale.  

The matter is REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hepatitis C is at least as likely as not related to his active military service, to include the September 1973 and October 1973 surgeries of the right second toe.  In rendering this opinion the examiner must specifically address the service treatment records showing: a September 1973 laceration to the right great toe treated with sutures following a motor vehicle accident; an October 1973 postoperative wound infection of the right second toe, organism undetermined; October 1973 secondary closure of the wound; and dressing changes and whirlpool baths over a 10 day period in October 1973 following the secondary closure.  The examiner must also address additional risk factors for hepatitis C, to include the Veteran’s tattoo (noted on the 1975 separation examination).  The complete rational for all opinions expressed must be provided.

 

2. If upon completion of the above action, the issue remains denied the matter must be returned to the Board after compliance with appellate procedures.

 

 

E. I. VELEZ

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	K. L. Wallin, 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.