Citation Nr: 21064928 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 17-16 005 DATE: October 22, 2021 REMANDED Entitlement to service connection for a liver disability, to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1986 to May 2006. A remand is necessary to obtain a medical opinion to ascertain the likely etiology of the Veteran's liver disorder. In December 2017, the Veteran was provided a VA compensation examination, during which the examiner confirmed that the Veteran has non-autoimmune steatotic hepatitis (NASH), which was diagnosed in 2015. The examiner opined that such diagnosis was less likely than not incurred in or caused by active service. The examiner stated that it is unlikely that the one to two years of taking Strattera caused NASH, noting that the Veteran's liver enzymes had actually been higher while off of the medication. The examiner also noted that the Veteran had been considered obese since 2000, approximately 15 years before the diagnosis of NASH. On review, however, the Board finds the December 2017 opinion inadequate to the extent that the examiner did not apply the correct standard of review when addressing secondary service connection. The proper question is whether the Veteran's NASH is proximately due to, or aggravated by, the medication prescribed for his service-connected mental health disorder. More recently, during the July 2021 Board hearing, the Veteran raised an alternative theory of service connection. He asserted that his liver disorder may be etiologically related to his service-connected diabetes mellitus. The Veteran and his representative referenced medical literature that purportedly relates diabetes mellitus type 2 to NASH. On remand, the examiner will have an opportunity to address this theory of entitlement as well. Lastly, during the hearing, the Veteran's representative challenged the adequacy of the 2017 VA examination because the examiner checked the box indicating that no records have been reviewed. On remand, the examiner will be asked to review the entire claims file. The matters are REMANDED for the following action: 1. Provide the Veteran with an additional VA examination of the liver to be conducted by an appropriate medical examiner. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. After examination of the Veteran and review of his record, the examiner is asked to respond to the following: a). Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the Veteran's NASH is (i) proximately due to, OR (ii) aggravated by, any medication prescribed for his service-connected depression. The questions of both causation and aggravation must be answered by the examiner. b). Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the Veteran's NASH is (i) proximately due to, OR (ii) aggravated by his service-connected diabetes mellitus. The questions of both causation and aggravation must be answered by the examiner. **In doing so, the examiner should address the Veteran's testimony that medical articles such as from the Mayo Clinic purportedly suggest a relationship between NASH and diabetes. He also referenced the National Center for Biotechnology Information. Please note: The United States Court of Appeals for Veterans Claims in Ward v. Wilkie, 31 Vet. App. 233 (2019) has held aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice connected disability. A complete rationale should be provided for all opinions. 2. Thereafter, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Beach, 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.