Citation Nr: 21065952 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 16-00 368 DATE: October 28, 2021 ORDER Entitlement to service connection for hepatitis C is denied. FINDING OF FACT The preponderance of the evidence shows that the Veteran's hepatitis C was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. CONCLUSION OF LAW The Veteran's hepatitis C was not incurred as a result of active duty service, nor may the disorder be presumed to have been incurred in service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1974 to August 1976, and again from November 1977 to November 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Board remanded the issue on appeal for additional development in August 2018, March 2020, and May 2021. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). This appeal is being adjudicated under the legacy system, and not under the newer procedures of the Appeals Modernization Act (AMA), which took effect on February 19, 2019. The Board notes that after the March 2020 Board decision remanded the issue under the legacy system, but before the AOJ had readjudicated the service connection claim for hepatitis C, the Veteran submitted a June 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), in which chose the Direct Review option and included his service connection claim for hepatitis C in addition to a separate service connection claim for a lumbar spine disorder. Although an August 21, 2020 letter indicated that the Veteran's appeal of these issues had been placed on the Board's Direct Review docket, a separate August 21, 2020 letter clarified that the Board did not accept the VA Form 10182 with respect to the Veteran's service connection claim for hepatitis C. The August 2020 letter acknowledged the Board's receipt of the June 2020 VA Form 10182 before explaining that at the time of the Department of Veterans Affairs' (VA's) receipt of the VA Form 10182, VA had not made a decision in the modernized review system for the issue of hepatitis C that the Veteran identified in his request. That August 21, 2020 letter also explained that the Veteran would be able to opt-in to the modernized review system if he received a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC) on or after February 19, 2019. The AOJ later issued an SSOC that readjudicated this issue in November 2020, and the SSOC included information notifying the Veteran that he was eligible to opt-in to the modernized review system based on his receipt of the November 2020 SSOC in addition to enclosing a fact sheet with an explanation of the decision review options and submission deadlines. However, the Veteran did not respond to the November 2020 or subsequent August 2021 SSOCs by submitting an appropriate form necessary to opt his claim into the modernized review system. As such, the issue remains in the legacy system. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2021). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection for a Hepatitis Disability Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include cirrhosis of the liver, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For cirrhosis, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. VA Law and Policy Alcohol and Substance Abuse The Veteran's record and statements by some medical examiners indicate a history of alcohol abuse during and after active service. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that compensation cannot be awarded pursuant to 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 105(a) either for a primary substance abuse disability incurred during service or for any secondary disability that resulted from primary substance abuse during service. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Direct service connection may be granted only when a disability was incurred or aggravated in line of duty, and not the result of the Veteran's own willful misconduct or, for claims filed after October 31, 1990, the result of his abuse of alcohol or drugs. 38 U.S.C. § 105; 38 C.F.R. § 3.301(a). Willful misconduct is defined as an act involving conscious wrongdoing or known prohibited action. It involves deliberate or intentional wrongdoing with knowledge or wanton and reckless disregard of its probable consequences, to include the abuse of alcohol or drugs. 38 C.F.R. § 3.301(a). For the purposes of this paragraph, alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user; drug abuse means the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non-prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301(d). See also 38 U.S.C. § 105; 38 C.F.R. § 3.1(m). Evidence and Analysis Hepatitis C The Veteran is claiming that his hepatitis C came from a blood transfusion he had during treatment for injuries endured in a September 1980 automobile accident while stationed in Germany during active service. He claimed he had internal bleeding from the accident and that the transfusion was necessary to restore his lost blood. The Veteran also pointed out he had a hemorrhoidectomy in 1983 during active service where he contracted hepatitis C. The Veteran's service treatment records are silent for any diagnosis or suspicion of hepatitis of any type, to include hepatitis C. In general, for service connection to be granted for hepatitis C, the evidence must show that a Veteran's hepatitis C infection, risk factor(s), or symptoms were incurred in or aggravated by service. The evidence must further show by competent medical evidence that there is a relationship between the claimed in-service injury and the Veteran's hepatitis C. Risk factors for hepatitis C include intravenous (IV) drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, shared toothbrushes or razor blades. See VBA (Veterans Benefits Administration) letter 211B (98-110) November 30, 1998. A VA "Fast Letter" issued in June 2004 (Fast Letter 04-13, June 29, 2004) identified "key points" that included the fact that hepatitis C is spread primarily by contact with blood and blood products, with the highest prevalence of hepatitis C infection among those with repeated, direct percutaneous (through the skin) exposure to blood (i.e., intravenous drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and hemophiliacs treated with clotting factor before 1987). Another "key point" was the fact that hepatitis C can potentially be transmitted with the reuse of needles from tattoos, body piercing, and acupuncture. The Fast Letter indicates that the large majority of hepatitis C infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992, and injection drug use. The Veteran receives Social Security disability and those records are part of the claims file, but the disability determination is based on the Veteran's chronic renal failure, and no other condition. There is no mention of any form of hepatitis in the Social Security medical records. The earliest indication of the Veteran's hepatitis C is a diagnosis from a private medical treatment provider in 1999, referenced in an August 2003 medical record. The Veteran was being seen by a private physician and kidney specialist for mesangial proliferative glomerulonephritis. The Veteran was referred to a specialist but he never went, per the physician author of that August 2003 medical record. There was no discussion of etiology, contributing factors or causes, or any other discussion regarding the method and timing of contracting the condition. The formal diagnosis was hepatitis C, moderately active, grade III, with micronodular cirrhosis at stage IV due to alcohol abuse. Lab analysis indicated hepatitis C RNA of 4,860,000 IU/ml and was classified as genotype 1b. A liver biopsy was performed and the result was grade 3 inflammation and stage 4 fibrosis/cirrhosis. The Veteran received 24 weeks of interferon therapy and the hepatitis C virus was considered suppressed, though not eradicated. No further treatment for hepatitis was accomplished. The Veteran presented a statement from his private physician, Dr. T.E.T., dated October 2012. This physician commented on the Veteran's hepatitis C, saying "the cause of the chronic active hepatitis C remains somewhat unclear. [The Veteran] denies any specific risk factor for exposure to hepatitis C such as prior intravenous drug use of blood transfusion." This examiner did note the Veteran's hemorrhoidectomy during service and noted that while the Veteran did not receive a blood transfusion during the surgery or any other blood product, "it is possible [the Veteran] contracted hepatitis C at the time related to the medical procedure." Dr. T.E.T. provided no other reason as to possible cause of the Veteran's hepatitis C or its etiology. VA provided an examination in February 2013 to address the Veteran's claim regarding his hepatitis C. The VA physician examiner noted the Veteran's automobile accident of September 1980 at a US military base in southern Germany, and that the Veteran's injuries from that accident were described as a head injury. The Veteran was observed in a military medical hospital for several hours and had normal vital signs throughout the observation period. The Veteran was admitted for an overnight stay as part of the observation and discharged the next day. There was no medical note of any internal bleeding or other bleeding injury, and no evidence of a blood transfusion as claimed by the Veteran. The examiner noted the lab work accomplished as part of the treatment, and that the hematocrit value was 50 percent and well within the normal range, indicating that there had been no substantial blood loss or any transfusion in that period. The Veteran, during this examination, denied his previous assertion that he had ever had a blood transfusion or had ever used intravenous drugs at the time. The Veteran did say he had given himself a tattoo when he was age 13, which was the only identified risk factor. This examiner also noted the 1983 hemorrhoidectomy but that the record indicated no blood loss, instance of infection, or other blood-related problem with that outpatient procedure. This examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran's hepatitis C was related to active service, including the auto accident or the hemorrhoidectomy, based on the lack of corroborating data from those two incidents noted. The Veteran received a VA examination in August 2019. This examiner continued the previous diagnosis of hepatitis C from 1999 but noted the cause as unknown. The Veteran's cirrhosis of the liver, diagnosed in 2003, was also noted. The hepatitis C unable to be treated because of comorbid glomerulonephritis. Symptoms of daily fatigue and intermittent anorexia were noted. The examiner noted only one possible risk factor for the Veteran, that of a self tattoo at age 13, and no other. No incapacitating episodes were noted. The August 2019 VA examiner provided a negative opinion for direct service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran's hepatitis was incurred in or caused by the claimed in-service injury or illness. The examiner's rationale was that there was no data or evidence to suggest the Veteran's hepatitis C was incurred in service. The treatment notes for the hemorrhoidectomy provided no indication of the use of any blood product or transfusion, and those notes did not indicate the Veteran had any risk factors for hepatitis C. Additionally, the treatment following the in-service auto accident was similar; there were no signs of bleeding, internal or external, no blood product or transfusion was part of the treatment, and there were no other indicators that the Veteran's hepatitis C existed at that time. VA provided an addendum opinion for the Veteran's hepatitis C in May 2020, to address questions from the medical record regarding the Veteran's complaints of abdominal pain during service and a specific opinion regarding possible alcohol abuse. The examiner noted multiple evaluations during service regarding abdominal pain, attributed to excess alcohol consumption by multiple examiners at the time. As an example after one such treatment for complaints of abdominal pain, abnormal lab values were noted for SGPT and SGOT, with bilirubin of 1.3 after admission to the hospital in November 1981. The various diagnoses assigned during these episodes of pain were alcoholic gastritis, possible pancreatitis and other similar diagnoses. Hepatitis A and B were considered but ruled out with negative hepatitis testing. At the time of the Veteran's service, per the examiner, hepatitis C testing was not available; it did not become readily available until after 1990. This examiner continued, noting that as the labs ameliorated over time from that November 1981 episode, it is less likely than not these abnormalities were due to hepatitis C, then called "Non A, Non B hepatitis." The May 2020 examiner continued, noting the Veteran was diagnosed with hepatitis C in 1999 and with cirrhosis in 2003. The pathology report cited above revealed fibrosis and micro-nodular cirrhosis. This is considered classic for alcoholic cirrhosis. Therefore, as the acute episodes were more likely than not due to alcohol abuse and the pathology is due to alcoholic cirrhosis, it is more likely than not that the veteran's liver dysfunction is due to alcohol abuse and is not directly related to the hepatitis C. Additionally, the abdominal pain is explained by complications of alcohol abuse including probable gastritis and possible pancreatitis. Therefore, the examiner opined, it is less likely than not that the abdominal pain in service is due to hepatitis C. Though hepatitis C testing was not available during the time of the Veteran's active service, the pathology would take precedence in determining the cause of the liver damage. This examiner continued, and "considered it speculative to try and determine when the Veteran was exposed to hepatitis C. It is less likely than not due to the hemorrhoidal surgery in service. Surgical protocols would have been followed, and in the absence of a cluster of documented hepatitis cases, it is highly unlikely that contaminated surgical instruments, needles, etc., were the source." The examiner concluded by saying that other than contaminated surgical instruments or blood products, sexual practices and shared drug paraphernalia are the two most likely candidates for exposure, and those are not discussed in any medical record or any statement by the Veteran. Entitlement to service connection for hepatitis C The Board finds the VA examination reports and opinions from February 2013, August 2019, and May 2020 to be of great probative value. These examiners considered the timing and etiology of the Veteran's diagnosed hepatitis C, discussed the possible risk factors in accordance with medical knowledge and VA policy, and took into account the Veteran's full history. Indeed, the examiners considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion in each opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's negative opinion was supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board also notes the private opinion of Dr. T.E.T. who in October 2012 opined "the cause of the chronic active hepatitis C remains somewhat unclear." This examiner did note the Veteran's hemorrhoidectomy during service and noted that while the Veteran did not receive a blood transfusion during the surgery or any other blood product, "it is possible [the Veteran] contracted hepatitis C at the time related to the medical procedure." Dr. T.E.T. provided no other comments regarding etiology or other comments that would serve the Veteran's claim to service connection. The Board finds this opinion to be of low probative value when it comes to possible service connection because the physician qualified his comments to the level of possibility or speculation. The use of the words "possible," "may," or "can be" make a doctor's opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 12728 (1998) (quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993)) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by physician is too speculative). It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). The Board acknowledges that the Veteran is competent to testify as to his beliefs that his disability is related to service. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of his personal knowledge." Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran is competent to testify about his symptoms relating to his claimed hepatitis C, and also possible incidents and risk factors that may have led to his diagnosis. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology of a hepatitis C symptom or risk factor. See 38 C.F.R. § 3.159(a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. In addition, the Board finds that the 15-year gap in time between the Veteran's last date of active service, in November 1984, to his initial diagnosis by any medical provider regarding his hepatitis C in 1999 to be probative of a lack of nexus between the diagnosed current disability and active service. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board also notes multiple inconsistent statements between the Veteran and what the medical examiners and treatment providers have noted in their reports. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); Pond v. West, 12 Vet. App. 341 (1999) (although the Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam). There is no competent medical opinion of probative value in favor of a positive nexus to service from any VA or private medical examiner. The Board notes the Veteran's record of alcohol abuse along with VA's law and policy regarding service connection for alcohol and substance abuse, to include consideration of possible willful misconduct on the part of the Veteran with regard to his claim. The Board, however, clearly notes the May 2021 VA examiner who opined the Veteran's liver dysfunction, including diagnosed cirrhosis in 2003, is due to alcohol abuse and is not directly related to the hepatitis C, and therefore declines at this time to reach any finding whether or not the Veteran's noted alcohol abuse relates to his claimed hepatitis C, as it is not necessary to reach a decision in this case. 38 U.S.C. § 105; 38 C.F.R. § 3.301(a); Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Upon review of the record, the Board concludes that entitlement to service connection for hepatitis C is not warranted. The Board notes a current diagnosis of the hepatitis C disability, and thus the requirement for a current disability is shown. The Board acknowledges the Veteran's contentions, and the Veteran's post-service statements are noted. However, the Veteran's service medical records, to include all examinations, are silent for any existing hepatitis C condition at the time of separation, and, and there is no competent evidence to tie the current assertion to any in-service disease or injury. Multiple VA examiners have extensively discussed all of the Veteran's liver disabilities, to include hepatitis C and all possible risk factors raised by the record. The VA examiners who provided the negative nexus opinions noted all those VA treatment notes and examinations, and opined that hepatitis C is not related back to active service. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. (CONTINUED ON NEXT PAGE) Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed hepatitis C disability was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a hepatitis C disability on a direct basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Setter, 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.