Citation Nr: 21006218 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 15-26 795 DATE: February 3, 2021 ORDER Service connection for gallbladder removal, to include as secondary to service-connected Hepatitis C, is granted. FINDING OF FACT The probative and competent evidence is at least in equipoise that the Veteran’s gallbladder removal was proximately due to or caused by service-connected Hepatitis C. CONCLUSION OF LAW The criteria for service connection for gallbladder removal, as secondary to service-connected Hepatitis C, are met. 38 U.S.C. §§ 1110, 1113, 1131; 38 C.F.R. § 3.303, 3.310(a).   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1979 to June 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at an April 2019 video conference hearing, and a transcript of those proceedings is of record. This matter was previously before the Board in September 2020, when it was remanded to the Agency of Original Jurisdiction (AOJ) for additional development. It has now returned for appellate review. Service connection for gallbladder removal, to include as secondary to service-connected Hepatitis C, is granted. The Veteran seeks service connection for gallbladder removal surgery, to include as secondary to Hepatitis C. Specifically, he contends that his untreated Hepatitis C resulted in gallbladder polyps which necessitated gallbladder removal surgery. See 09/13/2013 VA 21-4138 Statement in Support of Claim. In ¬¬a November 2020 rating decision, the Veteran was awarded service connection for Hepatitis C. Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all of the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d). Service connection requires evidence showing: (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 condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The standard of proof to be applied in decisions on claims for Veterans benefits is set forth at 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran underwent gallbladder removal surgery in 2005. 02/26/2014 CAPRI at 7. At a February 2014 VA examination, the Veteran reported that gallstones were noted during a liver ultrasound to evaluate Hepatitis C, and that he had to undergo gallbladder removal surgery before treatment for Hepatitis C could commence. Regarding nexus, the February 2014 VA examiner opined that the Veteran’s gallbladder removal was less likely than not proximately due to or the result of the Veteran’s Hepatitis C. See 02/26/2014 CAPRI at 9. The examiner reasoned that the Veteran’s gallbladder was removed due to an incidental finding of a gallbladder polyp, but the cause of the gallbladder polyp was unknown. Id. In July 2014, the Veteran submitted a private medical opinion from Dr. M.M., MD. See 07/23/2014 Medical Treatment Record – Non-Government Facility. Dr. M.M. opined that the Veteran’s 2005 gallbladder removal was more likely than not necessitated by his Hepatitis C infection. Dr. M.M. reasoned that Hepatitis C often causes cholestasis, which can cause cholelithiasis and chronic irritation resulting in polyps and inflammation necessitating surgical removal of the gallbladder. In contrast, a September 2020 VA examiner opined that the Veteran’s gallbladder removal was less likely than not proximately due to, the result of, or aggravated by service-connected Hepatitis C. See 10/22/2020 C&P Examination. As rationale, the examiner reasoned that there is no statistically significant cause and effect relationship between Hepatitis C and gallbladder polyps. See id. The Board has reviewed the nexus opinions of record and concludes that the weight of the evidence is at least in equipoise that the Veteran’s gallbladder removal surgery was proximately caused by or due to service-connected Hepatitis C. On balance, the Board finds that Dr. M.M.’s favorable opinion is more probative and persuasive, as it shows greater consideration of relevant lay and medical evidence, and provides a more thorough medical rationale. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the credibility and weight of opinions are within the province of the adjudicator). Notably, Dr. M.M.’s opinion detailed the etiological relationship between Hepatitis C, cholestasis, and cholelithiasis, which can result in chronic irritation and inflammation necessitating gallbladder removal surgery. See 07/23/2014 Medical Treatment Record – Non-Government Facility at 3. As Dr. M.M.’s opinion shows adequate consideration of the relevant evidence and is supported by a medical rationale, the Board finds it is worthy of probative weight. Conversely, the rationale for the February 2014 opinion was simply that there was no evidence of a causal relationship between Hepatitis C and gallbladder removal surgery. See 02/26/2014 CAPRI at 9. However, the February 2014 VA examiner failed to consider whether there was a causal relationship between Hepatitis C and the gallbladder polyp that led to the gallbladder removal surgery. Further, the September 2020 opinion does not show adequate consideration of the relevant evidence. See 10/22/2020 C&P Exam. Significantly, the September 2020 VA examiner failed to show consideration of Dr. M.M.’s June 2014 medical opinion. As the February 2014 opinion lacks an adequate rationale and the September 2020 does not show consideration of the relevant evidence, the Board finds that the February 2014 and September 2020 opinions are entitled to very little weight.   Based on the above, and resolving doubt in favor of the Veteran, the Board finds that the Veteran’s gallbladder removal was proximately caused by or due to service-connected Hepatitis C. 38 U.S.C. § 5107(b). Entitlement to service connection for gallbladder removal surgery, as secondary to Hepatitis C, is warranted. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Tremont 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.