Citation Nr: 21023510 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 16-20 593 DATE: April 20, 2021 ORDER Entitlement to a compensable initial disability rating for bilateral hearing loss is denied. Entitlement to service connection for diabetes mellitus, type II, (DM), to include as due to herbicide exposure, is denied. Entitlement to service connection for hypertension, to include as secondary to DM, is denied. REMANDED Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for cirrhosis of liver, to include as secondary to hepatitis C, is remanded. FINDINGS OF FACT 1. The preponderance of the competent and credible evidence of record indicates that the Veteran’s bilateral hearing loss has been manifested by no worse than a Level II hearing impairment for the right ear, and a Level III hearing impairment in the left ear. 2. The Veteran does not have service in the Republic of Vietnam, was not presumptively exposed to herbicides during service, and was not actually exposed to herbicides during service. The currently diagnosed diabetes mellitus was not incurred in service and is not etiologically related to service, including as due to exposure to herbicides. 3. The Veteran’s hypertension did not originate in service and is not otherwise related to his active service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a compensable initial disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3 4.85, Diagnostic Code (DC) 6100. 2. The criteria for service connection for DM have are not met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 5107(b), 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from September 1968 to September 1972. These matters are before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested to appear at a hearing before the Board in his February 2016 VA Form 9, Appeal to Board of Veterans’ Appeals. The Veteran withdrew his request for a hearing in February 2017. As such, his hearing request is considered withdrawn. In an October 2018 decision, the Board remanded the claims on appeal for further evidentiary development. As will be described below, a review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A supplemental statement of the case (SSOC) was issued in July 2020. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. Initial Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1. The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. 1. Entitlement to a compensable initial disability rating for bilateral hearing loss The Veteran asserts that his currently diagnosed bilateral hearing loss is worse than that represented by his current noncompensable rating. He has been provided VA audiological examinations for the relevant claims period to assess the nature and severity of the hearing loss. A review of the results of these examinations, and other relevant evidence, shows that the Veteran’s hearing loss, at worst, does not meet the criteria for a compensable rating, under the appropriate Diagnostic Code. Therefore, the claim for a compensable initial disability rating for bilateral hearing loss must be denied. In rating service-connected hearing loss, disability ratings are derived from a mechanical application of the rating schedule to numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Ratings of bilateral hearing loss range from 0 percent to 100 percent based on impairment of hearing acuity. To rate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels designated from I for essentially normal acuity, through XI for profound deafness. 38 C.F.R. § 4.85, Tables VI, VII. Audiological examinations used to measure impairment must be conducted by a state-licensed audiologist and must include both a controlled speech discrimination test (Maryland CNC) and pure tone audiometric tests. 38 C.F.R. § 4.85(a). The Ratings Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based upon a combination of the percent of speech discrimination (horizontal rows) and the pure tone threshold average (vertical columns), which is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. 38 C.F.R. § 4.85, Diagnostic Code 6100. The Roman numeral designation is located at the point where the percentage of speech discrimination and puretone threshold average intersect. 38 C.F.R. § 4.85(b). When the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b) Table VII is used to determine the percentage rating by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. The percentage rating is located at the point where the row and column intersect. 38 C.F.R. § 4.85(e). The Board finds that a review of the August 2013 and October 2019 VA audiological examinations, show that pure-tone threshold results from the Veteran’s October 2019 audiological examination to represent the most severe assessment of the Veteran’s hearing acuity during the claims period. The Veteran’s pure tone thresholds from an August 2013 examination, in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 20 20 50 70 40 LEFT 40 30 50 55 44 The examination included a speech recognition ability test results under the Maryland CNC guidelines which noted a 96 and 94 percent speech discrimination scores, for the right and left ear respectively. The Veteran’s pure tone thresholds from an October 2019 examination, in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 20 25 50 90 46 LEFT 45 35 65 75 55 The examination included a speech recognition ability test results under the Maryland CNC guidelines which noted a 98 and 96 percent speech discrimination scores, for the right and left ear respectively. In addition to these VA examinations, the Veteran has submitted a private audiological examination for his hearing, conducted in August 2012; the pure tone thresholds are as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 30 40 60 85 54 LEFT 45 45 60 65 54 The examination included a speech recognition ability test results under the Maryland CNC guidelines which noted a 92 percent speech discrimination scores for both ears. Applying the findings of the October 2019 VA examination, because they represent the worse audiometric finding for the claims period, to the rating criteria for hearing impairment, the Board finds that the criteria for a compensable initial rating for bilateral hearing loss have not been met. The Veteran’s hearing acuity was measured using 38 C.F.R. § 4.85, Table VIA, considering an audiological examination testing without speech audiometry (Maryland CNC). 38 C.F.R. § 4.86(a). Under Table VIA, the right ear hearing acuity was manifested by a Level II impairment, and the left ear, by Level III. Applying those findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule results in a zero percent rating for bilateral hearing loss. Even considering the August 2012 private examiner’s results, the rating criteria for a compensable rating is still not met. The Veteran’s hearing acuity was measured using 38 C.F.R. § 4.85, Table VI, considering an audiological examination testing with the speech audiometry (Maryland CNC). 38 C.F.R. § 4.86(a). Under Table VI, both ears hearing acuity was manifested by a Level I impairment. Applying those findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule results in a 0 percent rating for hearing loss. The Board finds that the results of the audiology examinations are contemporaneous and indicative of the severity of the current disability. Accordingly, those results are the most probative in determining whether the Veteran’s hearing loss disability warrants a higher disability rating. The Board notes that in addition to providing objective test results, the VA audiologists fully described the functional effects caused by the Veteran’s hearing loss disability in their final reports. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Board has considered the Veteran’s statements regarding the severity of his bilateral hearing loss. The Board does not discount the difficulties that the Veteran experiences as a result of his hearing loss. However, disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric evaluations. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Consideration has been given to assigning further staged ratings. However, at no time during the period under review has the disability warranted a higher schedular rating than those ratings currently assigned. The Board accepts the test results as reliable as the evidence of record does not show that the results are not reliable. As the mechanical application of the rating schedule yields no more than a zero percent rating, the preponderance of the evidence is against a finding that a compensable rating is warranted on a schedular basis. Thus, the claim for a compensable initial disability rating for service-connected bilateral hearing must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran is currently diagnosed with diabetes mellitus type II and hypertension, both which are listed as a “chronic disease” under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for “chronic” in-service symptoms and “continuous” post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as diabetes mellitus and hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962, and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. The presumption of herbicide exposure is warranted for service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); see also Haas v. Nicholson, 20 Vet. App. 257 (2006), rev’d sub nom. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). In order to establish qualifying “service in Vietnam,” a veteran must demonstrate actual duty or visitation in the Republic of Vietnam. Service on a deep-water naval vessel off the shores of Vietnam has traditionally not been considered service in the Republic of Vietnam for purposes of 38 U.S.C. § 101(29)(A). 38 C.F.R. § 3.307(a)(6)(iii); VAOPGCPREC 27-97. The following diseases are deemed associated with herbicide exposure under VA law: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin’s disease, Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), Multiple myeloma, Non-Hodgkin’s lymphoma, Parkinson’s disease, early onset peripheral neuropathy, Porphyria cutanea tarda, Prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma), Parkinsonism, bladder cancer, and hypothyroidism;. 38 C.F.R. § 3.309(e); see also National Defense Authorization Act 2021. Accordingly, diabetes mellitus is a disease for which presumptive service connection based on exposure to herbicides may be granted. Notwithstanding the foregoing presumption provisions for herbicide exposure, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff’g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Generally, the degree of probative value which may be attributed to a medical professional’s opinion accounts such factors as its thoroughness and degree of detail, and whether there was review of the Veteran’s claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Additional significant factors include whether the examining medical professional had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. 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) (rejecting medical opinions because examiner failed to consider certain relevant information). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. 49. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by, or obtained on behalf of, the appellant 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); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 2. Entitlement to service connection for DM to include as due to herbicide exposure. The Veteran generally contends that the claimed DM is related to herbicide exposure during active service. Specifically, the Veteran asserts that he was exposed to herbicide while he served in Okinawa, Japan, at Kadena Air Force Base between January 1970 and August 1971. He generally alleged that he was exposed to herbicides while serving in Japan through the use of herbicide on the grounds around the base or incidental to his work on aircrafts that may have been in contact, stored, or sprayed herbicides. To this end, the Veteran has not only submitted personal lay statements asserting his exposure to these herbicides, but he has also submitted lay statements for fellow soldiers who served with him in Japan. Initially, the Board finds that the Veteran is currently diagnosed with diabetes mellitus type II. Both private and VA post-service treatment record clearly demonstrates an ongoing diagnosis of DM, to include the use of insulin. Therefore, the Board finds that a current disability is found. Upon review of all the evidence of record, both lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran did not have “service in the Republic of Vietnam,” so may not be presumed to have been exposed to herbicides during service, and did not otherwise have actual exposure to herbicides during service, to warrant presumptive service connection for DM. Here, the Veteran does not allege, and the evidence does not show, that he served in Republic of Vietnam, in waters off the coast of the Republic of Vietnam, in the Republic of Korea, or in any other qualifying Air Force Bases in the region, the Board finds that presumptive exposure to an herbicide agent is not demonstrated. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The Board likewise finds the Veteran’s assertion that he was exposed to herbicides while serving in Japan unjustified by the evidence. In October 2019, the JSRRC responded to a request for information regarding the Veteran’s dates of service in Japan. The JSRRC response revealed a determination that there was no evidence that any “Agent Orange was used, stored or transported at Kadena Air Base in Okinawa, Ryukyu Islands, Japan,” and in turn, no exposure to herbicide can be concluded to the Veteran for his service therein. While the Board recognizes that the Veteran has provided lay accounts, to include accounts from fellow soldier, of use of herbicides at the base in Japan, the Board finds that such lay statements do not have the same probative value as officials findings by the JSRRC with regards to exacting records that show no herbicides were used, stored, or transported through the base in Japan. Here, neither the Veteran nor his fellow soldiers has demonstrated any training and/or expertise in chemicals or herbicides as to be able to competently identify the chemicals being used to “treat” the surrounding land around the base as Agent Orange. As such, the Board finds that such lay statements to be not competent in identifying the chemicals being used on the base in Japan as Agent Orange, and in turn, exposure during his service in Japan is not found, on a direct basis. The Federal Circuit has held that, when a veteran is not found to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents, but must also determine whether the current disability is otherwise the result of active service. After reviewing all of the lay and medical evidence of record, the Board finds that the weight of the evidence demonstrates that the current disability did not have its onset during, and is not otherwise related to, active service. In this regard, service treatment records (STRs) do not reflect any history, complaints, diagnosis, or treatment for any symptoms of DM, to include upon separation. Similarly, the Board finds that the weight of the evidence is against finding that symptoms of DM were “chronic” in service. As discussed above, STRs do not reveal any complaints, diagnosis, or treatment for any symptoms of DM, nor has the Veteran asserted that symptoms of DM began during active service. The Board next finds that the weight of the evidence is against finding that symptoms of DM were “continuous” since service separation. In this regard, the Veteran has not even asserted that his DM symptoms have been present since service separation in September 1972. VA and private treatment records also do not reflect any evidence of DM until decades after separation. As such, the Board does not find that such claimed disability arose directly (within a year) after service and has been ongoing and “continuous” until the present. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran’s current DM and active duty service. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claim of service connection for DM on a direct, presumptive, or any other 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. 3. Entitlement to service connection for hypertension, to include as secondary to DM The Veteran contends that his hypertension was caused by, or secondary to, his DM. However, in light of the decision above that denied entitlement to service connection for DM, the claim of secondary service connection hypertension must be denied. This claim is based on the underlying claim of service connection for DM, which the Veteran contends caused his hypertension. Where the underlying disability is not service connected, the claim of secondary service connection has no foundation and must be denied. 38 C.F.R. § 3.310. Nevertheless, the Board will consider whether the claimed hypertension was incurred in the Veteran’s military service. VA treatment record reflects that the Veteran was diagnosed with hypertension during the relevant period on appeal. Thus, the first element of service connection is met. The Veteran’s STRs do not show the Veteran complained of symptoms related to or was diagnosed with hypertension or high blood pressure during active service, to include upon separation from service. Post-service medical evidence reflects that the Veteran was not diagnosed with hypertension until decades after separation from active duty. A review of the record does not indicate, and the Veteran does not allege, that his hypertension is directly related to service or had its onset within one year from separation from active duty. The record does not contain any competent evidence relating the Veteran’s hypertension to service, and neither the Veteran nor his representative has presented, identified, or alluded to the existence of any such opinion. Instead, the Veteran contended that his hypertension is caused by his non-service-connected DM. Thus, the Board finds that the Veteran’s hypertension did not have its onset during active duty service and service connection on a direct basis must be denied. Further, the Board has considered whether service connection for hypertension is warranted on a presumptive basis as a chronic disease or based on continuity of symptomology. As previously indicated, the evidence of record does not show treatment for or symptomatology related to hypertension within a year from separation from active service. Thus, presumptive service connection is not warranted. Regarding a VA examination for hypertension, the claim for service connection for hypertension was not asserted or otherwise indicated to have developed in service or proximate to service or otherwise to be directly causally linked to service, but rather, it was claimed secondary to DM. As service connection for DM was denied, secondary service connection is denied based on the absence of a primary service-connected disability on which to base this claim. Thus, absent an indication that a link may be established between service or a service-connected disability and the Veteran’s hypertension, a VA examination is not warranted. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to service connection for hypertension is denied on both direct and secondary bases. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for hepatitis C is remanded. With regard to the claims for service connection for hepatitis C, the Board finds that the opinions obtained by the RO on the last remand are inadequate, and remand is required to obtain additional opinion for the VA to fulfill the duty to assist the Veteran. The Board notes that the VA’s statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is inadequate, as it is here, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Pursuant to the October 2018 Board Remand, the Veteran was afforded a VA examination with medical opinion in October 2019 as to the claimed hepatitis C. The Board finds that the October 2019 VA opinion to be inadequate and require an addendum. Specifically, the Veteran’s contention that his hepatitis C was caused by the use of air-injector gun during active service was not adequately addressed, to include addressing and reconciling the VA examiner’s negative findings with the positive private opinion letters of record. Here, the Board notes that in the October 2019 VA opinion, the examiner concluded that the Veteran’s hepatitis C was less likely than not due to the use of air-guns for inoculations during the Veteran’s active service. To this end, the examiner dispelled the scientific articles noted by the Veteran regarding correlation between air-gun inoculations and contracting hepatitis C and noted the Veteran’s other risk factors such as home-made tattoos and potential intervenous drug use. Critically, while the VA examiner dispelled a correlation between air-gun use in the military and contracting hepatitis C, the examiner’s opinion failed to speak to any specific relationship cited by the Veteran’s private treating physicians who note opinions that the Veteran’s hepatitis C was related to air-gun inoculations during service. Here, a letter from Dr. M. E. from June 2015 noted that the Veteran did not have a history of rick-factors for contracting hepatitis C, except for the use of air-jet gun injectors in service. Likewise, a letter from L. F., a physician’s assistant treating the Veteran, noted the use of air injection guns maybe have spread the contamination to the Veteran during service. While the Board does not find these opinions to be dispositive to the claim, the Board does find that such positive opinions should be reconciled by the VA examiner. Additionally, the Board finds the October 2019 VA examiner’s rationale to be incomplete, and logically inconsistent. Specifically, the examiner based the negative nexus finding, in part, on the fact that the Veteran’s STRs did not demonstrate any evidence of symptom or a diagnosis for hepatitis C during active service, to include upon separation. However, upon concluding the opinion’s rationale, the examiner explicitly noted that two risk factors for contracting hepatitis C, to include the use of intravenous drugs and ‘home-made’ tattoos. Here, the Veteran has continuously denied, and the Board finds consistent with the record that the Veteran did not use intervenous drugs, and that the reporting regarding such use, was misinterpreted, as explained by the Veteran. Therefore, as there is no evidence of intervenous drug use, the VA examiner’s other risk factor, homemade tattoos, was admitted by the Veteran but such was also noted on the Veteran’s entrance examination prior to service. Thus, the Board finds that the examiner’s finding of a risk factor that happened prior to service, and a finding that that the Veteran did not have hepatitis C during active service, to be logically inconsistent, and render the opinion inadequate. An addendum opinion reconciling these findings is required, to include a finding of if the Veteran entered service with hepatitis C. Therefore, remand is required. 2. Entitlement to service connection for cirrhosis of liver, to include as secondary to hepatitis C is remanded. With regard to the claim for service connection for a liver disability, as secondary to hepatitis C, the Board notes that as claim for hepatitis C is being remanded for additional development, the outcome of that claim could be a direct bearing on the Veteran’s claim for his liver disability. Therefore, the Board finds that these claims are inextricably intertwined. Accordingly, since that claim is being remanded, the Board finds that it would be potentially prejudicial to the Veteran for the Board to consider this derivative claim prior to the determination of that other claim. Bernard v. Brown, 4 Vet. App. 384 (1993); Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: The AOJ shall refer the VA claims file to a clinician with appropriate expertise to provide an opinion as to the claimed hepatitis C disability. The clinician is requested to review the claims file in its entirety including all service treatment records, VA, and private treatment records. If the clinician determines that an examination is necessary, one should be scheduled. Then, the clinician should respond to the following: (a) Is it clear and unmistakable (i.e., highest degree of medical certainty) that the Veteran entered service with any pre-existing hepatitis C? To this end, the examiner must speak to the Veteran’s entrance examination which noted homemade tattoos, and the previous examiner’s finding that such is a risk factor for contracting hepatitis C. (b) If YES, is it clear and unmistakable (i.e., highest degree of medical certainty) that any pre-existing hepatitis C condition WAS NOT aggravated (not permanently worsened beyond the natural progression of the disease) during service (c) If the examiner does not find that the Veteran clearly and unmistakably had a pre-existing hepatitis C condition, is it at least as likely as not (50 percent or greater probability) that any such condition is related to service or any incident of active service, to specifically include the use of air-gun injections? The examiner must speak to and reconcile any opinion with that of those offered in opinion letters or record, by the Veteran’s treating physicians. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ziheng Zhu, 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.