Citation Nr: 21028503 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 15-37 509 DATE: May 11, 2021 REMANDED Entitlement to service connection for hepatitis is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1975 to December 1975 and had active duty for training in March 1976 and May 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Veteran testified at a videoconference hearing in front of the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claim file. In May 2019, the Board reopened and remanded the claim of entitlement to service connection for hepatitis C. In April 2020 and December 2020, the Board remanded the claim for further development. VA treatment records reflect that hepatitis B core antibody (HBcAb) IgM was noted in February 2001 and that the assessments on admission to an October 2002 hospitalization included hepatitis B. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the claim on appeal includes all forms of hepatitis. At the January 2019 hearing, the Veteran testified that he was reevaluated and reapproved for Social Security disability benefits. The RO should obtain these records. In November 2012, the Veteran submitted some treatment records from the Miami VA Healthcare System. In those records, he noted that he started receiving VA treatment in 1998. A July 2010 VA treatment record from the Biloxi VA Medical Center reflects that the Veteran had recently moved to the area and that he had been treated at the West Palm Beach VA Medical Center. The RO should obtain all records from the Miami VA Healthcare System and the West Palm Beach VA Medical Center from January 1998 to July 2010 and any additional records from the Gulf Coast Veterans Health Care System from December 2020 to the present. The Veteran alleges that his hepatitis is due to the following in-service risk factors: air-gun injections to administer vaccinations, high-risk sexual contact, sharing razors, getting an earring, and getting tattoos during active duty for training in Puerto Rico. The Veteran's service treatment records reflect that he received numerous vaccinations from September 1975 to October 1975. In a June 2002 statement, the Veteran reported that he got tattoos on his right arm and back in Puerto Rico and that one year later he was hospitalized for hepatitis. He has asserted that he was hospitalized for hepatitis in late 1977. The Veteran's service personnel records reveal that he had active duty for training in Puerto Rico in March 1976. An addendum to the latest VA medical opinion is necessary to address the in-service risk factors as well as the nature and existence of hepatitis B. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all treatment for hepatitis B and C and obtain any identified records. Obtain the Veteran's VA treatment records from the Miami VA Healthcare System and the West Palm Beach VA Medical Center for the period from January 1998 to July 2010 and from the Gulf Coast Veterans Health Care System for the period from December 2020 to the present. 2. Obtain the Veteran's federal records from the Social Security Administration regarding the Veteran's claim for disability benefits. Document all requests for information as well as all responses in the claims file. 3. After the development in 1 and 2 is completed, the RO should arrange for the Veteran's claims file to be reviewed by the VA doctor who wrote the medical opinion in February 2021 for preparation of an addendum opinion. If that physician is unavailable, arrange for the claims file to be reviewed by an appropriate clinician. The Veteran should only be scheduled for another examination if the February 2021 VA doctor or the new clinician deems it necessary. The clinician should be informed that VA treatment records reflect that hepatitis B core antibody (HBcAb) IgM was noted in February 2001, that the assessments on admission to an October 2002 hospitalization included hepatitis B, and that the Axis I diagnoses during the October 2002 hospitalization included cocaine abuse in remission. The clinician should determine whether the Veteran has or has had hepatitis B since May 2011. If the Veteran has or has had hepatitis B since May 2011, the clinician must opine whether it is at least as likely as not that hepatitis B is related to an in-service injury, disease, or event, including any of the following in-service events: high-risk sexual activity, sharing razors, getting an earring, air-gun injections to administer vaccinations during active duty from August 1975 to December 1975, and getting tattoos during active duty for training in March 1976. If the examiner finds that the hepatitis B is related to any of those in-service events, the clinician should identify all related in-service events. The clinician must opine whether it is at least as likely as not that hepatitis C is related to an in-service injury, disease, or event, including any of the following in-service events: high-risk sexual activity, sharing razors, getting an earring, air-gun injections to administer vaccinations during active duty from August 1975 to December 1975, and getting tattoos during active duty for training in March 1976. If the examiner finds that the hepatitis C is related to any of those in-service events, the clinician should identify all related in-service events. 4. After development above has been completed, the RO should readjudicate the Veteran's claim. If the claim remains denied, the Veteran should be issued a supplemental statement of the case, with a copy to his counsel, and afforded an opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cherry, 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.