Citation Nr: 21031525 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 08-02 479 DATE: May 24, 2021 ORDER Service connection for chronic obstructive pulmonary disease (COPD) for accrued benefits purposes is denied. Service connection for cirrhosis of the liver for accrued benefits purposes is denied. Service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's COPD is the result of his active service, to include exposure to JP-4 jet fuel. 2. The preponderance of the evidence is against a finding that the Veteran's cirrhosis of the liver is the result of his active service, to include exposure to JP-4 jet fuel. 3. The principal or contributory cause of the Veteran's death was not a service-connected disability or a disability for which service connection should have been established. CONCLUSIONS OF LAW 1. The criteria for service connection for COPD for accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for cirrhosis of the liver for accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for the cause of the Veteran's death have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1310, 1312, 5103, 5103A, 5107; 38 C.F.R. § 3.5, 3.102, 3.159, 3.303, 3.307, 3.309, 3.311, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1957 to February 1961. He died in October 2006. The Appellant is his surviving spouse. These matters come to the Board on appeal of rating decisions issued in February 2007. In a February 2013 decision, the Board denied the claims. The Appellant appealed to the Court of Appeals for Veterans Claims (Court). In an August 2014 Memorandum Decision, the Court vacated the February 2013 decision and remanded the claims to the Board because the claims file contained a VA Form 21-4142 which did not belong to the Veteran (thus, possibly rebutting the presumption of regularity in VA's assembly of the record); and on the grounds that the Board did not adequately explain whether a June 2006 report constituted positive medical evidence regarding the claim of cirrhosis. The Court averred that the June 2006 clinician's conclusion that the Veteran's in-service exposures probably caused his cirrhosis was not speculative and implied a degree of certainty at least equivalent to the "as likely as not" standard. In June 2015, November 2015, and July 2020, the Board remanded the claims for further evidentiary development. Substantial compliance with the remand requests having been accomplished, the Board may proceed to consider the claims. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Procedural Considerations The Board reflects that when a veteran dies during the pendency of a claim for benefits, a surviving spouse has several options to pursue benefits. Three separate and distinct types of claims may be available, including claims for accrued benefits, substitution, and cause of death. Claims for accrued benefits and claims where an appellant is substituted for a deceased claimant are distinct. See 38 U.S.C. §§ 5121A, 5121(a); Reliford v. McDonald, 27 Vet. App. 297 (2015). An eligible appellant may file a claim for accrued benefits within a year of the veteran's death on any claim received by VA prior to death. See 38 C.F.R. § 3.1000. The appellant takes the veteran's claim as it stood on the date of death. The record is closed as of the date of the veteran's death and thus any evidence received by VA after the date of death may not be considered. Exceptions exist for records in VA's constructive possession; records received by VA but not physically associated with the claims file by the time of the veteran's death; and evidence necessary to establish that the claimant is within the category of persons eligible to receive accrued benefits. See 38 U.S.C. § 5121(c); 38 C.F.R. § 3.1000(d)(4). When the Veteran died on or after October 10, 2008, an appellant may file a claim for substitution within a year of the veteran's death on any claim received by VA prior to death. Substitution allows an eligible appellant to step into the shoes of a deceased claimant. The record remains open and an approved substitute may submit additional evidence in support of the deceased veteran's claim. See 38 U.S.C. § 5121A; 38 C.F.R. §§ 3.1010. Finally, an eligible appellant may submit a claim for service connection for the cause of the veteran's death. Service connection for the cause of a veteran's death may be demonstrated by showing that the veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. A cause of death claim may be developed for additional evidence beyond the date of the veteran's death. Here, the Veteran submitted claims for service connection for COPD and cirrhosis in July 2006, preceding his death. Following his October 2006 death, the Appellant submitted a claim for accrued benefits and cause of death. As such, she took on the claims for service connection for COPD and cirrhosis as they stood on the date of death. Accordingly, the only evidence which may be considered regarding those claims is the evidence in the claims file prior to the Veteran's death. The Board notes that there is additional evidence of record which was in VA's constructive possession at the time of death, and therefore that evidence must also be considered, specifically to include military personnel records and VA treatment records. Although an October 2019 letter was issued by VA which indicated that the Appellant had been properly substituted for the COPD and cirrhosis service connection claims, as the Veteran's death was prior to October 10, 2008, substitution for the outstanding service connection claims is not available. As such, service connection for COPD and cirrhosis will be considered solely on an accrued benefits basis. Although the record was effectively closed as regards the COPD and cirrhosis service connection claims as of the date of the Veteran's death, the Board has previously remanded for additional development to further explore the nature and etiology of his cause of death, including the inextricably intertwined COPD and cirrhosis diagnoses. The additional evidence obtained from the requested development may be considered regarding the cause of death claim. Duty to Assist The Appellant has contended that a duty to assist error occurred with regards to the COPD and cirrhosis service connection claims. The records in question were obtained after the Veteran's death and may be considered in connection to the cause of death claim. The Appellant argued that VA failed to obtain private medical records prior to the February 2007 rating decisions denying the claims on appeal. She asserted that there was evidence in the claims file that the Veteran received treatment from a private clinician which put the Board on notice of the existence of private records and triggered the Board's duty to obtain the records. The claims file contained no VA Form 21-4142, Authorization for Release of Information, submitted for the Veteran's records. However, the file did previously contain a VA Form 21-4142 submitted by a different veteran in connection to an unrelated claim. She contended that the misfiling rebutted the presumption of regularity in VA's assembling the record. In the August 2014 Memorandum Decision, the Court found that resolving whether VA misfiled a VA Form 21-4142 submitted by the Appellant or otherwise mishandled her claims file required making determinations in the first instance that are fact-based, evidentiary, and potentially not based on the record before the Board at the time of the February 2013 decision. As such, the Court exercised its discretion to remand the matter to the Board for consideration of whether the inclusion of another veteran's VA Form 21-4142 in the record constituted clear evidence to rebut the presumption of regularity in VA's claims filing process. The private records that were in the claims file reflected treatment by a private clinician for hearing problems in December 2004. Additional current diagnoses of cirrhosis and COPD were listed by the clinician. In a December 2004 VA treatment record establishing initial VA care, the Veteran reported treatment by the private clinician. He described a history of cirrhosis and COPD. He noted that the etiology of cirrhosis had never been determined and that he had had a chest x-ray by the private clinician within the last month or two which was reportedly stable. In a June 2006 VA treatment record, the Veteran reported that the private clinician had told him that he had a "liver problem" and that he had undergone either a CT scan or abdominal ultrasound for evaluation of his liver. VA has a duty to assist a claimant in obtaining evidence necessary to substantiate the claim. 38 U.S.C. § 5103A(a)(1). This obligations requires VA to make reasonable efforts to obtain relevant records, including private medical records, that the claimant adequately identifies and authorizes VA to obtain. 38 U.S.C. § 5103A(b)(1). Principles of administrative regularity dictate a presumption that government officials "have properly discharged their official duties." Saylock v. Derwinski, 3 Vet. App. 394, 395 (1992) (quoting United States v. Chem. Found. Inc., 272 U.S. 1, 14-15 (1926); Ashley v. Derwinski, 2 Vet. App. 307, 308-09 (1992). However, the presumption of regularity is not absolute and may be rebutted by the submission of "clear evidence to the contrary." Warfield v. Gober, 10 Vet. App. 483, 486 (1997) (quoting Rosler v. Derwinski, 1 Vet. App. 241, 242 (1991). In a November 2006 letter, the AOJ informed the Appellant that if a private physician or facility treated the Veteran, records of treatment may be able to be requested upon submission of a completed VA Form 21-4142. As noted above, no completed form was in the claims file. In a brief submitted to the Court, the Appellant stated that she "believes" that she returned an authorization and that its absence from the record was a result of an irregularity in VA's receipt of documents. She pointed to the misfiled document as evidence that the AOJ was not properly handling authorization form submissions during the time period in which a form submitted by her "would have been delivered." The Board finds that the misfiling of another veteran's authorization form in the Veteran's claims file is not sufficient evidence to rebut the presumption of regularity. The misfiled authorization forms were not received around the same time that the Appellant would have submitted an authorization form; the documents were received by VA two weeks prior to the AOJ's mailing of the authorization form to the Appellant. Under the circumstances, the misfiling of another veteran's authorization forms in the Veteran's claims file which were date-stamped as being received two weeks prior to the VA's mailing of authorization forms to the Appellant is not clear evidence rebutting the presumption of regularity in this case but instead amounts to mere conjecture. The Board finds persuasive the Appellant's statement that she believed she had sent in the form, rather than a more definitive statement that she had in fact mailed the form to the AOJ. Indeed, both of the February 2007 rating decisions, the December 2007 and August 2008 Statements of the Case (SOC), and the August 2008 Supplemental Statement of the Case (SSOC) listing the evidence considered therein did not note any private treatment records nor a VA Form 21-4142. There is no indication in the claims file that these documents were not received by the Appellant. In her March 2007 Notice of Disagreement (NOD) the Appellant did not indicate that there were outstanding private treatment records. She noted in her January 2008 Substantive Appeal that she had been told in 1995 that the Veteran had old scar tissue on his liver but she did not provide any identifying information for records of such or intimate that earlier-identified records had not been obtained. The Board attaches significant probative weight to the fact that the Appellant was informed multiple times that no private records had been considered and she did not mention any missing records on her NOD or Substantive Appeal. Based on the foregoing, the Board finds that the presumption of regularity has not been rebutted by clear evidence to the contrary. The Board further finds that the private records regarding hearing problems were insufficient evidence to put VA on notice that relevant private records existed regarding the current claims on appeal. In Ivy v. Derwinski, 2 Vet. App. 320 (1992), the Court held that VA was put on notice of the existence of private records because in an appellant's request to reopen his claim for service connection for a left scrotum condition, he mentioned treatment for pain in his urinary tract and provided the treating physician's name and address. Id. at 323. Additionally, an examining VA physician suggested a review of the old records from the private urologist and the appellant also referenced a second private physician in a statement in support of his claim. Id. Here, when the Veteran filed his claim for service connection for cirrhosis of the liver and COPD, he specifically notified VA that his records could be requested from the Birmingham and Jasper VA facilities. See July 2006 VA Form 21-4138, Statement in Support of Claim. He did not indicate the existence of any relevant private treatment records nor did he request that VA obtain treatment records from the private clinician who treated him for hearing problems. Although the Veteran told VA clinicians that he had had a chest x-ray and prior treatment for his liver from the private clinician including either a CT scan or an abdominal ultrasound, his treating VA clinician did not seek to obtain those records. Rather, he referred the Veteran to the VA cirrhosis clinic for testing. The results of laboratory tests, including a CT scan, were evaluated by his VA physicians. As for the January 2008 Substantive Appeal statement that the Appellant had been told that the Veteran had old scar tissue on his liver in 1995, nowhere in the statement did the Appellant allege that the private clinician diagnosed the Veteran with cirrhosis or performed any surgery on his liver. In contrast to the circumstances in Ivy, these circumstances are not reasonably characterized as sufficient to put VA on notice that the private clinician was in possession of relevant records that should be obtained despite the lack of request or authorization by the Veteran or Appellant. Additionally, there was no indication in documents in the claims file at the time that any records from that private clinician were relevant to the claims. In the December 2004 VA record, it was noted that the etiology of the Veteran's cirrhosis had never been determined. Nowhere is it contended that the private clinician told the Veteran that his cirrhosis or COPD were related to service. That is the crux of the service connection claims; the diagnosis and treatment of the conditions is not. Without an indication that the records are relevant to the claim, any failure to obtain them is non-prejudicial. See Marciniak v. Brown, 10 Vet. App. 198, 201 (1997); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). Based on the foregoing, the Board finds that because the presumption of regularity was not rebutted by clear evidence to the contrary and because there was insufficient evidence to put VA on notice that relevant private records existed regarding the current claims on appeal, no duty to assist error occurred. As noted above, this determination affects the COPD and cirrhosis service connection claims only; as the records in question were subsequently added to the claims file, they will be considered in connection with the cause of death claim. Service Connection The Appellant has contended that service connection for COPD and cirrhosis are warranted based on the Veteran's exposure to JP-4 jet fuel during active service. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing direct service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. § 3.303. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. In determining whether service connection is warranted for a disability, 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 the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The evidence in the claims file or in VA's constructive possession at the time of the Veteran's death included his service treatment records (STRs); service personnel records; private ear, nose, and throat treatment records; a VA audiological examination; and VA treatment records from December 2004 to October 2006. At service entrance, the Veteran denied shortness of breath; chronic cough; stomach, liver, or intestinal trouble; or jaundice. A lung and abdomen examination were normal. It was noted that his preservice occupation was service station operator. The Veteran was seen several times in service for various conditions. In April 1957, he was diagnosed with acute pharyngitis, organism undetermined. Clinicians stated that the condition did not exist prior to service entry and onset two days previously. Several days later, he reported that he had passed out at inspection. He had an elevated temperature and complained of a "cold." In August 1957, the Veteran was seen for a common cold, presenting with a 24-hour history of malaise, headaches, general myalgias, and a dry cough with no gastrointestinal symptoms. An examination demonstrated an elevated temperature and a red pharynx. The condition improved a day later and two days later he was noted to be afebrile and discharged to duty. In November 1957, the Veteran was seen by clinicians for a cold, sore throat, nausea, and general malaise. The impression was that he was dehydrated. A chest x-ray conducted in April 1959 was negative. In August 1959, the Veteran had a cold, cough, general malaise, and an elevated temperature. In September 1959, he reported difficulty gaining wait. His weight was 140 pounds and was reportedly never more. He was advised to not smoke. The Veteran was seen by clinicians in December 1959 for a head cold, cough, sore throat, and earache. An examination revealed that the throat was inflamed and he had several blotches. He was diagnosed with an upper respiratory infection (URI). A January 1960 STR reflected the Veteran's report of stomach pains after each meal, lasting three weeks. Follow-up notations included nausea and epigastric cramps for the past several days with no vomiting, diarrhea, or cardio-respiratory symptoms. The abdomen was soft, bowel sounds were hyperactive, and there was no hepatosplenomegaly. The impression was gastritis. In May 1960, the Veteran described sharp pain in his chest on inhalation, cough, and much sputum for 8 months. On examination, his lungs were clear to auscultation and he had a normal heart examination. The impression was mild bronchitis. He was advised no smoking for 14 days and prescribed medication. In June 1960, he was diagnosed with acute gastroenteritis, cause unknown. He described 12 hours of cramping abdominal pain and a persistent slight productive cough for several weeks which was partially relieved when he cut down on cigarettes. A lung examination revealed a few scattered wheezes, otherwise they were clear. An abdominal examination was soft with slight tenderness to the periumbilical area on the right and the right upper quadrant. There were normal bowel sounds with no rebound or masses. Later records reflected that he was much improved on medication and eating a regular diet. Clinicians suspected mesenteric adenitis or acute enteritis. He was discharged to duty. The Veteran's January 1961 separation examination demonstrated normal evaluations of the abdomen and lungs. A chest x-ray was negative. Military personnel records did not identify the Veteran's military occupational specialty but did confirm his service aboard the U.S.S. Essex. As noted above, private treatment records from December 2004 listed current diagnoses of COPD and cirrhosis. A December 2004 VA treatment record establishing initial VA treatment reflected his report of COPD that was diagnosed in approximately 1998 and cirrhosis diagnosed at the time of an abdominal aortic aneurysm repair. The Veteran reported that the etiology of cirrhosis had never been determined but that he had not consumed alcohol to any significant extent and had no history of jaundice or hepatitis. Varices were also found but he had not previously bled from them. The Veteran also stated that he had had a chest x-ray within the last month or so which was reportedly stable. Upon examination, the Veteran had a few faint, scattered wheezes but no respiratory distress. His abdomen was soft with good bowel sounds no masses or organomegaly, no tenderness, no reported pain or weight loss, and good appetite. He tested negative for Hepatitis C. At a February 2005 VA audiological examination, the Veteran described working on the flight deck of an aircraft carrier for three years during service. He reported that prior to entering the military, he worked at a gas station. Post-service, he worked for a tire and rubber company for 2 years and then for a power company for 30 years. A January 2006 VA treatment record reflected a lung evaluation that was clear to auscultation and unlabored respirations. The abdomen was soft, slightly distended, nontender, without definite mass, and the liver was not really palpable. Clinicians stated that COPD was stable and cirrhosis was stable with no evidence of bleeding. In June 2006, the Veteran reported to VA clinicians some dyspnea on exertion. He also described coughing up small amounts of blood if coughing excessively, but this was thought to be related to esophageal varices. He reported tobacco use of less than a pack per day for 50 years. He did not use alcohol and had probably been negative for hepatitis. He stated that his private clinician had done either a CT scan or an abdominal ultrasound for evaluation of his liver. It was noted that the Veteran had worked as a mechanic, retiring in 1996. VA clinicians diagnosed a history of cirrhosis, probably due to paint and other exposures reported, no clear etiology. He was referred to the VA cirrhosis clinic and liver tests were ordered. COPD was diagnosed per patient. Metered dose inhalers were provided to the Veteran. In a July 2006 record, the Veteran stated that he was diagnosed with cirrhosis when he underwent abdominal surgery in 1996. He reported a history of professional exposure to paint and gas fumes for 3 years in service and other exposures when working in a garage. A VA clinician noted that the history of cirrhosis of uncertain etiology was thought to be related to paint and other exposures in his occupation and service. The Veteran underwent a CT scan in August 2006 which revealed cirrhosis. Gastrointestinal specialists diagnosed autoimmune hepatitis that likely caused his cirrhosis. A follow-up with the gastroenterology clinic included a note that the likelihood of autoimmune hepatitis was low, particularly of active disease. The Veteran likely had non-alcoholic steatohepatitis (NASH) which lead to his cirrhosis. 1. Service connection for COPD for accrued benefits purposes is denied. Based on the foregoing evidence, the Board finds that service connection for COPD for accrued benefits purposes is not warranted. Although his military personnel records do not specifically confirm the Veteran's duties, the Board will assume that he was exposed to jet fuel while aboard the U.S.S. Essex as contended by the Appellant. However, there is no diagnosis of COPD during active service. There were several notations with respiratory complaints including a diagnosis of acute pharyngitis, a common cold, a sore throat, a URI, mild bronchitis, and productive cough. The conditions presented as acute symptomology, being limited in frequency and duration. They resolved with treatment and rest and were noted to improve when the Veteran reduced smoking and he was advised to discontinue smoking. Chest x-rays conducted in April 1959 and at separation in January 1961 were negative, indicating no ongoing pathology in the lungs at the culmination of service. By the Veteran's own report, he was diagnosed with COPD in approximately 1998, more than 35 years after service separation. He also indicated that he had smoked cigarettes for 50 years. The Board attaches significant probative value to the lack of chronic symptomology in service, no lung pathology upon x-ray at separation, the significant gap in time until COPD was diagnosed, and no indication in the STRs or post-service records that exposure to JP-4 fuel caused any relevant symptomology. The only indications in the record of a connection between JP-4 fuel exposure in service and the subsequent diagnosis of COPD are the opinions of the Veteran and Appellant who have not been shown to have the requisite medical expertise to provide a competent opinion regarding etiology of a complex medical condition. As such, the opinions are not afforded probative weight. Accordingly, the Board finds that the preponderance of the evidence is against a finding that COPD was the result of active service, including as due to exposure to JP-4 fuel exposure. Therefore, service connection is not warranted. 2. Service connection for cirrhosis of the liver for accrued benefits purposes is denied. Based on the foregoing evidence, the Board finds that service connection for cirrhosis of the liver for accrued benefits purposes is not warranted. During service, the Veteran reported stomach pains, nausea, and epigastric camps which were diagnosed as gastritis, cramping abdominal pain, acute gastroenteritis, and suspected mesenteric adenitis or acute enteritis. The symptoms resolved with treatment and rest and a separation examination revealed no relevant symptomology or complaints. The STRs and normal separation examination indicated that these complaints represented acute symptomology rather than chronic conditions. No relevant findings were made throughout service regarding the Veteran's liver. By the Veteran's own report, he was diagnosed with cirrhosis during an abdomen surgery in 1996, 35 years after service separation. Several potential etiologies were posited by treating clinicians, including autoimmune hepatitis, NASH, and paint and other exposures in his occupation and service. Clinicians later determined that autoimmune hepatitis was unlikely, given the Veteran's presentation. Clinicians stated that both NASH and paint and other exposures in his occupation and service were likely etiologies without providing any further supporting rationale. As such, the conclusions are afforded similar probative weight. However, it was noted that the Veteran worked at a gas station prior to service and as a mechanic at a power company for many years, post-service. Clinicians confirmed that paint and other exposures were likely both from service and from his civilian occupation, which occurred over a much longer timeframe than any service exposures. Clinicians did not differentiate between the effects of the shorter-term service exposure and longer-term civilian exposures. Further, the notation regarding paint and other exposures was made by a primary care clinician prior to clinical testing. The determination that NASH was likely was made after examination by a gastrointestinal specialist and a CT scan confirming cirrhosis. As such, the Board finds the notation regarding likely NASH to carry more probative weight than the notation regarding occupation and service exposures. With no diagnosis or relevant symptomology of cirrhosis during service or within a year of separation, service connection on a presumptive basis as a chronic condition is not warranted. Further, the Board finds that the preponderance of the evidence is against a finding that cirrhosis was the direct result of service, to include as due to JP-4 fuel exposure. There was no direct evidence of exposure causing symptomology during service and although a VA clinician found cirrhosis likely due to paint or other exposures, such exposures occurred during service and over the course of his much longer post-service employment. Further, a specialist later determined, after clinical evaluation, that NASH was the likely cause. The only evidence of record suggesting that in-service JP-4 fuel exposure directly caused the Veteran's cirrhosis are opinions by the Veteran and Appellant who have not been shown to have the requisite medical expertise necessary to determine the etiology of a complex medical condition. As such, their opinions are afforded no probative value. Accordingly, the Board finds that the weight of the competent and credible evidence is against service connection for cirrhosis of the liver, to include as due to JP-4 fuel exposure. Therefore, service connection is not warranted. Cause of Death The Appellant has contended that the Veteran's cause of death is the result of active service, to include exposure to JP-4 fuel. The death of a veteran will be considered to result from a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. Therefore, service connection for the cause of a veteran's death may be demonstrated by showing that the veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. A disability will be considered the principal cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. A disability will be considered a contributory cause of death when it contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. As noted above, the Board will consider the evidence already outlined above and evidence added to the record after the Veteran's death, summarized below. Private treatment records from an April 1993 hospitalization for a myocardial infarction noted that the Veteran had an isocyanide inhalation injury in November of 1992. He reported esophagus problems since the chemical exposure. He indicated that he smoked 1 and a half packs of cigarettes a day until one month previously. He did not drink alcohol. A chest x-ray was negative. A private operative report from January 1996 demonstrated micronodularity of the liver, presenting with a slight golden color rather than the deep reddish-brown color normally associated with the liver. During the course of treatment for an abdominal aortic aneurysm, an abdominal CT conducted in January 2000 demonstrated a normal liver. In February 2000, private clinicians listed chronic bronchitis in the Veteran's past medical history. It was noted that he continued to be an active smoker with symptoms of chronic cough, wheeze, and sputum production. He was subsequently diagnosed with COPD. By September 2000, an abdominal ultrasound revealed fatty infiltration of the liver. A CT of the abdomen conducted in October 2002 revealed a normal liver. Lung bases were clear. A CT of the chest was conducted in December 2003 for suspected asbestosis. The examining clinician stated that there was no evidence of pleural plaques or interstitial disease to suggest asbestos-related disease. COPD, emphysema, bronchitis, possible early cylindrical bronchiectasis, and nonspecific pre-tracheal lymphadenopathy were diagnosed. In October 2006, the Veteran was hospitalized for confusion. His medical history noted "severe COPD/cigarette smoking" and "advanced cirrhotic liver disease." He was diagnosed with encephalopathy most likely related to his underlying liver disease. Clinicians stated that the etiology of cirrhosis was not known. He was not a former alcohol drinker, but it might be related to a form of alcohol abuse. It was noted that he continued to be a 1 pack-per-day smoker. Clinicians later indicated that he had a large left temporal parenchymal intracranial hemorrhage with resulting encephalopathy. He underwent a progressive decline and became comatose and unresponsive, leading to his ultimate death on October 21, 2006. The Veteran's death certificate indicated that the immediate cause of death was intracerebral hemorrhage with another significant condition contributing to death but not resulting in the underlying cause noted to be cirrhotic liver disease. Over the course of the appeal, the Appellant submitted numerous articles pertaining to jet fuels, health effects of jet fuel exposure, and causes of intracerebral hemorrhages. One article from June 1995 indicated that breathing in large amounts of JP-4 would cause painful breathing. Changes in liver cells were seen in animals exposed to JP-4 vapor and breathing in JP-4 fuel may cause liver and kidney damage. A January 2006 fact sheet noted that breathing JP-4 fuel may cause irritation to the nose, throat, and respiratory tract, and liver and kidney damage. A JP-4 material safety data sheet indicated that inhalation may cause irritation, anesthetic effects, and respiratory system effects. Long-term exposure may cause effects to specific organs, such as the liver. In a June 2012 statement, the Appellant noted that the Veteran fueled jets with JP-4 fuel while aboard the U.S.S. Essex during service. He had extensive exposure to the fuel on his skin and through breathing. She noted that JP-4 affected skin and liver cells, caused skin lesions, decreased blood platelets, and caused bleeding disorders. She stated that risk factors for intracerebral hemorrhage included decreased levels of blood platelets, disseminated intravascular coagulation, and liver disease. When speaking to one of the Veteran's treating clinicians, she stated that he did not give a direct cause for cirrhosis and never mentioned NASH. He mentioned autoimmune hepatitis but stated that he did not think that was the cause of the Veteran's cirrhosis. In December 2012, the Appellant asserted that JP-4 fuel caused liver cell changes and blood cell changes. During service, she stated that the Veteran was in sick bay for lesions on his arms caused by dipping his arms into the fuel tank. Because he would have to immerse his arms in the tank that contained the fuel on a daily basis, she believed the fuel was absorbed into his body and bloodstream resulting in his later-diagnosed COPD, cirrhosis, and death from intracerebral hemorrhage. In a March 2021 statement, the Appellant noted that JP-4 jet fuel can cause trouble with any organ in the body as it is absorbed through the skin and enters the blood. Because her husband had been slim during service, he could get his arm down into the fuel tanks and retrieve the nozzle when it fell off. Other servicemembers' arms were too big to go into the tank, so he needed to do it. She stated that the Veteran did not have NASH because his treating clinicians told her they did not believe it was NASH and that he had old scarring on his liver. The Appellant also contended that COPD was not caused from smoking because he never smoked prior to service. Multiple VA medical opinions have been obtained to determine the etiology of the Veteran's cause of death. A VA medical expert opinion was obtained in April 2012. The clinician reviewed and listed the relevant evidence of record. He determined that it was less likely than not that a respiratory disorder was caused or aggravated by service, including exposure to jet fuel fumes. He stated that COPD was due to an intervening factor, most likely the Veteran's significant history of exposure to tobacco smoke. The clinician also concluded that it was less likely than not that the Veteran's cirrhosis of the liver was caused or aggravated by service, including exposure to jet fuel. He determined that cirrhosis of the liver was due to NASH. He defined NASH as a condition in which the patient lacks a history of significant alcohol consumption but has liver biopsy findings indistinguishable from alcoholic steatohepatitis. It is associated with obesity/metabolic syndrome, certain drugs, and certain extensive abdominal surgeries. As neither COPD or cirrhosis were deemed to be caused by service, the clinician did not determine whether either condition contributed substantially and materially to the Veteran's death, including his intracerebral hemorrhage. He further determined that it was less likely than not that the intracerebral hemorrhage was caused or aggravated by service including exposure to jet fuel. In support, he stated that there was no medical evidence that intracerebral hemorrhage is associated with jet fuel exposure in humans in the scenario relevant to this Veteran. Citing medical treatises, the clinician stated that in human studies, there was little evidence that acute or long-term exposure to jet fuel results directly in cancer, serious organic disease, or death in humans. With regard to respiratory effects in humans, observed symptoms and signs were primarily with recent exposure (i.e. the symptoms developed concomitantly with exposure). The respiratory effects were acute and primarily irritative in nature. The respiratory symptoms usually occurred quickly after high-level exposures and resolved within weeks to months. In massive dose exposures, the victim might be overcome by vapors, lose consciousness, or become violently ill (none of which occurred in this Veteran). The hepatic effects are subtle in humans and may be characterized by elevations in the liver enzymes. Once again, the findings usually occurred quickly after high-level or chronic exposures and resolved within weeks to months. Another VA opinion was obtained in February 2017. The clinician determined that the Veteran's COPD was less likely than not caused or aggravated by service, including exposure to jet fuels. In support, she stated that the Veteran was noted to have COPD/emphysema as early as 2000 and possibly before with a history of tobacco smoking of over 50 years. Tobacco smoking is the most common cause of COPD. Radiographic results of a chest CT showed changes of COPD/emphysema but did not show changes to suggest asbestos-related lung disease. This was noted to be significant because the Veteran was in the Navy and possibly exposed to asbestos. Exposure to jet fuel had not been shown to cause or aggravate COPD/emphysema. The STRs did not demonstrate chronic respiratory problems and the separation physical did not indicate any lung disease. Therefore, the clinician concluded that the Veteran's military service, including exposure to jet fuel, did not cause or aggravate his COPD/emphysema. The clinician also determined that the Veteran's cirrhosis of the liver was less likely than not caused or aggravated by service, including exposure to jet fuels. In support, she stated that cirrhosis was diagnosed in 1996. Various records suggested Hepatitis C (which was ruled out by negative testing), NASH, or autoimmune hepatitis. The exact cause of his cirrhosis was not established from the medical records, but it was clear that he had signs and complications of cirrhosis, including abnormalities of his coagulation caused by cirrhosis, which likely contributed to his fatal intracerebral hemorrhage. Jet fuel has not been shown to cause or contribute to development of cirrhosis. STRs did not show any hepatitis or symptoms suggestive of liver disease and the separation physical did not indicate any liver disease. Therefore, she determined that the Veteran's cirrhosis was less likely than not related to military service, including exposure to jet fuels. Despite the Veteran's many medical problems, he had been relatively stable and independent prior to October 2006 when he was brought to the hospital with a dramatic change in mental status. His coagulation tests showed abnormalities consistent with his cirrhosis, and these abnormalities increased his chance of suffering a hemorrhage. Unfortunately, he had had a significant intracranial hemorrhage with little chance of meaningful survival. Jet fuel exposure does not cause abnormalities of coagulation and his treating doctor also attributed the coagulation abnormalities to his cirrhosis. In addition, the Veteran's STRs and separation physical did not indicate any diagnosis or symptoms related to abnormal coagulation. Therefore, it was the clinician's opinion that military service, to include exposure to jet fuel, did not cause or aggravate the Veteran's intracranial hemorrhage. Another VA opinion was obtained in February 2020. The clinician found that it was at least as likely as not that the Veteran's COPD was the result of exposure to jet fuels. In support, she cited another veteran's non-precedential Board decision which awarded service connection for COPD based on long in-service occupational exposure to jet fuels (one of which was JP-4) which have been known to cause irritation of skin, the upper respiratory tract, as well as the central nervous system. Asbestos exposure was limited and unlikely to be contributory. The clinician further determined that COPD less likely than not caused or contributed substantially or materially to the Veteran's death or to intracerebral hemorrhage. In support, she stated that there was no medical literature to suggest that COPD could cause or contribute substantially or materially to intracerebral hemorrhage. The clinician determined that it was less likely than not that the Veteran's cirrhosis of the liver had its onset during service or was otherwise related to service to include as due to in-service exposure to jet fuel, including JP-4, or to asbestosis. In support, the clinician stated that cirrhosis was far more likely to be related to the Veteran's lifestyle or infection rather than to service-related exposures. There was however some evidence that exposure to high concentrations of volatile organic compounds (VOCs) in paint can cause long-term damage to the liver. Another VA opinion was obtained in April 2020. The clinician determined that it was less likely than not that the Veteran's COPD had its onset during military service or was related to his service including due to JP-4 jet fuel exposure or asbestos. It was instead at least as likely as not that his COPD was the result of his extensive history of smoking. In support, he stated that there was extensive medical literature which documents that the primary cause of COPD is smoking. VA medical records documented a 50-year history of smoking. The prevalence of COPD increases with age. Based on available medical records, the Veteran developed COPD in his 50s. The onset of COPD in his 50s was very consistent with his long history of smoking and aging. STRs and the separation examination were negative for any chronic respiratory issues and a chest x-ray at discharge was normal with no evidence of COPD. There was no evidence of COPD over the next 30 years after discharge and no positive evidence linking COPD to JP-4 jet fuel exposure. Additionally, records were negative for any evidence of asbestos-related disease. A CT conducted specifically to evaluate for asbestosis was negative. The clinician also determined that it was less likely than not that the Veteran's cirrhosis of the liver had its onset during military service or was otherwise related to in-service exposure to JP-4 jet fuel or asbestos. In support, the clinician stated that the Veteran had a diagnosis of NASH. Non-fatty liver disease was the most common liver disorder in Western industrialized countries. Medical literature documented well-established risk factors for the development of that type of liver disease and the Veteran had well-established risk factors of increasing age, male sex, dyslipidemia, hypertension, and history of abdominal surgery. While the exact cause of the cirrhosis/NASH was not determined, the Veteran did have well-established risk factors for the development of NASH. The STRs and separation examination were negative for any evidence of cirrhosis or chronic liver disease. There was no evidence that the Veteran developed liver disease/cirrhosis over the next 30 years following discharge. Medical literature documents that high-level exposures to jet fuel (including JP-4) can result in elevation of liver enzymes. However, the elevated enzymes occur shortly after the exposure and resolve over time. Once the exposure is eliminated, the liver enzymes gradually resolve (within months). There was no evidence that the Veteran had elevated liver enzymes during service or in the years immediately after discharge. He was diagnosed with cirrhosis in 1996, over 35 years after separation. Thus, there was no nexus between service and his development of cirrhosis many years later. The clinician continued that VA notations that cirrhosis was due to paint and other exposures in occupation and service was likely based on the Veteran's testimony. Medical records documented an occupational exposure in November 1992 involving an isocyanide inhalation injury. While the Veteran was able to provide testimony of occupational paint exposure and jet fuel exposure, he was not an expert on etiology of his liver disease. His treating gastrointestinal specialist did not make a diagnosis of cirrhosis/liver disease due to environmental exposure but instead diagnosed cirrhosis/NASH. Again, the records were negative for any evidence of asbestos-related disease and a chest CT was negative. Another VA opinion was obtained in February 2021. The clinician made an exhaustive listing of all relevant notations in the STRs, post-service private and VA medical records, lay statements, and submitted articles and treatises. The clinician determined based on a review of the body of evidence and relevant medical literature and in accordance with accepted medical principles, that it was less likely than not that the Veteran's pulmonary disorder (including COPD and emphysema) began during, or was related to, any incident of active duty service. In support, he stated that the Veteran's job in service was refueling jets and he had regular exposures to JP-4 via vapor inhalation and skin contact throughout his service. He worked at a service station prior to service and as a mechanic at a power company post-service for 30 years. The specifics of his post-service job were not found in his records, but as a mechanic, it was highly probable that he had vapor and skin exposures of various types as part of his job. This is supported by documentation of an isocyanide inhalation injury in November 1992. Isocyanates are widely used in manufacturing and the automobile industry. That exposure suggests that the Veteran had inhalation exposures to toxic substances post-service. The Veteran was seen several times in service for various conditions, with none attributed to inhalation of fumes, dermal contact, or ingestion of JP-4. Records indicated that he was a smoker and continued to smoke for decades after separation from service. There was specific mention in the STRs that smoking was contributing to his various illnesses, with symptoms improved by cutting back on smoking. In an April 1957 STR, it was noted that the Veteran passed out during inspection. He had been ill with pharyngitis a week prior. The visit stated that he had a cold, his temperature was 101 degrees, and he was treated until the next day with forced fluids, aspirin, and bedrest. The Veteran was thin and did not have much body fat reserves so if he was not feeling well and not eating and drinking well due to his viral illness, he likely developed a transient drop in his blood pressure while in formation that resulted in a faint. His passing out was treated with fluids and bedrest and was not attributed to any type of JP-4 exposure. The other various viral URI and/or bronchitis symptoms noted in the STRs were discussed, including a record noting intermittent wheezing. The clinician stated that people who smoke often have intermittent wheezing due to the chronic irritative effect of the smoke. This is unrelated to a JP-4 fume exposure. Smokers most often have a chronic smoker's cough and can pull muscles between their ribs while coughing. This was most likely the cause of the Veteran's intermittent sharp chest wall pains noted on one visit. Smokers are also predisposed to getting respiratory infections as compared to nonsmokers and also can take longer to clear viral respiratory infections. The clinician continued that the Veteran had negative chest x-rays during service, including at separation. There was no evidence of COPD/emphysema on his service examinations or chest x-rays. Literature states that it is uncertain whether exposure to JP-4 causes respiratory effects in humans and that there are no reports of chronic human occupational exposure to JP-4. The clinician cited to a study which found that no respiratory effects were reported after an acute accidental inhalation exposure to high levels of JP-4. Animal studies of chronic exposure (12 months) to 1,000 or 5,000 mg/m3 of JP-4 did not cause respiratory tract irritation or pulmonary lesions in rats at the end of the exposure period or 12 months post-exposure. The cited article noted that very little is known about human health effects caused by JP-4. However, a great deal is known about the adverse health effects of smoking. Numerous epidemiologic studies indicated that tobacco smoking is overwhelmingly the most important risk factor for COPD. This Veteran's development of COPD more likely than not was a direct result of his long history of smoking. The date the Veteran was first diagnosed with COPD is unclear but a history of COPD and chronic bronchitis was noted in 2000. Based on the body of evidence, those chronic respiratory conditions were due to the Veteran's long history of smoking and were unrelated to any exposures to JP-4 in service. The clinician also determined that it was less likely than not that the Veteran's symptoms during service (i.e., general malaise, myalgias, stomach pains after meals, nausea, epigastric cramps, cramping abdominal pain, right upper quadrant abdominal pain, trouble with gaining weight, etc.) were related to the post-service diagnosis of cirrhosis of the liver. In support, the clinician stated that the STRs were silent for concerns for liver problems or cirrhosis. The myalgias and other symptoms were related to cold and flu type viral syndromes and were unrelated to any JP-4 exposures. The only exposure some of his visits attributed his symptoms to was his ongoing exposure to smoking. Although one record had indicated that the Veteran had difficulty gaining weight, he had gained 16 pounds since service entrance. Smoking suppresses appetite. The clinician stated that this was why he was advised to stop smoking. An in-service diagnosis of gastritis was also deemed likely to be caused by smoking as smoking increases stomach acid production. Gastritis is neither caused nor aggravated by JP-4 exposure and the Veteran's symptoms in service were not chronic. Diagnoses of acute gastroenteritis, mesenteric adenitis, or acute enteritis were transient viral bowel illnesses and unrelated. The clinician continued that the Veteran tested negative for Hepatitis C. There were some notations in the post-service treatment records that perhaps the cirrhosis was due to paint and other exposures in the Veteran's occupation and service, but no supporting evidence was provided for that statement. Records did not address the Veteran's work-related exposures post-service at a tire plant for two years or as a mechanic at a power company for 30 years. Records also did not describe the circumstances surrounding an isocyanate inhalation injury in 1992 and post-exposure symptoms. That exposure was 4 years before he was found to have cirrhosis. A gastrointestinal fellow noted a diagnosis of cirrhosis in 1996 and that he had ordered autoimmune markers and had a positive ANA test and smooth muscle consistent with autoimmune hepatitis. The gastrointestinal fellow subsequently discussed the case with the attending physician and a later note stated that the attending found that the likelihood of autoimmune hepatitis was low and that the patient likely had NASH which lead to his cirrhosis. The opining clinician determined that the body of evidence supported that the Veteran had a history of elevated lipids that lead to the development of NASH and ultimately cirrhosis. The clinician concluded that the Veteran's cirrhosis was most likely the result of NASH. Post-service, the Veteran was noted to have elevated lipids and was not able to tolerate lipid lowering medications. Chronic elevation of lipids can lead to a fatty infiltration of the liver referred to as NASH. In the Veteran's case, NASH resulted in liver inflammation that resulted in the development of cirrhosis. His cirrhosis was first noted at the time of an abdominal surgery. The clinician cited a medical treatise which stated that no studies were located regarding hepatic effects in humans after inhalation exposure to JP-4. Animal studies of chronic (12 months) intermittent exposure (5 days per week, 6 hours per day) to 1,000 to 5,000 mg/m3 of JP-4 caused no liver toxicity in rats that were examined at the end of the 12-month exposure period. The clinician continued that cirrhosis leads to development of coagulopathy and an associated increased risk of bleeding, including intracerebral bleeding, as occurred with this Veteran. 3. Service connection for the cause of the Veteran's death is denied. At the outset, the Board finds that the VA opinions of record, taken together and in conjunction with the entirety of the evidence, form an adequate basis upon which to determine the claim. Any prior defects in the opinions of record have been adequately cured. Based on the foregoing, the Board finds that service connection for the cause of the Veteran's death is not warranted. The immediate cause of death was intracerebral hemorrhage. A significant condition contributing to death but not resulting in the underlying cause was noted to be cirrhotic liver disease. The Appellant has contended that either COPD or cirrhosis of the liver or exposure to JP-4 fuel in service resulted in intracerebral hemorrhage and the Veteran's death. The Board notes that the Veteran was service-connected for bilateral hearing loss and tinnitus prior to his death. However, there is no evidence of record suggesting that either of the service-connected disabilities were the principal or contributory cause of his death. (a.) COPD COPD was not listed as either a primary or contributing cause of death on the Veteran's death certificate. Contemporaneous medical records during his final hospitalization noted severe COPD/cigarette smoking but did not reflect significant involvement of COPD symptomology in his final days. The VA opinions of record determined that COPD less likely than not caused or contributed substantially or materially to the Veteran's death or to intracerebral hemorrhage, finding that there was no medical literature to suggest that COPD could cause or contribute substantially or materially to intracerebral hemorrhage. There is no medical evidence of record suggesting that COPD results in intracerebral hemorrhage generally or in the Veteran's particular case. As such, the Board finds the preponderance of the evidence is against a finding that COPD was the principal or contributory cause of the Veteran's death. Although the Board need not determine whether COPD should have been service connected as it has been found not to have been a principal or contributory cause of death, the Board will discuss service connection as the Appellant has raised the issue and significant development has been undertaken in support. The Board finds that the preponderance of the evidence is against a finding that the Veteran's COPD was the result of his active service, including as due to JP-4 fuel exposure. COPD was not diagnosed during service or for many decades thereafter. The Veteran was a frequent smoker for 50 years and he experienced an isocyanide inhalation injury post-service. Multiple VA opinions have determined that his long history of smoking most likely caused his COPD. The onset of COPD was consistent with the Veteran's age and smoking history. These opinions are supported by extensive medical literature regarding the etiology of COPD as well as studies indicating that respiratory effects of JP-4 inhalation are immediate and resolve over time. The Board attaches significant probative weight to the February 2021 opinion as it discussed each notation in service of a respiratory complaint and analyzed whether or not such notation was indicative of COPD or other conditions due to JP-4 fuel. The clinician's findings were well-reasoned, detailed, and supported by the evidence of record. In contrast, the only positive opinion of record, the February 2020 VA opinion, found COPD was at least as likely as not caused by JP-4 exposure, but only provided another veteran's non-precedential Board decision in support. Such award was based on a different fact pattern and medical history. The fact that another veteran received service connection for COPD is not adequate medical support for a finding that this Veteran's COPD was caused by in-service exposure without any other medical rationale in support. As such, the finding is not afforded probative value. Further, the Appellant's contention that the Veteran's COPD is the result of JP-4 exposure does not represent competent evidence as she has not been shown to have the requisite medical expertise to provide an opinion regarding etiology of a complex medical condition. Although she has pointed to the numerous articles in the record as supportive of her claim, the February 2021 opinion discussed some of the cited materials, pointing out the inconclusive nature of their findings. Further, articles and treatises tend to be general in nature and to not relate to the specific facts in a given veteran's claim. The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). However, the articles submitted by the Appellant were not accompanied by an opinion of a medical professional relating the information to the specific facts in the Veteran's case. As such, they do not on their own provide a basis for service connection. Accordingly, the preponderance of the evidence is against service connection for COPD including as due to JP-4 fuel exposure. As such, service connection for the cause of the Veteran's death due to COPD is not warranted. (b.) Cirrhosis of the Liver Several of the VA opinions have determined that cirrhosis leads to development of coagulopathy and an associated increased risk of bleeding, including intracerebral bleeding. As such, the Veteran's cirrhosis of the liver constitutes a contributory cause of death. The question then is whether his cirrhosis should be service-connected such that service connection for cause of death is warranted. The Board finds that service connection for cirrhosis of the liver, including as due to JP-4 fuel exposure, is not warranted. Cirrhosis or any liver symptomology was not diagnosed or noted in the Veteran's STRs. Several abdominal complaints were reported but the February 2021 VA opinion analyzed each of these and provided a rationale for why such complaints were not due to jet fuel exposure or indicative of cirrhosis. Indeed, several of the complaints were found likely caused or aggravated by the Veteran's smoking. Cirrhosis was not diagnosed for many years thereafter. As such, service connection on a presumptive basis as a chronic condition is not warranted. Several etiologies have been proposed in the record for the Veteran's cirrhosis. As discussed earlier, treating doctors stated that it could be due to paint and other exposures from his occupation or service; however, these comments were made prior to clinical testing by VA clinicians, including a CT scan and blood testing. Further, the treating clinicians did not differentiate between the Veteran's work-related exposures post-service at a tire plant for two years or as a mechanic at a power company for 30 years and service-related exposures. The clinicians also did not describe the circumstances surrounding an isocyanate inhalation injury in 1992 (4 years prior to the cirrhosis diagnosis) and post-exposure symptoms. As discussed in several of the medical opinions, medical literature demonstrated that exposure to JP-4 resulted in elevated liver enzymes which usually occurred quickly after high-level or chronic exposures and resolved within weeks to months, rather than long-term effects as contended by the Appellant. There was no evidence that the Veteran had elevated liver enzymes during service or in the years immediately after discharge. As such, the Board finds that the evidence of record contradicts rather than supports the treating clinicians' statement that cirrhosis could be due to exposures from service. Following the CT and other testing, a gastrointestinal specialist diagnosed likely NASH. Although the Appellant has since stated that she was told by clinicians that his cirrhosis was not due to NASH, the Board finds the contemporaneous medical documentation by treating clinicians diagnosing likely NASH to be more credible. The VA opinions further noted that the Veteran had various risk factors for developing liver disease, including increasing age, male sex, dyslipidemia, hypertension, and history of abdominal surgery. Additionally, as discussed by the February 2021 clinician, the Veteran was noted to have elevated lipids and was not able to tolerate lipid lowering medications. Chronic elevation of lipids can lead to a fatty infiltration of the liver (NASH). Based on the foregoing, the Board finds that service connection for cirrhosis of the liver is not warranted. Each of the VA opinions determined that cirrhosis was less likely than not due to service, including as due to JP-4 fuel exposure. The opinions relied on the clinicians' training and expertise, medical treatise evidence specific to JP-4 fuel exposure, the Veteran's specific medical history and diagnoses, and the lay statements of record. As such, the Board attaches significant probative value to the VA opinions. As noted above, the Appellant does not have the requisite medical expertise to provide a competent opinion regarding the etiology of a complex medical condition. Additionally, the medical articles and treatises that were submitted in support of her claims reflected hepatic effects from JP-4 exposure that were temporary rather than chronic. Further, the articles were not accompanied by any positive nexus opinions discussing their findings in relation to the Veteran's particular medical history and circumstances. As such, they are afforded less probative weight. Although a definitive etiology of the Veteran's cirrhosis of the liver was not provided during his lifetime, the VA clinicians, particularly in the February 2021 opinion, provided strong evidence to suggest a higher likelihood of NASH as a causative factor than in-service exposures. Accordingly, the preponderance of the evidence is against a finding that the Veteran's cirrhosis is the result of his active service, to include as due to JP-4 fuel exposure. As such, service connection for cirrhosis is not warranted and service connection for cause of death is not warranted. (c.) Exposure to JP-4 Fuel The VA clinicians have also agreed that it is less likely than not than any exposure to JP-4 fuel resulted in the Veteran's intracranial hemorrhage. As noted above, there is significant support that his cirrhosis caused the hemorrhage. VA clinicians determined that there is no medical evidence that intracerebral hemorrhage is associated with jet fuel exposure in humans in the scenario relevant to this Veteran. Further, during his October 2006 hospitalization, his coagulation tests showed abnormalities consistent with his cirrhosis, and those abnormalities increased his chance of suffering a hemorrhage. Clinicians stated that jet fuel exposure does not cause abnormalities of coagulation and the Veteran's treating doctor also attributed the coagulation abnormalities to his cirrhosis. In addition, the Veteran's STRs and separation physical did not indicate any diagnosis or symptoms related to abnormal coagulation. There is no evidence of record suggesting that exposure to JP-4 fuel caused the intracerebral hemorrhage other than the Appellant's contentions which are not afforded probative weight, as she has not been shown to have the requisite medical expertise necessary to provide a competent opinion regarding etiology of a complex medical condition. Therefore, the preponderance of the evidence is against a finding that the principal or contributory cause of the Veteran's death was exposure to JP-4 fuel in service. As such, service connection for the cause of the Veteran's death is not warranted. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rachel E. Jensen, 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.