Citation Nr: 21032125 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 17-46 697 DATE: May 25, 2021 REMANDED Entitlement to service connection for Hepatitis C is remanded. Entitlement to service connection for diabetes mellitus (DM), to include as secondary to Hepatitis C is remanded. Entitlement to service connection for liver transplant, to include as secondary to Hepatitis C is remanded. Entitlement to service connection for multiple hernias to include as secondary to liver transplant is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from August 1966 to August 1968. The matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision. In January 2021, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. A transcript of the hearing is of record. 1. Entitlement to service connection for Hepatitis C is remanded. 2. Entitlement to service connection for diabetes mellitus (DM), to include as secondary to Hepatitis C is remanded. 3. Entitlement to service connection for liver transplant, to include as secondary to Hepatitis C is remanded. 4. Entitlement to service connection for multiple hernias, to include as secondary to liver transplant is remanded. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159. The Veteran contends that he had direct percutaneous exposure to blood by tattooing and also by blood donation during service while dry docked in San Juan, Puerto Rico. See May 2017 VA Form 21-4138. The Veteran contends that his Hepatitis C is due to tattoos obtained during service. He further contends that his disease was not discovered until 1989, which was well past his time in service, and that he was discharged from the Naval Reserve because of his Hepatitis C. See June 2016 Notice of Disagreement. The Veteran contends that his diabetes mellitus was secondary to his Hepatitis C, his liver transplant was also secondary to his Hepatitis C, and his multiple hernias are secondary to his liver transplant. At his January 2021 hearing, the Veteran identified potential in-service risk factors for Hepatitis C, to include obtaining several in-service tattoos. He testified that at the time he entered service, he had one tattoo, which he had given himself, and that there was no chance that there was any contaminated blood on his tattoo needle. During his active duty, his ship went into drydock in Puerto Rico and, during that time, he obtained four additional tattoos; the tattoo equipment was not clean. The Veteran testified that he did not get sick during the remainder of his active duty and he had a clean bill of health when he left active duty. He testified that the four additional tattoos were not documented on his exit examination in 1968, but that he was in dress whites when they performed it; and that they did not ask about the tattoos. He did not get any additional tattoos or any blood transfusions after leaving service, and he is not aware of having close personal contact with anyone who had Hepatitis C. The Veteran testified that, shortly after his discharge in 1968, someone noticed his higher enzyme levels; he had a liver biopsy and they started talking about it potentially being Hepatitis A or B. He further testified that he has tried to obtain the hospital records pertaining to this biopsy, but he has been told that after 20 years the records are destroyed. The Veteran further testified that after his active duty he went into the active Reserves for a total of 18 years. He received a letter because he had Hepatitis C and was given options to be discharged or to be transferred to the Retired Reserve; he chose the transfer to Retired Reserve. The Veteran testified that after his Hepatitis C diagnosis he was tired all the time, he had internal bleeding, and his liver was failing, so he was evaluated for liver transplant. He was told that his liver failure was caused by Hepatitis C and that he would need a liver transplant. He further testified that he received a liver transplant, but he still had Hepatitis C and he developed diabetes; his Hepatitis C has been eradicated from his body and he does not currently have Hepatitis C, but he is still diabetic and takes insulin daily. The Veteran testified that he was told that his diabetes was related to the liver transplant and the medications that he had to take. He also testified that his liver seems to be doing good, but that he has residual problems from the liver transplant including multiple hernias in his stomach which resulted in four 12-hour surgeries to try to repair them. He testified that he has continual pain and his stomach is shifted to one side as a result of the surgeries. See Hearing Transcript pages 5-17. As an initial matter, there is no dispute that the Veteran had been diagnosed with Hepatitis C. See March 1996 Medical Board Evaluation. Regarding the second requirement for service connection, the Veteran's service treatment records are silent as to his in-service tattoos; both his entrance and exit examinations document only one tattoo. However, as discussed above, the Veteran testified that he obtained four additional tattoos during service, and the Board notes that the Veteran has submitted statements offered by his brothers that the Veteran had one tattoo before going into the service, obtained four additional tattoos while in the service, and left active duty with a total of five tattoos. See August 2017 Buddy Statements. As part of its duties to assist a Veteran in a claim for service connection, VA may be required to provide an examination. Such an exam is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the claimant's service or with another service-connected disability, and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Board finds that there is competent evidence to suggest that there may be a link between the Veteran's claimed condition and his active duty service. As such, the Board finds that the evidence of record surpasses the "low" threshold set forth in McLendon. On remand, a VA examination should be scheduled, and an opinion obtained addressing the etiology of the Veteran's Hepatitis C. With regard to the Veteran's claims for service connection for diabetes mellitus, to include as secondary to Hepatitis C; service connection for liver transplant, to include as secondary to Hepatitis C; and service connection for hernias, to include as secondary to liver transplant, the Board finds these to be inextricably intertwined with his claim for service connection for Hepatitis C. Therefore, since the Veteran's claim for Hepatitis C is being remanded, these should also be remanded. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (providing that two or more issues are inextricably intertwined if one claim could have significant impact on the other). Further, there is no medical opinion of record regarding the nature and etiology of the Veteran's diabetes mellitus, liver transplant, or hernias. Therefore, opinions should also be provided on these matters. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. Give the Veteran an additional opportunity to submit, or authorize VA to obtain on his behalf, any records of private treatment for his Hepatitis C, liver transplant, diabetes mellitus, or hernias that are not already associated with the claims file. All efforts to obtain these records should be fully documented. 3. Take all appropriate efforts to obtain and associate with the file the Veteran's Naval Reserve medical records. 4. Following completion of the above, obtain medical opinions to determine the nature and etiology of the Veteran's Hepatitis C, diabetes mellitus, liver transplant, and hernias. A complete copy of the claims file must be made available to the clinician(s) for review. Following review of the entire record, to include the January 2021 Board hearing transcript, the reviewing clinicians(s) should address the following, as appropriate: (a) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's Hepatitis C had onset in or is otherwise related to his period of active duty service? The examiner is specifically requested to consider and comment upon all of the Veteran's identified in-service risk factors, to include obtaining in-service tattoos. (b) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's diabetes mellitus is proximately due to the Veteran's Hepatitis C? (c) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's diabetes mellitus was aggravated by the Veteran's Hepatitis C? (d) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's liver transplant was proximately due to the Veteran's Hepatitis C? (e) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's liver transplant was aggravated by the Veteran's Hepatitis C? (f) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's multiple hernias are proximately due to the Veteran's liver transplant? (g) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's multiple hernias were aggravated by his liver transplant? In offering any opinion, the examiner must consider the full record, to include the lay statements of record, and the opinion should reflect such consideration. A complete rationale should be given for all opinions and conclusions expressed. A discussion of the facts and medical principles involved must be provided, and the examiner should fully explain from a medical perspective the conclusion reached. If it is the determination of the opinion provider that an in-person or telehealth examination or interview is required to provide responses to the questions above, such should be scheduled. (Continued on Next Page) 5. After completing the above, readjudicate the Veteran's claims based on the entirety of the evidence. If the benefits on appeal should remain denied, the Veteran and his representative should be issued a supplemental statement of the case and an opportunity to respond. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Fulmer, 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.