Citation Nr: 23005642 Decision Date: 01/28/23 Archive Date: 01/28/23 DOCKET NO. 18-36 964 DATE: January 28, 2023 ORDER Service connection for hepatitis C is granted. Service connection for peripheral neuropathy of the right upper extremity, as secondary to service-connected hepatitis C, is granted. Service connection for peripheral neuropathy of the left upper extremity, as secondary to service-connected hepatitis C, is granted. Service connection for peripheral neuropathy of the right lower extremity, as secondary to service-connected hepatitis C, is granted. Service connection for peripheral neuropathy of the left lower extremity, as secondary to service-connected hepatitis C, is granted. REMANDED Entitlement to service connection for hepatitis B is remanded. Entitlement to service connection for rheumatoid arthritis is remanded. Entitlement to service connection for an overactive immune system is remanded. FINDINGS OF FACT 1. The Veteran's hepatitis C had its onset in service. 2. The Veteran's peripheral neuropathy of the right upper extremity is caused by his service-connected hepatitis C. 3. The Veteran's peripheral neuropathy of the left upper extremity is caused by his service-connected hepatitis C. 4. The Veteran's peripheral neuropathy of the right lower extremity is caused by his service-connected hepatitis C. 5. The Veteran's peripheral neuropathy of the left lower extremity is caused by his service-connected hepatitis C. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis C have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 2. The criteria for service connection for peripheral neuropathy of the right upper extremity, as secondary to service-connected hepatitis C, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for service connection for peripheral neuropathy of the left upper extremity, as secondary to service-connected hepatitis C, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for service connection for peripheral neuropathy of the right lower extremity, as secondary to service-connected hepatitis C, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 5. The criteria for service connection for peripheral neuropathy of the left lower extremity, as secondary to service-connected hepatitis C, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from April 1968 to July 1970, including service in the Republic of Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal of a May 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that denied service connection hepatitis C; hepatitis B; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; peripheral neuropathy of the left lower extremity; rheumatoid arthritis; and for an overactive immune system. 1. Hepatitis C Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). The term "active military, naval, or air service" includes active duty, any period of active duty for training during which the individual was disabled or died from a disease or injury incurred in or aggravated in the line of duty, and any period of inactive duty training during which the individual was disabled or died from an injury incurred in or aggravated in the line of duty. 38 U.S.C. § 101(24). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to certain herbicide agents (e.g., Agent Orange). In the case of such a veteran, service incurrence for the following diseases will be presumed if they are manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and sub-acute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, and trachea), and soft-tissue sarcomas. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Effective August 31, 2010, 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), is included as a disease associated with herbicide exposure under 38 C.F.R. § 3.309 (e). (Under 38 C.F.R. § 3.309 (e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309 (e) (Note 3.). On January 1, 2021, the National Defense Authorization Act for Fiscal Year 2021 has added three disorders to the list of diseases presumptively associated with exposure to herbicide agents. Specifically, it amended 38 U.S.C. § 1116(a)(2), to include parkinsonism, bladder cancer and hypothyroidism. 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. 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 1372, 1376-77 (Fed. Cir. 2007). 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 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Veteran contends that he has hepatitis C that is related to service, to include as due to Agent Orange exposure. He specifically maintains that he has hepatitis C as a result of receiving inoculations by an air gun during service. The Veteran also denies that he used intravenous drugs while serving in the Republic of Vietnam. He indicates that he has a strong aversion to needles, and that he would never use needles on himself. The Veteran essentially asserts that his hepatitis C commenced during his period of service. The Veteran served on active duty in the Army from April 1968 to July 1970, including service in the Republic of Vietnam. His DD Form 214 indicates that he served in the Republic of Vietnam from April 1969 to August 1969, and from March 1970 to July 1970. The Veteran's occupational specialty was listed as a wheel vehicle mechanic. The Veteran served in the Republic of Vietnam. Therefore, his exposure to Agent Orange is conceded. The Veteran's service treatment records do not specifically show treatment for hepatitis, to include hepatitis C. Such records do contain references to drug use. A June 2010 consultation sheet notes that the reason for the request to a psychiatric clinic was the Veteran's history of a speed addiction. It was reported that the Veteran also used other drugs, and that he had volunteered for treatment. The provisional diagnosis was drug abuse. The examiner stated that the Veteran used all types of drugs, and that he was to board on Ward 9, but that, instead, he went into town, and he was picked up by the military police. The examiner indicated that the Veteran did not feel that he could get off drugs in the Army. The examiner maintained that the Veteran was not physically addicted, and that he was not a candidate for hospitalization. The examiner reported that the only further solution was a "212." On a medical history form at the time of a July 1970 separation examination, the Veteran checked that he had symptoms, including frequent and severe headaches; dizziness and fainting spells; cramps in his legs; depression or excessive worry; and nervous trouble of any sort. There was also a check mark next to any drug or narcotic habit. The reviewing examiner reported that the Veteran had headaches with a concussion, when he was eleven or twelve years old, and that he had nothing severe or chronic since. It was also noted that the Veteran had dizziness and fainting spells, with the concussion only. The examiner stated that the Veteran had cramps in his legs after periods of prolonged and excessive walking or running only. The examiner maintained that the Veteran admitted to short-lived periods of depression secondary to external events, and that he described himself as a nervous person. It was noted that the Veteran was never under the care of a psychiatrist or on medications. The examiner indicated that the Veteran had intermittent marijuana use for the previous two years, intravenous speed use and barbiturates during the previous three months, and no drug use for the previous two weeks. An objective July 1970 separation examination report notes that the Veteran had drug abuse, and that a psychiatric evaluation was enclosed. There were notations that the Veteran's endocrine system; upper extremities; feet; lower extremities; and neurologic evaluation, were all normal. Post-service private and VA treatment records show treatment for hepatitis B and for hepatitis C. A December 2015 VA gastroenterology outpatient note, performed by a VA physician, indicates that the Veteran had a genotype 1 and 2 hepatitis C virus infection, hepatitis B on medication, and compensated cirrhosis. It was noted that the Veteran was seen for a twenty-six week follow-up and that his hemoglobin was back to normal. The assessment was genotype 1 and 2 hepatitis C virus infection, with compensated cirrhosis, here for a regular follow-up, with hemoglobin back to normal at 14. The physician reported that the Veteran only completed sixteen weeks of medication. It was noted that the Veteran's peripheral neuropathy was being treated with Gabapentin, 1800 mg a day, with some relief. The physician reported that the Veteran had no risk factors for hepatitis C. The physician stated that the Veteran had not undergone blood transfusions, or used intravenous drugs, and that he was not promiscuous and had no tattoos. The physician indicated that the most likely source of the Veteran's hepatitis C was from his basic training series of immunizations. The physician maintained that the Veteran should be considered for service connection for hepatitis C. A September 2021 statement from M. S., M.D., indicates that he reviewed the Veteran's claims file, his VA treatment records, and a statement from the Veteran. Dr. M. S., reported that the Veteran served in the Army from April 1968 to July 1970, and that his April 1968 enlistment examination does not reveal any prior medical conditions, history, exposures, or diseases, except for a mild concussion as a child. It was noted that the Veteran was found fit for service at that time. Dr. M. S., stated that, as part of the Veteran's induction process, he was given inoculations by an air gun, and that the inoculations were given in a mass process involving hundreds of new recruits. Dr. M. S., related that the inoculation process occurred in April 1968. Dr. M. S., indicated that the Veteran served in Vietnam on two occasions in 1969 and 1970, and that he reported using marijuana and barbiturates. Dr. M. S., reported that the Veteran maintained, in his statement, that he did not use intravenous drugs in Vietnam. Dr. M. S., stated that the Veteran underwent a psychiatric consultation in June 1970 for drug abuse, and that there was no indication of intravenous drug use in the notes of the examination. It was noted that the Veteran underwent a psychiatric examination for separation from service in July 1970, and that the psychiatrist noted no evidence of drugs or alcohol. Dr. M. S., reported that a physical examination for separation was performed in July 1970, and that no findings were made that show needle marks or other indications of intravenous drug use. Dr. M. S., indicated that, in the comments, the examiner reported that the Veteran said he used speed intravenously. Dr. M. S., reported that there was no medical history concerning hepatitis C from the Veteran's discharge until 2005. It was noted that in 2005, the Veteran's principal care provider made an incidental finding of a hepatitis C virus during a routine blood sample. Dr. M. S., discussed the Veteran's medical history in some detail. Dr. M. S., reported that in December 2015, a VA treating gastroenterologist indicated that it was his opinion that the Veteran's hepatitis C virus was caused by air gun inoculations that he received during his induction into service. Dr. M. S., stated that in considering the VA physician's opinion, it should be noted that the VA physician was a specialist in the area in question, and that he had treated the Veteran since 2010 when his treatment for the hepatitis C virus began. Dr. M. S., maintained that because of the VA physician's special training and his personal experience with the Veteran, his opinion carried significant weight. Dr. M. S., reported that the VA physician did not provide any medical literature to support his opinion. Dr. M. S. referred to a medical treatise and stated that medical literature exists that supports the opinion that the Veteran's hepatitis C was caused by an air gun inoculation. It was noted that needleless air gun injections were commonly used at the time when the Veteran was in the service, and that since that time, it had been recognized that air gun injections took very small amounts of blood to transmit blood-borne viruses. Dr. M. S., maintained that needleless air gun injection devices had clearly been shown to transmit blood, and they had been documented in hepatitis transmission. It was noted that there was medical literature documenting blood-borne illnesses being transmitted by jet gun inoculation. Dr. M. S., related that there was research showing blood transmission occurred using jet injections no matter how carefully done. Dr. M. S., reported that there was documentation of lack of practices of proper sterilization practices in the Army, and referred to a medical treatise. Dr. M. S., maintained that there were multiple references in the medical literature documenting the fact that such injection devices, even when designed to reduce transmission, did, in fact, transmit blood-borne viruses. Dr. M. S., referred to additional medical treatises. Dr. M. S., stated that there were several other matters that were not discussed in the VA physician's opinion, but which were well known to physicians who treat patients like the Veteran. Dr. M. S., indicated that the first was the amount of time that passed from the date of inoculation to the first symptoms. Dr. M. S., maintained that it was well known in the medical community that the hepatitis C virus could lie dormant or asymptomatic for decades after exposure. It was noted, that according to the Centers for Disease Control, up to 80 percent of those exposed to the virus experienced no symptoms. Dr. M. S., stated that it was hard to tell when the first symptoms occurred in the Veteran, but the fact that the symptoms occurred decades after the inoculations did not rule out the inoculations as the causative event. Dr. M. S., reported that the VA physician noted that there were no other risk factors in the Veteran's history. Dr. M. S., stated that the examinations before the Veteran's separation raise the question of intravenous drug use in the service. Dr. M. S., maintained that there were three examinations in June 1970 and July 1970, and that, two of the examinations, were psychiatric examinations performed by specialists. Dr. M. S, reported that neither of those examinations mentioned intravenous drug use. The examiner stated that the third examination was performed for separation, and that there was a notation in which the Veteran said that he used intravenous speed. It was noted that the physical examination, at that time, provided no supporting physical evidence such as needle marks ort corroborate such finding. Dr. M. S., maintained that two examiners, at least one of which was a trained psychiatrist, made no findings of intravenous drug use. It was noted that the third examiner indicated that the Veteran volunteered that he had intravenous drug use. Dr. M. S., reported that there was no physical evidence of intravenous drug use, and that the Veteran stated that he had a significant fear of needles since childhood and that he was certain that he did not use intravenous drugs in service. Dr. M. S., maintained that, from a medical point of view, there was not enough to rest an opinion on intravenous drug use. Dr. M. S., indicated that in his opinion, and he presumed from the note from the VA physician, that there was no adequate evidence of intravenous drug use to support a finding that such was the cause of the hepatitis C virus. Dr. M. S. stated that it was his opinion that the opinion by the VA physician was supported by the medical literature and the facts of the case. Dr. M. S., indicated that it was at least as likely as not that the Veteran's hepatitis C virus was caused by air gun inoculations in the induction process. Dr. M. S. further reported, as to conditions secondary to hepatitis C, that in June 2009, the Veteran's treating physician for rheumatoid arthritis indicated that he could not rule out hepatitis C virus immune complex disease as the cause of his rheumatoid arthritis symptoms. It was noted that, in 2010, the Veteran's treatment medications for his hepatitis C virus were changed, and that he developed an immediate increase in his rheumatoid arthritis symptoms. Dr. M. S., maintained that such incident strongly suggested that the cause of the Veteran's rheumatoid arthritis symptoms was the hepatitis C virus infection. Dr. M. S., reported that a relationship between the hepatitis C virus and rheumatoid arthritis was supported by medical literature, and he referred to a medical treatise. He stated that the most significant effect of the hepatitis C virus involves the hepatic system, and that end stage liver disease causes 8,000 to 10,000 deaths annually in the United States. It was noted that the hepatitic C virus was the leading cause of liver replacement surgery. Dr. M. S., indicated that in addition to the mortality and morbidity associated with the liver, the hepatitis C virus had significant extrahepatic morbidity. Dr. M. S., maintained that the most common extrahepatic complication of the hepatitis C virus involved rheumatoid-like symptoms of the joints, and that those symptoms included arthralgia, arthritis, paresthesia, and myalgia. Dr. M. S., stated that it appeared that such symptoms mimicked the symptoms of rheumatoid arthritis. Dr. M. S., indicated that it was very difficult to distinguish between true rheumatoid arthritis and rheumatoid arthritis caused by the hepatitis C virus. It was noted that the drugs used to treat rheumatoid arthritis were contraindicated for hepatitic C virus patients. Dr. M. S., reported that in considering the relationship between the hepatitis C virus and rheumatoid arthritis and neuropathies, it was important to understand that the fact that rheumatoid arthritis and neuropathies may have been diagnosed before the hepatitis C virus was not dispositive of the causation issue. It was noted that the hepatitis C virus was known as a silent killer, and that before the virus would become symptomatic itself, it could do significant damage to the body. Dr. M. S., maintained that, in the Veteran's case, the first sign of the disease may have been extrahepatic symptoms, but those symptoms were caused by the smoldering hepatitis C virus infection. Dr. M. S., indicated that based on his review of the Veteran's medical records, it was his opinion that it was at least as likely as not that the Veteran's upper and lower extremity neuropathies, and his rheumatoid arthritis, were caused by his hepatitis C virus infection. In a September 2021 lay statement, the Veteran's wife indicates that she married the Veteran in April 1971, and that they had lived together since that time. She maintained that she knew the Veteran made a statement that he was had a fear of needles, and that she could confirm that he had always been afraid of needles and taking shots. The Veteran's wife reported that early in their marriage, she noticed that the Veteran avoided anything that had to do with getting shots, and that he told her that he hated needles and did whatever he could to avoid them. The Veteran's wife reported that she did give the Veteran shots since he developed arthritis, and that he had to be given medication by a shot in the stomach. She stated that when she first started giving him shots, it was agony for the Veteran because of seeing the needle. She stated that she could see in his face that he had an extreme fear of needles. The Veteran's wife stated that he had become a little better in that regard, but that he still clenched his jaw whenever he saw a needle. The Board observes that the Veteran's service treatment records do not specifically show treatment for hepatitis, to include hepatitis C. The Board notes that such records do include references to drug use. A June 2010 consultation sheet indicates that the reason for the request to a psychiatric clinic was the Veteran's history of a speed addiction. It was reported that the Veteran also used other drugs, and that he had volunteered for treatment, and a provisional diagnosis of drug abuse was provided. The examiner stated that the Veteran used all types of drugs, that he did not feel that he could get off drugs in the Army, and that he was not physically addicted. The examiner reported that the Veteran was not a candidate for hospitalization, and the only further solution was a "212." On a medical history form at the time of a July 1970 separation examination, there was a check mark next to any drug or narcotic habit. The reviewing examiner indicated that the Veteran had intermittent marijuana use for the previous two years, intravenous speed use and barbiturates during the previous three months, and no drug use for the previous two weeks. An objective July 1970 separation examination report notes that the Veteran had drug abuse, and that a psychiatric evaluation was enclosed. There were notations, including that the Veteran's endocrine system was normal. The Board notes post-service private and VA treatment records show treatment for hepatitis C. A December 2015 VA gastroenterology outpatient note, performed by a VA physician, relates an assessment of genotype 1 and 2 hepatitis C virus infection, with compensated cirrhosis, here for a regular follow-up, with hemoglobin back to normal at 14. The physician reported that the Veteran had no risk factors for hepatitis C. The physician stated that the Veteran had not undergone blood transfusions, or used intravenous drugs, and that he was not promiscuous and had no tattoos. The physician indicated that the most likely source of the Veteran's hepatitis C was from his basic training series of immunizations. The physician maintained that the Veteran should be considered for service connection for hepatitis C. The Board observes that the VA physician indicated that the most likely source of the Veteran's hepatitis C was from his basic training series of immunizations, and that the Veteran should be considered for service connection for hepatitis C. The Board observes that there is no indication that the VA physician reviewed the Veteran's claims file. Although claims file review is not necessary, the probative value of a medical opinion is based on its reasoning and its predicate in the record so that the opinion is fully informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the VA physician did not specifically address the notation, on a medical history form at the time of that Veteran's July 1970 separation examination, that the Veteran had intermittent marijuana use for the previous two years, intravenous speed use and barbiturates during the previous three months, and no drug use for the previous two weeks. Therefore, the Board finds that the VA physician's opinions, pursuant to the December 2015 VA gastroenterology outpatient note, are somewhat less probative in this matter. A September 2021 statement from Dr M. S., indicates that he reviewed the Veteran's claims file, his VA treatment records, and a statement from the Veteran. Dr. M. S., discussed the Veteran's medical history in detail, including the notations of drug use in his service treatment records. Dr. M. S., stated that it was his opinion that the opinion by the VA physician was supported by the medical literature and the facts of the case. Dr. M. S., specifically indicated that it was at least as likely as not that the Veteran's hepatitis C virus was caused by air gun inoculations in the induction process. The Board observes that the Dr. M. S. found that it was at least as likely as not that the Veteran's hepatitis C virus was caused by air gun inoculations in the induction process (during service). The Board observes that the M. S. reviewed the Veteran's claims file; discussed his medical history in detail, including the references to drug use during service; and addressed the opinions provided by the VA physician, pursuant to the December 2015 VA gastroenterology outpatient note. Dr. M. S., also provided detailed rationales for his opinions. Additionally, the Board notes that the opinions from Dr. M. S., as to the etiology of the Veteran's hepatitis C, are consistent with the evidence of record, especially in light of the fact that there are no negative etiological opinions of record in that regard. Therefore, the Board finds that the opinions by Dr. M. S., pursuant to the etiology of the Veteran's claimed hepatitis C., are very probative in this matter. The Veteran is diagnosed with hepatitis C. In a very probative opinion, as to the etiology of the Veteran claimed hepatitis C, Dr. M. S., found that that it was at least as likely as not that the Veteran's hepatitis C virus was caused by air gun inoculations in the induction process (during service). Resolving any doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise as to whether his hepatitis C commenced during his period of service. In light of the foregoing, the Board finds that the evidence at least approximates and thus supports the Veteran's claim of service connection for hepatitis C. Thus, service connection for hepatitis C is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. 2. Peripheral Neuropathy of the Right Upper Extremity; Peripheral Neuropathy of the Left Upper Extremity; Peripheral Neuropathy of the Right Lower Extremity; and Peripheral Neuropathy of the Left Lower Extremity As discussed above, service connection is now in effect for hepatitis C. The Veteran contends that he has peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity, that are related to service, to include as due to Agent Orange exposure, or more specifically, that are related to his now service-connected hepatitis C. The Veteran's service treatment records do not specifically show treatment for peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; or for peripheral neuropathy of the left lower extremity. Post-service private and VA treatment records show treatment for chronic pain/neuropathy; chronic neuropathy; idiopathic peripheral autonomic neuropathy; peripheral autonomic neuropathy; peripheral neuropathy; polyneuropathy; and for neuropathies of the upper and lower extremities. A March 2017 VA treatment report notes that the Veteran was seen for a follow-up. The Veteran stated that he had no complaints, but that he wanted a little increase in his Methadone for his back pain. The assessment included genotype 1 and hepatitis C virus infection; hepatitis B on antivirals, intermittently; cirrhosis; rheumatoid arthritis; and polyneuropathy secondary to hepatitis B and C. A September 2021 statement from M. S., M.D., was discussed above. In the September 2021 statement, Dr. M. S., also addressed the etiology of the Veteran's claimed peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity. Dr. M. S., indicated that based on his review of the Veteran's medical records, it was his opinion that it was at least as likely as not that the Veteran's upper and lower extremity neuropathies were caused by his hepatitis C virus infection. The Board notes that the Veteran is currently diagnosed with peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity. The Board observes that Dr. M. S., in a September 2021 statement, indicated that it was at least as likely as not that the Veteran's upper and lower extremity neuropathies were caused by his hepatitis C virus infection. The Board finds that Dr. M. S., opinion, as to the etiology of Veteran's claimed upper and lower (peripheral) neuropathies, pursuant to the September 2021 statement, is very probative in this matter. The Board notes that the statement from Dr. M. S., as to those claimed disorders, is consistent with the evidence of record. For example, a March 2017 VA treatment report relates an assessment of polyneuropathy secondary to hepatitis B and C. The Board therefore finds that the Veteran's peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity, are due to, or the result of, his service-connected hepatitis C. Thus, the evidence at least approximates and thus supports secondary service connection for peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity. See 38 C.F.R. § 3.310. As the Board has granted secondary service connection it need not address direct service connection, or any other theories for service connection, in this matter. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for hepatitis B; rheumatoid arthritis; and for an overactive immune system. As discussed above, the Board has granted service-connection for hepatitis C; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity. Given this change in circumstances, and to accord the Veteran due process, the RO should readjudicate the issue of entitlement to service connection for hepatitis B; rheumatoid arthritis; and for an overactive immune system. The Veteran contends that he has hepatitis B; rheumatoid arthritis; and an overactive immune system, that are related to service, to include as due to Agent Orange exposure. He also contends that his claimed rheumatoid arthritis and overactive immune system are secondary to his now service-connected hepatitis C. The Veteran's service treatment records do not specifically show treatment for hepatitis B; rheumatoid arthritis; or for an overactive immune system. Post-service private and VA treatment records show treatment for hepatitis B and for rheumatoid arthritis. Such records do not specifically show treatment for an overactive immune system. The Board notes that a September 2021 statement from M. S., M.D., in part, discussed the etiology of the Veteran's claimed rheumatoid arthritis. Dr. M. S. reported, as to conditions secondary to hepatitis C, that in June 2009, the Veteran's treating physician for rheumatoid arthritis indicated that he could not rule out hepatitis C virus immune complex disease as the cause of his rheumatoid arthritis symptoms. It was noted that, in 2010, the Veteran's treatment medications for his hepatitis C virus were changed, and that he developed an immediate increase in his rheumatoid arthritis symptoms. Dr. M. S., maintained that such incident strongly suggested that the cause of the Veteran's rheumatoid arthritis symptoms was the hepatitis C virus infection. Dr. M. S., reported that a relationship between the hepatitis C virus and rheumatoid arthritis was supported by medical literature, and he referred to a medical treatise. He stated that the most significant effect of the hepatitis C virus involves the hepatic system, and that end stage liver disease causes 8,000 to 10,000 deaths annually in the United States. It was noted that the hepatitic C virus was the leading cause of liver replacement surgery. Dr. M. S., indicated that in addition to the mortality and morbidity associated with the liver, the hepatitis C virus had significant extrahepatic morbidity. Dr. M. S., maintained that the most common extrahepatic complication of the hepatitis C virus involved rheumatoid-like symptoms of the joints, and that those symptoms included arthralgia, arthritis, paresthesia, and myalgia. Dr. M. S., stated that it appeared that such symptoms mimicked the symptoms of rheumatoid arthritis. Dr. M. S., indicated that it was very difficult to distinguish between true rheumatoid arthritis and rheumatoid arthritis caused by the hepatitis C virus. It was noted that the drugs used to treat rheumatoid arthritis were contraindicated for hepatitic C virus patients. Dr. M. S., reported that in considering the relationship between the hepatitis C virus and rheumatoid arthritis, it was important to understand that the fact that rheumatoid arthritis may have been diagnosed before the hepatitis C virus was not dispositive of the causation issue. It was noted that the hepatitis C virus was known as a silent killer, and that before the virus would become symptomatic itself, it could do significant damage to the body. Dr. M. S., maintained that, in the Veteran's case, the first sign of the disease may have been extrahepatic symptoms, but those symptoms were caused by the smoldering hepatitis C virus infection. Dr. M. S., indicated that based on his review of the Veteran's medical records, it was his opinion that it was at least as likely as not that the Veteran's rheumatoid arthritis was caused by his hepatitis C virus infection. The Board notes that the Dr. M. S., indicated that it was at least as likely as not that the Veteran's rheumatoid arthritis was caused by his hepatitis C virus infection. The Board observes, however, that the Dr. M. S., provided statements in support of his opinion that are somewhat speculative. For example, Dr. M. S., maintained that that, in June 2009, the Veteran's treating physician for rheumatoid arthritis related he could not rule out hepatitis C virus immune complex disease as the cause of his rheumatoid arthritis symptoms. Dr. M. S., also stated that, while referring to a medical treatise, that it was very difficult to distinguish between true rheumatoid arthritis and rheumatoid arthritis caused by the hepatitis C virus, and that the drugs used to treat rheumatoid arthritis were contraindicated for hepatitic C virus patients. The Board notes that a medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board observes that the Veteran has not been afforded VA examinations, as to his claimed hepatitis B; rheumatoid arthritis; and an overactive immune system. In light of the above, the Board finds that the Veteran should be afforded a VA examination, with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to his claims for service connection for a hepatitis B; rheumatoid arthritis; and for an overactive immune system. Such an examinations must be accomplished on remand. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for hepatitis B; rheumatoid arthritis; and for an overactive immune system, since January 2022. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the onset and/or etiology of his claimed hepatitis B; rheumatoid arthritis; and an overactive immune system. The examiner must specifically indicate if the Veteran has currently diagnosed hepatitis B; rheumatoid arthritis; and an overactive immune system. The examiner must opine as to whether it is at least as likely as not that any diagnosed hepatitis B; rheumatoid arthritis; and an overactive immune system, are related to, or had their onset during, the Veteran's period of service, to include his presumed exposure to Agent Orange during service. The examiner must specifically acknowledge and discuss any reports by the Veteran of symptoms he thought were due to hepatitis B; rheumatoid arthritis; and an overactive immune system, during service and since service. The examiner must state whether it is at least as likely as not that any diagnosed hepatitis B; rheumatoid arthritis; and an overactive immune system, are caused or aggravated by the Veteran's service-connected hepatitis C; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. D. Regan, 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.