Citation Nr: 25002016 Decision Date: 02/11/25 Archive Date: 02/11/25 DOCKET NO. 14-34 677A DATE: February 11, 2025 ORDER Entitlement to service connection for the cause of the veteran's death is denied. FINDING OF FACT The evidence of record persuasively weighs against finding that the veteran's death was proximately due to or the result of his period of service, to include his exposure to herbicides. CONCLUSION OF LAW The criteria for service connection for cause of the Veteran's death have not been met. 38 U.S.C. §§ 1110, 1310, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1959 to October 1959, and April 1962 to October 1981, with service in Vietnam. He died in August 2010. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision. The appellant testified at a Board hearing in November 2017. In November 2021 the Board denied this claim. The appellant appealed this matter to the Court of Appeals for Veterans' Claims (CAVC) which in an October 2022 decision vacated the Board's decision and remanded the matter to the Board. The Board remanded this matter in May 2023 and November 2024 for development in order to comply with the CAVC's directives. Such has been completed and this matter is returned to the Board for additional consideration. Service Connection for Cause of the Veteran's death Dependency and indemnity compensation may be awarded to a veteran's surviving spouse, children, or parents for death resulting from a service-connected disability. 38 U.S.C. § 1310 (West 2014); see also Hanna v. Brown, 6 Vet. App. 507, 510 (1994). Dependency and indemnity compensation benefits are thus predicated upon an adjudicatory finding that service connection for the cause of the veteran's death is warranted. Before an award of dependency and indemnity compensation may be made, therefore, service connection for the cause of the veteran's death must be established. To warrant service connection for the cause of the Veteran's death, the evidence must show that a service-connected disability was either a principal or a contributory cause of death. 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. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Where a veteran served 90 days or more during a period of war and certain chronic diseases, become manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Additionally, a disability which is proximately due to or the result of service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Secondary service connection may be established by a showing that a nonservice-connected disability is caused or aggravated (chronically worsened) by a service-connected disability beyond the normal progression of the disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may be also granted on a presumptive basis for certain diseases, associated with exposure to herbicide agents. 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6). If a veteran was exposed to an herbicide agent during active military, naval, or air service, and develops certain diseases to a compensable degree any time after such service, the disease shall be service-connected even though there is no record of such disease during service, provided that the rebuttable presumption provisions of § 3.307(d) are also satisfied. 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). These diseases are AL amyloidosis; chloracne; type II diabetes; Hodgkin's disease; ischemic heart disease, all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers; and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309 (e). Effective January 1, 2021, the National Defense Authorization Act for Fiscal Year 2021 added bladder cancer, hypothyroidism, and Parkinsonism to 38 U.S.C. § 1116 (a)(2) as a condition presumed to be caused by in-service herbicide exposure. Notwithstanding the foregoing, a Veteran may establish service connection with proof of direct causation. 38 U.S.C. § 1113 (b); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In claims for benefits, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The appellant asserts that the Veteran's hepatitis C is related to his service in Vietnam and contributed to his death. At her November 2017 hearing she testified that the Veteran was sent to Vietnam with an open wound from a knee surgery. She also indicated that he had heart problems beginning in the 1980s but at the time they didn't think to associate it with Agent Orange exposure. She testified that shortly before he died, had a hernia, and needed surgery, but heart specialist did not approve the procedure. She confirmed that the Veteran was diagnosed with Hepatitis C. She indicated that the Veteran was an alcoholic but had quit drinking for over 10 years. Transcript pg., 4-6. The Veteran's death certificate indicates that his immediate cause of death in August 2010 was cirrhosis of the liver. Private treatment records from shortly before the Veteran's death show a diagnosis of cirrhosis with portal hypertension secondary to hepatitis C and alcohol. Service treatment records (STRs) are negative for any issues with the Veteran's liver or heart. Repeatedly, examinations and reports of medical histories were negative for liver such as jaundice or hepatitis or heart issues including on entrance in April 1962, April 1965, July 1969, January 1973, and February 1974. He did endorse stomach, liver, or intestinal trouble in a September 1975 report of medical history without further elaboration on the nature of the trouble, but again denied jaundice or hepatitis. In May 1973 he was seen for chest pain with an impression of musculoskeletal pain, and no cardiovascular diagnosis made. In his October 1981 retirement examination and report of medical history he denied heart and liver trouble including hepatitis and his examination was normal including liver and his hear was regular rate and rhythm. However, an ECG of October 1981 showed poor precordial right wave progression, otherwise unremarkable. Private treatment records from February 2003, July 2004, February 2005, and August 2006 showed that the Veteran was treated for pulmonary diseases including chronic obstructive pulmonary disease (COPD), emphysema, and bronchial asthma. Acute bronchitis was also treated in August 2005. He was also noted to have a diagnosis of glaucoma. However, he was not noted to have any liver disease or heart diseases diagnosed in any of these records. Evidence of liver or heart problems were not shown until 2010. In June 2010 he was admitted to the hospital progressively worsening edema of the lower extremities. He also was noted to have increasing dyspnea without chest pain. He had been recently diagnosed with a right inguinal hernia, but had not received cardiac clearance, and had not followed up with cardiovascular testing prior to planned surgery. His medical history was noted to include atrial fibrillation, COPD, hypertension, and glaucoma. He also gave a history of drinking several beers a day, from 6 to 8 per day, and he also had a decreased appetite. Labs showed hyponatremia and his assessment included differential diagnoses of hyponatremia includes secretion of inappropriate antidiuretic hormone versus low salt intake concomitantly with large amounts of water and alcohol intake, specifically beer versus edema related to cirrhosis and hypalbuminemia. Upon discharge later the same month his diagnosis was confirmed to be cirrhosis with portal hypertension secondary to hepatitis C and alcohol. He was also diagnosed with hyponatremia, COPD exacerbation, and hypertension. The hospital records noted CT scan findings of abnormal liver consistent with cirrhotic liver and portal venous hypertension. Also, echocardiogram showed nonconcentric LVE with an ejection fraction of 55 to 60 percent. On discharge he was given congestive heart failure instructions. Other treatment records from July 2010 through August 2010 addressed his disease progression prior to his death. In July 2010 he continued to show treatment for cirrhosis with portal hypertension, moderate to severe ascites, history of chronic alcohol and hepatitis C, COPD, chronic atrial fibrillation (A-fib), hypertension and hyponatremia. The records from July 2010 addressing abdominal distention and pain noted that he had alcoholism causing his cirrhosis. His history included COPD, hypertension, chronic atrial fibrillation, and hyponatremia. He was assessed with cirrhosis with portal hypertension, moderate to severe ascites, history of chronic alcohol and hepatitis C, COPD, chronic atrial fibrillation, hypertension, and hyponatremia. He underwent paracentesis at the end of July 2010 for ascites and his abdomen distension was noted to be causing a restrictive lung disease, resulting in shortness of breath. He was also seen by cardiology who recommended continuing medication for portal hypertension and A-fib. The records from August 2010 indicated that he was not a candidate for hemodialysis and was to be discharged for hospice care with a DNR. His prognosis was poor given his end stage liver disease. On August 12, 2010 he was described as being in end stage liver failure with hepatitis C and alcoholism, with a medical history which continued to include A-fib, congestive heart failure, COPD, cirrhosis secondary to hepatitis C and alcoholism, and hypertension. He was noted to have last drank eight weeks earlier in these records addressing his end stage liver failure. Among the medical evidence there are private medical opinions from a private family doctor, Dr. T.D.B. The first opinion dated January 9, 2012 stated, "I feel this patient's condition is related to his military service and Agent Orange exposure." The second opinion dated January 12, 2013 stated, "I feel the Veteran's liver disease is most likely due to Agent Orange exposure in Vietnam and was a major contributing factor on his cause of death." No rationale was given for these opinions. In June 2019, a VA medical opinion was obtained, which included review of the record. The examiner determined that it was less likely than not that hepatitis was incurred in service, noting that hepatitis C was not diagnosed until 2002 which is over 20 years following separation from service (1981). The examiner further opined that there is no objective evidence from service or immediately after service demonstrating hepatitis. The examiner further opined that there was no objective evidence to suggest that hepatitis went unnoticed for decades. While the examiner provided adequate rationale to support a finding that hepatitis was not incurred in service, the examiner did not provide adequate rationale regarding whether the Veteran's hepatitis C was related to herbicide exposure in Vietnam. The examiner stated that herbicide exposure is not an established etiology of hepatitic disease in medical literature. However, the examiner failed to cite to the source of the medical literature to support this opinion, making this rationale inadequate. Additionally, the opinion regarding whether the Veteran had any heart disorder attributable to herbicide exposure was not supported by adequate rationale. The examiner stated that there was no evidence of ischemic heart disease (IHD) and further stated that there is insufficient evidence to establish a diagnosis of congestive heart failure (CHF). However, the examiner did not address the etiology of other heart issues including a diagnosed atrial fibrillation (AFIB) or the fact that his surgeon did not want to perform hernia surgery unless he had cardiac clearance, which his heart specialist declined to do. Furthermore, the examiner did not address the findings of an abnormal heart rhythm noted in an October 1981 EKG showing poor precordial right wave progression, but otherwise unremarkable findings. This finding should be considered in addressing whether any diagnosed heart disorder may have been of in-service onset, not just due to herbicide exposure. An addendum opinion was obtained in July 2021 to further clarify these matters. The examiner stated that it is less likely than not that the Veteran's hepatitis C is due to herbicide exposure in Vietnam. The examiner explained that hepatitis C is spread through contact with blood from an infected person. Hepatitis C is not spread through herbicide exposure in Vietnam. The examiner included a citation to a CDC source to support this opinion. https://www.cdc.gov/hepatitis/hcv/index.htm. The examiner further discussed that there is no evidence of ischemic heart disease that is the primary cardiac disorder linked with herbicide exposure, noting that there is no evidence of ischemic heart disease in the Veteran's C-file; consequently, the Veteran does not have any heart conditions due to likely herbicide exposure. His heart history included an atrial fibrillation (A. fib/flutter), this is not considered IHD. The examiner further clarified it is less likely than not that there is any other identified disorder besides cirrhosis which contributed substantially to or materially to the Veteran's death or combined to cause his death or aided or lent assistance to the production of his death. In the medical rationale the examiner noted that the Veteran's death was August 20, 2010 and the cause of death was listed as cirrhosis. There was no contributory factor of death listed. Private treatment records from shortly before the Veteran's death showed a diagnosis of cirrhosis with portal hypertension secondary to hepatitis C and alcohol. Social Security Administration (SSA) records obtained in June 2003 after the Board's May 2023 remand include records showing treatment for medical problems that included cardiovascular issues. These include a record from September 1993 showing treatment for chest pain and heartburn symptoms diagnosed as possible peptic disease. An October 1996 record addressing a syncopal episode diagnosed a vasovagal syncope and vertigo. Records from 2002 included another near syncopal episode with hypertension documented in July 2002 and on follow up in August 2002 he was diagnosed with coronary artery disease (CAD) and possible myocardial infarction (MI) along with hypertension. An EKG of August 2002 included a finding of old septal infarct. In October 2002 he underwent cardiac workup, with a significant history of cigarette smoking noted and symptoms that included shortness of breath and probable emphysema with essentially normal cardiac findings, but with high blood pressure noted. He was assessed with hypertension and probable chronic obstructive pulmonary disease (COPD). A September 2006 disability examination noted the Veteran had COPD and hypertension but with normal heart evaluation and no heart complaints. Following the May 2023 remand, VA examination opinions were obtained in August 2023. Among these opinions was one that addressed whether the Veteran had any heart disorder that approximately at least as likely as not either began in service or is attributable to herbicide exposure either on a direct basis or presumptive basis (i.e., ischemic heart disease). If so, the examiner was to discuss whether it is approximately at least as likely as not that any identified disorder contributed substantially or materially to his death, combined to cause his death, or aided or lent assistance to the production of his death. The examiner opined that the claimed condition was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. The rationale discussed that the Veteran's August 2010 Certificate of Death dated lists his immediate cause of death as "cirrhosis of liver", with date of death as 08/20/2010. The examiner explained that cirrhosis of the liver occurs when there is permanent inflammation and scarring of the liver that damages and interrupts liver function. Cirrhosis of the liver is often due to chronic alcohol use, excess fatty tissue stored in the liver, hepatitis C, hepatitis B, certain medications, certain inherited disorders, and certain cardiovascular conditions, such as CHF. The available documentation noted the Veteran has a PMH of "atrial flutter and atrial fibrillation". Under the new PACT Act, the VA recognizes certain health conditions as presumptive diseases associated with exposure to certain herbicides/toxins during military service in certain areas during certain periods of time. However, atrial flutter and atrial fibrillation are not conditions considered by VA to be presumptive conditions associated with exposure to herbicides/toxins while in service. There is no medical or scientific evidence available that provides any indication of a relationship between the development of the condition(s) at issue and the TERA. The August 2023 examiner stated that the etiology of the claimed atrial flutter and atrial fibrillation are related to risk factors outside of military service. Review of the medical literature does not reveal a medical nexus between the Veteran's potential exposure and the claimed condition(s). There is no objective medical evidence noted to support or confirm a link between the claimed atrial flutter and atrial fibrillation and the Veteran's time in service, including potential toxic exposure risk activity(ies) after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic combined effect of all toxic exposure risk activities of the Veteran. The August 2023 examiner concluded that it is less likely than not that atrial flutter and atrial fibrillation are due to or the result of the indicated toxic exposure risk activity(ies) after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic combined effect of all toxic exposure risk activities of the Veteran. In addition, the available documentation lists the Veteran's immediate cause of death as cirrhosis of liver. Cirrhosis of liver and atrial flutter and atrial fibrillation are separate conditions that are not medically related. A review of medical literature failed to demonstrate a causal relationship between cirrhosis of the liver, atrial flutter, and atrial fibrillation. There is no objective medical evidence noted to support or confirm a conclusion that cirrhosis of the liver is due to or the result of atrial flutter and atrial fibrillation. Therefore, it was less likely than not the Veteran's heart disorder contributed substantially or materially to his death, combined to cause his death, or aided or lent assistance to the production of his death. A nexus has not been established. The examiner cited to medical literature to support this opinion. Another August 2023 VA examination addendum further addressed whether it is approximately at least as likely as not that the Veteran's hepatis C was incurred in service. In addressing this the examiner was asked to specifically discuss the likelihood that the Veteran's hepatitis C virus was acquired in service but progressed unnoticed for decades. The examiner provided an opinion that the claimed condition was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. In the rationale it was noted that the Veteran had claimed hepatitis C as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is a lack of substantiating evidence supporting a nexus between the current diagnosis of hepatitis C and military service. The August 2023 examiner's rationale stated that without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. The available documentation lists the Veteran's active duty dates as from April 1959 to October 1959 and from April 1962 to October 1981. The available medical records do not note medical evaluations, treatment, or a diagnosis of hepatitis C while on active duty or within one year of separation from active duty. The reports of hepatitis C while on active duty were subjective only and not confirmed in the claims file. The separation exam date 10/20/1981 did not note a diagnosis of "hepatitis C"; noted "negative" for hepatitis. The examiner was unable to confirm a diagnosis of hepatitis C while on active duty using the available documentation. The available documentation does not note mention of a diagnosis of hepatitis until 2010. The available documentation dated 07/06/2010 noted "GI saw him on 06/15/2009 and ordered a hepatitis profile". The August 2023 examiner concluded that there is no objective medical evidence noted in the available documentation to support or confirm a link between the Veteran's diagnosis of hepatitis C and the Veteran's time on active duty. Therefore, it was less likely than not the Veteran's hepatitis C incurred in or was caused by service. A nexus has not been established. The examiner also pointed out that the available documentation noted "cirrhosis w/portal HTN secondary to hepatitis C and alcohol; severe cirrhosis secondary to alcohol abuse and hepatitis C". The available documentation noted that the cirrhosis of the liver is due to both alcohol abuse and Hep C. There is a lack of sufficient objective medical evidence noted in the available documentation confirming or supporting a conclusion that the cirrhosis of the liver is strictly due to the Hep C only. Therefore, it was less likely than not the cause of the Veteran's death incurred in or was caused by (the) hepatitis C during service. A nexus has not been established. In September 2023 an addendum was obtained to address some etiology questions that were not fully addressed by the prior examinations. The requested clarification was for the examiner to specifically discuss the likelihood that the Veteran's hepatitis C virus was acquired in service but progressed unnoticed for decades. Additionally, it was requested that the addendum examiner consider and discuss private treatment records from July 2010 shows cardiac diagnoses of congestive heart failure and atrial fibrillation. The September 2023 examiner stated that after review of the medical evidence, claims file, relevant evidence, lay testimony, and private treatment records the cause of the Veterans death was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the Hepatitis (hep) C during service. The September 2023 examiner stated that while it is acknowledged that the Veteran was potentially exposed to Hep C by air gun injection of immunization during service, there is a lack of any health concerns due to liver issues until 2010 which is a good 30-plus years post service. There have also been no case reports of HCV being transmitted by an air gun transmission. The veteran did not report any acute phase symptoms which may include jaundice, fatigue, nausea, fever, and muscle aches. It is reported that the veteran had no other potential "exposure" to the Hepatitis C. However, he had a history of alcoholism, which can cause alcoholic hepatitis. He had been informed to stop drinking and it does not appear he was successful in his efforts to do so. Many people with alcoholic hepatitis are infected with the hepatitis C virus. If you continue to drink alcohol, the liver will continue to be damaged. Over time, cirrhosis will develop. The available documentation dated 06/15/2010 noted "drinks 6 beers a day, possible cirrhosis". The available documentation dated 07/06/2010 noted "cirrhosis w/portal HTN secondary to hepatitis C and alcohol". The available documentation dated 07/29/2010 noted "severe cirrhosis secondary to alcohol abuse and hepatitis C". The official cause of death on the death certificate is "Cirrhosis of the Liver". Therefore, it is less likely than not that the Hepatitis C caused the death of this veteran. A nexus has not been established. The September 2023 VA examiner further addressed the Veteran's heart disorders, stating that the claimed condition was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. It was reasoned that, after review of the medical evidence, claims file, relevant evidence, lay testimony, and private treatment records, the Veteran's heart disorders are less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. He was noted to have been diagnosed with congestive heart failure and atrial fibrillation. Neither of these heart conditions are considered ischemic heart disease. Thus, these would not be considered to be Agent Orange (herbicide exposure). It was noted that the veteran had an ECG (electrocardiograph) completed on 10/20/1981 which showed Poor Precordial Right Wave Progression. Poor R wave progression in right precordial leads is a relatively common electrocardiogram (ECG) finding and it is observed frequently in apparently normal individuals. Of note, the ECG dated 10/17/2002 does not show such R wave abnormality. Therefore, it is less likely than not that his congestive heart failure and atrial fibrillation contributed substantially or materially to his death, combined to cause his death, or aided or lent assistance to the production of his death. A nexus has not been established. In June 2024 additional VA opinions were obtained. Following review and recitation of the comprehensive evidence the examiner provided the following opinions. Regarding hepatitis C, the examiner stated that it is less likely than not that the Veteran contracted hepatitis C in service and the condition progressed unnoticed for decades. The Veteran served from 04/26/59 to 10/24/59 and from 04/30/62 to 10/31/81. All of the Veteran's Report of Medical History indicate that he had no liver problems during service. All of the Veteran's Report of Medical Exams for the yearly physicals and the separation exam from service show no signs or symptoms of hepatitis or liver disease. The examiner pointed out that risk factors for contracting Hepatitis C (HCV) include: individuals who had blood transfusions, blood products, or organ donations prior to June, 1992, when HCV screening tests were introduced. The Veteran had none of these risk factors. The Veteran's DD214 shows service in Vietnam. However, the Veteran had no Purple Heart Medal of record, no history of blood transfusion, and no documented exposure to wounds or Hepatitis C contaminated blood. As to a history of intravenous drug abuse (IVDA) injections, the Veteran had no such IVDA history. He also had no pre-existing history of HCV on entry into service. As for high-risk sexual behavior, multiple partners, unprotected sex, and sexually transmitted diseases (STDs), there is no record of the Veteran having been treated for STDs in service or having engaged in high-risk sexual behavior. In June 2024 additional VA opinions were obtained that addressed conflicting medical evidence. Following review and recitation of the comprehensive evidence the examiner provided the following opinions. Regarding hepatitis C, the examiner stated that it is less likely than not that the Veteran contracted hepatitis C in service and the condition progressed unnoticed for decades. The Veteran served from 04/26/59 to 10/24/59 and from 04/30/62 to 10/31/81. All of the Veteran's Report of Medical History indicate that the Veteran had no liver problems during service. All of the Veteran's Report of Medical Exams for the yearly physicals and the separation exam from service show no signs or symptoms of hepatitis or liver disease. The June 2024 examiner pointed out that risk factors for contracting Hepatitis C (HCV) include: individuals who had blood transfusions, blood products, or organ donations prior to June, 1992, when HCV screening tests were introduced. The Veteran had none of these risk factors. His DD214 shows service in Vietnam. However, the Veteran had no Purple Heart Medal of record, no history of blood transfusion, and no documented exposure to wounds or Hepatitis C contaminated blood. As to a history of intravenous drug abuse (IVDA) injections, the Veteran had no such IVDA history. He also had no pre-existing history of HCV on entry into service. As for high-risk sexual behavior, multiple partners, unprotected sex, and sexually transmitted diseases (STDs), there is no record of the Veteran having been treated for STDs in service or having engaged in high-risk sexual behavior. As to a history of snorting cocaine and using shared equipment. The Veteran had no history of drug abuse. Regarding shared personal items with someone who is HCV infected, the June 2024 examiner noted that lay testimony at the BVA hearing raised the issue of potential exposure for the Veteran due to service in Vietnam, as well as exposure from the use of air injectors for vaccinations. The examiner noted that there is no objective evidence to support either method of transmission for the Veteran. If the Veteran had been exposed to Hepatitis C due to a non-documented method of exposure, he would have had an acute phase of the Hepatitis C infection. None of the Veteran's medical records are consistent with an onset of Hepatitis C in service with a quiescent period of decades after an initial infection in service. The examiner concluded that there is no established medical nexus for the Veteran's Hepatitis C incurred in or caused by service. With respect to the Veteran's conceded exposure to the herbicide Agent Orange, the June 2024 examiner concluded that a review of the Veteran's medical records, as well as a thorough search of the scientific and medical literature, does not show any established causal relationship between exposure to Agent Orange and the development of Hepatitis C. There is no established medical nexus. As for the cardiac condition, the June 2024 VA examiner reviewed the Veteran's medical records and concluded they did not support an onset or etiology for the Veteran's cardiac condition due to service. All of the Veteran's Report of Medical History for yearly physicals, as well as his separation examination, indicate that he had no cardiac symptoms or problems. All of the Veteran's Report of Medical Exam show a normal cardiac exam for his yearly physicals and his separation exam. All of the chest x-rays in service were normal with no cardiomegaly or other findings consistent with the CHF noted in 2010. The Veteran had a poor R wave progression on his separation EKG dated 10/20/81. The EKG was otherwise normal. Poor R wave progression can be associated with heart failure, left ventricular hypertrophy or right ventricular hypertrophy. However, poor R wave progression can also be a normal variant associated with diminished anterior forces of the heart. The June 2024 VA examiner opined that it is more likely than not that the poor R wave was a normal variant for the Veteran. He had a completely normal echocardiogram on 10/17/02, which is not consistent with occult cardiac disease twenty years prior. The Veteran's cardiac condition in 2010 is consistent with CHF due to atrial fibrillation. Congestive heart failure develops in the setting of atrial fibrillation or atrial flutter due to the abnormal contractility and ineffective pump function of the heart. Atrial fibrillation is a commonly recognized comorbidity in patients with liver cirrhosis. The fact that the Veteran was not cleared by the cardiologist for hernia surgery prior to his death is not surprising as AFib and CHF would represent significant risk factors for surgery. There is no established medical nexus. Atrial fibrillation and CHF have no anatomic or pathophysiological relationship to the Veteran's exposure to the herbicide Agent Orange during service in Vietnam. The examiner stated that there is no evidence of Ischemic heart disease due to the Veteran's Agent Orange exposure. There is no established medical nexus for the Veteran's cardiac condition incurred in or caused by service to include his exposure to Agent Orange, and/or his EKG abnormality on separation from service. The examiner cited to multiple medical treatises to support this opinion. In October 2024 the Veteran submitted a private opinion from a Dr. C. Dr. C confirmed review of the Veteran's medical file including STRs. Dr. C. noted a history of multiple injections in service, as well as some in-service treatment for gastrointestinal (GI) symptoms such as vomiting and diarrhea in October 1968 and January 1973 and dizziness and flu like symptoms including diarrhea in June 1975. The examiner further noted post service treatment for cardiovascular symptoms and diagnoses from the 1990's to records prior to the Veteran's death in 2010. The examiner further discussed the records from June to August 2010 prior to his death, with diagnoses that included end stage liver failure, generally attributed to alcohol related cirrhosis, as well as hepatitis C, and congestive heart failure. Dr. C. also reviewed the favorable opinion from Dr. D. linking liver disease to Agent Orange exposure, as well as the multiple unfavorable VA opinions. Dr. C. then discussed at length the Veteran's service and the multiple injections he received, including as likely including injections from multiple use nozzle jet injectors (MUNJI) which were described as commonly used by the military during his periods of service. Dr. C. discussed the medical treatises that supported a link between the MUNJI and exposure to bloodborne diseases such as Hep C, as well as the evidence showing the Veteran had no other risk factors. The evidence in the records and examination reports of the Veteran being asymptomatic for years after service was further addressed, with Dr. C. stating that the medical treatise evidence did not support the conclusions made by VA examiners that a lack of acute symptoms is evidence against service connection. Dr. C indicated that Hep C can remain asymptomatic for decades after service and that it is possible that symptoms of infection could be manifested long after exposure by air gun injections during service. As for the cirrhosis leading to the Veteran's death, Dr. C. gave an opinion that the hepatitis C initiated an inflammatory process that culminated in the cirrhosis leading to his eventual death. Dr. C. discussed in detail how this inflammatory process took place, citing to medical treatises. Dr. C. concluded that after a review of the lay and medical evidence, it is at least as likely as not that the Veteran's in-service MUNJI resulted in transmission of the Hep C infection. The Hep C infection was deemed more likely than not to have resulted in the development of the cirrhosis that led to the Veteran's death in 2010. As for the unfavorable opinions attributing the Veteran's cirrhosis to a history of alcohol abuse, Dr. C. stated that although the records indicate that he was a drinker, the records indicate that he had been abstinent for years prior to his being diagnosed with Hep C. Dr. C conceded that it is well established that alcohol can exacerbate the severity of a Hep C infection due to a synergistic effect of liver damage. However it was his opinion that but for the presence of Hep C, it is unlikely that his level of alcohol use would have resulted in cirrhosis or death. Dr. C. additionally concluded that although the Veteran had congestive heart failure at the time of death, it is unlikely that this contributed in any way to his death. VA examination addendums from November 2024 were obtained following the Board's November 2024 remand. Among the opinions were one pertaining to the toxic exposure risk activities (TERA). The examiner gave an opinion that the claimed condition was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The rationale referenced the TERA memo which showed exposure to an herbicide agent. The examiner confirmed review of the exposure information provided at https://www.publichealth.va.gov/exposures/. The Other Deployment and Non-Deployment Related Exposure can be described as SSA records obtained in June 2023 that include a record from August 2002 showing a diagnosis of CAD, which is presumptive to Agent Orange exposure. Review of the Veteran's service department records including his DD 214 depicting Vietnam service. Records reviewed indicate the following risk factors outside of military service: Age, alcohol use, hepatitis C. The veteran is claiming service connection for cirrhoses of the liver claimed as based on exposures to Agent Orange. The frequency (daily), duration and routes of exposure (dermal and inhalation) were discussed. The examiner opined that the claimed condition is less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after review of the pertinent records and medical literature, and considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran. The rationale is there is no medical or scientific evidence available that provides any indication of a relationship between the development of the condition(s) at issue and the TERA. At this point there is insufficient objective evidence in the medical literature to confirm causativeness between agent orange exposure and cirrhosis of the liver. Another November 2024 addendum opinion was obtained, which again confirmed that the claimed condition leading to the Veteran's death was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner confirmed review of the evidence and recited the evidence in detail. The examiner noted that the Veteran's death from cirrhosis of the liver, documented in the discharge summary dated in June 2010, is less likely than not proximately due to his heart conditions, including hypertension and coronary artery disease (CAD) diagnosed in August 2002. The cirrhosis was identified as secondary to hepatitis C and alcohol use, which are well-established primary causes of liver damage and portal hypertension. These conditions are unrelated to hypertension or CAD, which do not directly cause cirrhosis or liver failure. While heart conditions such as hypertension and CAD could exacerbate systemic stress or contribute to general health decline, the medical records do not indicate that these conditions materially worsened the cirrhosis or its fatal complications, such as variceal bleeding or hepatic failure. Furthermore, the October 17, 2002 echocardiogram showed normal heart function, further supporting that the heart conditions were not a substantial factor in the progression of the Veteran's liver disease. Based on the evidence, the Veteran's heart conditions did not substantially or materially contribute to, combine to cause, or aid in the production of his death, which was primarily due to cirrhosis caused by hepatitis C and alcohol use. Finally, a December 2024 addendum further clarified matters. First, the examiner gave an opinion that the claimed condition (leading to the Veteran's death) was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. In the rationale it was noted that the diagnosis of coronary artery disease (CAD) is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) caused by the indicated TERA. This was followed by a discussion about Agent Orange presumptive disease as well as a discussion of the nature of ischemic heart disease (also known as CAD). The examiner further noted findings in 1981 of an EKG showing poor precordial R wave progression and determined that this finding does not establish a pattern of chronic pathology. Therefore, the claimed condition was less likely than not incurred in or caused by the claimed in-service abnormal EKG. After confirming review of the medical evidence to include the BVA remand letter from November 12, 2024, the examiner stated that the Veteran's death from cirrhosis of the liver, documented in the discharge summary dated 06/14/2010-06/21/2010 from the private treatment records, is less likely than not proximately due to his heart conditions, including hypertension diagnosed in July 2010 and coronary artery disease (CAD) diagnosed in August 2002 at private/post military treatment facilities. The Veteran's CAD is service connected as it is presumptive to agent orange. The cirrhosis was identified as secondary to hepatitis C and alcohol use, which are well-established primary causes of liver damage and portal hypertension. These conditions are unrelated to hypertension or CAD, which do not directly cause cirrhosis or liver failure. While heart conditions such as hypertension and CAD could exacerbate systemic stress or contribute to general health decline, the medical records do not indicate that these conditions materially worsened the cirrhosis or its fatal complications, such as variceal bleeding or hepatic failure. Furthermore, the examiner noted that the 10/17/2002 echocardiogram showed normal heart function, further supporting that the heart conditions were not a substantial factor in the progression of the Veteran's liver disease. The lack of cardiac clearance for hernia surgery underscores the severity of the Veteran's CAD but does not change the conclusion that the Veteran's heart conditions, including CAD, were not a substantial or material cause of his death. Based on the evidence, the December 2024 examiner stated that the Veteran's heart conditions did not substantially or materially contribute to, combine to cause, or aid in the production of his death, which was primarily due to cirrhosis caused by hepatitis C and alcohol use. Upon review of the record, the Board finds that service connection for cause of the Veteran's death is not warranted. In making this finding, the Board lends the greatest probative value to the multiple VA examiner opinions from July 2019 through December 2024 discussed above, when considered together in totality. The opinions in June 2019 and the July 2021 determined that the Veteran's hepatitis C and cirrhosis was not incurred in service, nor was it caused by his herbicide exposure. These opinions were accompanied by adequate rationale, with the July 2021 addendum citing to CDC medical treatise evidence to support a finding that Agent Orange exposure did not cause his hepatitis C or cirrhosis. Regarding the heart disease to include congestive heart failure, the July 2019 VA examiner and July 2021 addendum confirmed that the Veteran did not have ischemic heart disease or congestive heart failure. The July 2021 addendum did confirm that the Veteran had a history of A-fib. However, the July 2021 addendum clarified that it is less likely than not that there is any other identified disorder besides cirrhosis, which contributed substantially to or materially to the Veteran's death, or combined to cause his death, or aided or lent assistance to the production of his death. The Veteran's records from June through August 2010 further support a finding that his liver disease was the primary contributor to his death. The VA examiner opinions from August 2023, and September 2023 further elaborated on causation, and discussed at length that the Veteran's death from cirrhosis was not caused by any inservice incurrence including due to exposure to TERA, including Agent Orange, including not due to any presumptive heart disease such as ischemic heart disease. The opinions explained how the congestive heart failure and atrial fibrillation contributed substantially or materially to his death, combined to cause his death, or aided or lent assistance to the production of his death. Rather the examiners explained how the death was due to his cirrhosis, which in turn was more than likely related to his history of alcohol abuse. Further the September 2023 addendum provided an explanation with adequate rationale describing how it was less likely than not that a diagnosed Hep C was less likely than not of inservice incurrence, including due to air gun injections in service. The examiner provided adequate rationale including a detailed discussion which conceded a likelihood of exposure to Hep C by air gun injection of immunization during service but noted a lack of any acute phase symptoms and a 30 year absence of liver related health concerns prior to 2010. The September 2023 examiner further explained that the Veteran's history of alcoholism likely culminated in a hepatitis diagnosis and eventual cirrhosis. Finally, the VA opinions obtained in June 2004, November 2004, and December 2004 further clarified that any of the Veteran's cardiovascular disorders, including the CAD/ischemic heart disease confirmed as due to in-service herbicide exposure, neither directly caused nor contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death. These examination opinions further confirmed that the Veteran's participation in TERA likewise did not cause nor contribute substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death, with the only disease attributable to it shown to be the CAD/ischemic heart disease. Rather these opinions confirmed that the Veteran's death was primarily due to cirrhosis caused by hepatitis C and alcohol use. The Board notes that the favorable opinions by the private medical provider Dr. T.D.B dated in January 2012 and January 2013 are without probative weight, as they were not accompanied by rationale. Regarding the favorable opinion by Dr. C stating that the Veteran's hepatitis C that contributed to the fatal cirrhosis was as likely as not due to in-service inoculations from an air gun, this opinion was accompanied by rationale. However, the rationale was speculative in nature as to explaining the lengthy period where the Veteran was asymptomatic after service, as shown by the statement that symptoms of infection could be manifested long after exposure by air gun injections during service. By contrast, the opinion from the September 2023 examiner discussed at length how despite the evidence of possible exposure to hepatitis C by air gun injection, the lack of liver issues for 30-plus years post service did not support a finding of exposure to hepatitis C due to air gun injection of immunization during service. In sum, the Board finds the multiple unfavorable opinions from the VA examiners, with adequate rationales, when considered together, to be more probative than those opinions from the private medical providers. In light of the foregoing, although the appellant may sincerely believe that the Veteran's death was caused by or contributed to by service, including herbicide exposure, for all the reasons noted above, the evidence of record demonstrates otherwise. Moreover, as a layperson, she is not competent to offer an opinion as to the cause of the terminal liver disease. Rather, this question requires application of medical training or expertise to all pertinent evidence due to the complex nature of the question of causation between the liver disease and the Veteran's service. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Consequently, her lay assertions of medical etiology cannot constitute evidence upon which to grant the claim for service connection. Lathan v. Brown, 7 Vet. App. 359, 365 (1995). For all the foregoing reasons, the Board conclude that the evidence is persuasively against the claim of service connection for the cause of the veteran's death. The benefit of the doubt doctrine is not for application where the clear weight of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. at 55; 38 U.S.C. § 5107 (b). Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eckart, C. 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.