97-07 964

Citation Nr: 1101581 Decision Date: 01/13/11 Archive Date: 01/20/11 DOCKET NO. 97-07 964 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to an effective date prior to March 20, 2007 for the grant of service connection for prostate cancer. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. M. Powell, Counsel INTRODUCTION The Veteran had active service from February 1970 to August 1971. These matters come to the Board of Veterans' Appeals (Board) on appeal from two rating decisions of the St. Louis, Missouri, Regional Office (RO) of the Department of Veterans Affairs (VA). In an April 2005 rating decision, the RO denied service connection for hepatitis C. The Veteran perfected an appeal as to the RO's decision and in August 2008, the Board remanded the issue for further development. The requested development has been completed and the issue is again before the Board for further appellate consideration. In a May 2007 rating decision, the RO granted service connection for prostate cancer and assigned a 100 percent rating, effective March 20, 2007. The Veteran perfected an appeal as to the effective date assigned. However, the Board affirmed the effective date assigned by the RO in a decision dated in August 2008. The Veteran appealed the August 2008 Board decision to the United States Court of Appeals for Veterans Claims (Court), which in an January 11, 2010 Order, granted a Joint Motion for Partial Remand of the case to the Board. The Board notes that the motion only pertained to the claim for entitlement to an effective date earlier than March 20, 2007 for the grant of service connection for prostate cancer and that the Veteran expressly abandoned his appeal for those portions of the Board decision that denied entitlement to an effective date prior to May 13, 2004 for a 60 percent rating for bronchial asthma and the propriety of the reduction of compensation due to incarceration. Although not specifically stated in the Court's Order, such Remand action serves to vacate that portion of August 2008 Board decision that denied entitlement to an effective date earlier than March 20, 2007 for the grant of service connection for prostate cancer . In March 2008, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge with respect to the issues on appeal. A transcript of that hearing has been associated with the claims file. The issue of entitlement to an effective date prior to March 20, 2007 for the grant of service connection for prostate cancer is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT An etiological relationship between the Veteran's hepatitis C and air gun injector inoculations in active service has been shown to be biologically plausible, and such etiology has not been definitively excluded by competent medical evidence of record. CONCLUSION OF LAW Hepatitis C was incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Further regarding notice, on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman holds that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, the Department of Veterans Affairs (VA) is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned in the award of the benefit sought. With respect to the issue on appeal, the agency of original jurisdiction (AOJ), issued VCAA notice letters to the appellant in June 2004 and March 2006 that informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence and notified him of the elements for consideration in the assignment of a disability rating and/or effective date in the event of award of the benefit sought, per Dingess/Hartman. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the U.S. Court of Appeals for Veterans Claims held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In the present case, complete VCAA notification was not achieved until after the initial AOJ adjudication of the claim. Nevertheless, the Court in Pelegrini noted that such requirement did not render a rating decision promulgated prior to providing the veteran full VCAA notice void ab initio, which in turn would nullify the notice of disagreement and substantive appeal filed by the veteran. In other words, Pelegrini specifically noted that there was no requirement that the entire rating process be reinitiated from the very beginning. Rather, the claimant should be provided VCAA notice and an appropriate amount of time to respond and proper subsequent VA process. Here, the Board finds that any defect with respect to the timing of any VCAA notice letter was harmless error. Although the notice was provided to the appellant after the initial adjudication, the case was readjudicated thereafter, and the appellant has not been prejudiced thereby. The content of the notice provided to the appellant fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Not only has the appellant been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices, but the actions taken by VA have essentially cured the error in the timing of notice. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his claim. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal. With regard to the duty to assist, the claims file contains the Veteran's service treatment records, private treatment records, and a report of VA examination. Additionally, the claims file contains the Veteran's statements in support of his claim. The Board has carefully reviewed such statements and concludes that he has not identified further evidence not already of record. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. A VA examination and opinion with respect to the issue on appeal was obtained. 38 C.F.R. § 3.159(c) (4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examination and opinion obtained in this case is more than adequate, as it is based on detailed and thorough physical examination and the examiner provided a well-supported rationale for his stated opinion. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). Thus, based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims. Essentially, all available evidence that could substantiate the claim has been obtained. Legal Criteria The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102 (2009). When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2010). Regulations also provide that 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) (2010). Present disability resulting from disease or injury in service is required to establish entitlement to service connection. Degmetich v. Brown, 104 F. 3d 1328 (Fed. Cir. 1997). To establish service connection for a disability, there must be competent evidence of a current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498, 507 (1995). The isolated and infrequent use of drugs by itself will not be considered willful misconduct; however, the progressive and frequent use of drugs to the point of addiction will be considered willful misconduct. Where drugs are used to enjoy or experience their effects and the effects result proximately and immediately in disability or death, such disability or death will be considered the result of the person's willful misconduct. Organic diseases and disabilities which are a secondary result of the chronic use of drugs and infections coinciding with the injection of drugs will not be considered of willful misconduct origin. (See 38 C.F.R. § 3.301(d) regarding service connection where disability or death is a result of abuse of drugs.) Where drugs are used for therapeutic purposes or where use of drugs or addiction thereto, results from a service-connected disability, it will not be considered of misconduct origin. 38 C.F.R. § 3.301(c)(3). An injury or disease incurred during active military, naval, or air service shall not be deemed to have been incurred in line of duty if such injury or disease was a result of the abuse of alcohol or drugs by the person on whose service benefits are claimed. For the purpose of this paragraph, alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user; drug abuse means the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non-prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301(d). See also 38 U.S.C.A. § 105; 38 C.F.R. §§ 3.1(m) (2002). VA's General Counsel has confirmed that direct service connection for a disability that is a result of a claimant's own abuse of alcohol or drugs is precluded for purposes of all VA benefits for claims filed after October 31, 1990. See VAOPGCPREC 7-99 (1999), published at 64 Fed. Reg. 52,375 (June 9, 1999); VAOPGCPREC 2-98 (1998), published at 63 Fed. Reg. 31,263 (February 10, 1998). Legal Analysis The Veteran asserts that service connection is warranted for hepatitis C. In order to establish service connection on a direct-incurrence basis, the Veteran must provide evidence of a current disability, an in-service injury or disease, and a nexus between the current disability, and an in-service injury or disease. With respect to a current disability, post-service treatment records show that the Veteran has been diagnosed with, and treated for, hepatitis C since 2003. With respect to an in- service injury or disease, the Veteran contends that he was exposed to blood (a hepatitis C risk factor) in service as a result of being immunized with an injector air gun while at Ft. Leonardwood, Missouri. (Transcript (T.) at page (pg.) 16-17.) The Veteran's service treatment records indeed show that he was immunized on numerous occasions between 1970 and 1971. He also contends that he displayed hepatitis C symptoms while in service. (Transcript (T.) at page (pg.) 18-20.) The Board notes that the record reflects that the Veteran has referenced hepatitis C risk factors other than exposure to blood during immunization in service. For example on a hepatitis questionnaire that he submitted in June 2004, the Veteran indicated that he had shared toothbrushes or razor blades. However, the record does not show that the Veteran has alleged that he shared toothbrushes or razor blades during service. Additionally, the record demonstrates that the Veteran has a history of drug abuse. Specifically, a December 1990 clinic note from the Texas Department of Corrections shows that drug use was a chronic illness or disability. Further, during his March 2008 Travel Board hearing, the Veteran reported a history of intravenous drug use. (Transcript (T.) at page (pg.) 21.) However, the competent evidence of record does not show that the Veteran ever used drugs during service. With respect to the etiology of the Veteran's hepatitis C, in October 2008, a VA examiner, after an examination of the Veteran and a review of his claims file, opined that it was less likely than not that the Veteran's hepatitis C was service-related. In reaching this conclusion the examiner noted that: Certain factors go against the Veteran's hepatitis C being related to his service. There was a greater than 30 years interval between the possible exposure and the diagnosis of hepatitis C. During this interval, there was no indication that the Veteran had hepatitis C. As noted above, multiple liver function tests were normal. There is evidence that during these 30 years, the Veteran was constantly receiving medical attention. In the BVA hearings, the Veteran has admitted that he has used drugs intravenously and also has used cocaine by nasal inhalation. At the present time, there is no presumption of regular transmission of hepatitis C by jet air injections either by the Veteran's Administration or the Department of Defense. However, the October 2008 VA examiner further stated that a relationship between the Veteran's hepatitis C and air gun injections in service cannot be excluded without resorting to speculation. Such clinical statements lend toward an interpretation that it is biologically plausible that the Veteran's hepatitis C was transmitted in service by air gun injector inoculations. The Board notes that to the extent that the October 2008 VA examiner suggests that the Veteran's hepatitis C is due to drug use, 38 U.S.C.A. § 1110 states that "no compensation shall be paid if the disability is the result of the person's own willful misconduct or abuse of alcohol or drugs." See also 38 C.F.R. § 3.1(n), 3.301. Thus, the law clearly states that for claims filed after October 31, 1990, direct service connection for disability that is a result of the claimant's own use of drugs is precluded for purposes of all VA benefits. See 38 C.F.R. § 3.301(a). In adjudicating a claim, including as to continuity of symptomatology, the Board must assess the competence and credibility of the veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Although the Veteran asserts that his current hepatitis C is related to service, he is not competent to provide an opinion requiring medical knowledge, such as a question of medical causation. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, he is competent to give evidence about what he experienced; for example, he is competent to report that he experienced certain symptomatology in service- i.e. fatigue and dark brown urine. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Board acknowledges that it cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, such lack of contemporaneous evidence is for consideration in determining credibility. In this case, the Veteran's service treatment records are devoid of objective evidence (including on laboratory testing) of hepatitis C in service. However, at the time of the Veteran's military service in 1970 and 1971, a test for antibodies of hepatitis C was not available. The Board acknowledges that the October 2008 VA examiner indicated that there was no indication that the Veteran had hepatitis C in the more than 30 year interval between the possible exposure and the diagnosis of hepatitis C and that multiple liver function tests were normal. However, it is observed that the record does not establish that a test of the Veteran for antibodies of hepatitis C had been made prior to 2003. In summary, the evidence of record establishes that the Veteran received inoculations by air gun injectors in service, a VA examiner's statement in October 2008 may be interpreted as establishing that it is biologically plausible for the Veteran's hepatitis C to have been transmitted by air gun injectors in service, and such relationship has not been definitively excluded by competent clinical evidence of record. As such, the Board finds that the evidence of record is in equipoise as to the issue on appeal. With resolution of doubt in the Veteran's favor, the Board finds that the evidence of record supports service connection for hepatitis C. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2010. ORDER Entitlement to service connection for hepatitis C is granted. REMAND VA must make reasonable efforts to assist the veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a)(West 2002); 38 C.F.R. § 3.159(c)(d) (2010). Such assistance shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(West 2002); 38 C.F.R. § 3.159(c)(4) (2010). The Veteran asserts that an effective date earlier than March 20, 2007 is warranted for the grant of service connection for prostate cancer. The record reflects that the March 20, 2007 effective date was assigned because it was the date that a VA pathology report showed a diagnosis of adenocarcinoma of the prostate. However, although the record shows that the Veteran may have been first diagnosed with prostate cancer in the March 20, 2007 VA pathology report, private treatment records (including laboratory test reports) show that the Veteran had elevated PSA levels that ranged between 5.7 to 7.6 ng/mL on several occasions between 2002 and 2004. Nevertheless, the record does not demonstrate that the Veteran has been provided a VA opinion to determine the clinical significance of such findings and to determine if such findings were, in fact, manifestations of the Veteran's prostate cancer. Therefore, because this case presents certain medical questions which cannot be answered by the Board, the Board finds that a VA opinion is warranted to determine whether it is at least as likely as not that the Veteran's elevated PSA levels found in private treatment records dated between 2002 and 2004 were manifestations of his current prostate cancer. See Colvin v. Derwinski, 1 Vet. App. 191, 175 (1999) [the Board is prohibited from exercising its own independent judgment to resolve medical questions]. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he furnish the names, addresses, and dates of treatment of all medical providers from whom he has received treatment for a prostate disability, to include elevated PSA levels and prostate cancer, since his military service. After securing the necessary authorizations for release of this information, seek to obtain copies of all treatment records referred to by the Veteran, not already of record. 2. Following completion of the above, including affording the appropriate period for response, the Veteran's claims file should be forwarded to the appropriate VA clinician who should provide an opinion as to the date of onset of the Veteran's prostate cancer. The examiner should specifically be requested to comment on the clinical significance of the elevated PSA levels (between 5.7 to 7.6 ng/mL) reported in private treatment records dated between 2002 and 2004. The examiner should also be requested to furnish an opinion concerning whether it is at least as likely as not that any such elevated PSA levels were manifestations of the prostate cancer that the Veteran was diagnosed with in a March 20, 2007 VA pathology report. If it is found that the elevated PSA levels were manifestations of prostate cancer, the examiner should also indicate what specific date represented the earliest manifestation of the Veteran's prostate cancer. The rationale for all opinions expressed should be set forth. All necessary tests should be performed. The claims file and a separate copy of this remand must be made available to and reviewed by the examiner prior, and pursuant, to conduction and completion of the examination. The examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. 3. Following completion of the above, readjudicate the issue on appeal. If the benefit sought on appeal is not granted, the Veteran and his attorney should be furnished an appropriate Supplemental Statement of the Case and be provided an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). _____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs