HEPATITIS C

JONATHAN HAGER · 2026 · Case ID: A26027639

GRANTED

Summary

The veteran, who served from March 1970 to March 1972, appeals the denial of service connection for hepatitis C and secondary cirrhosis of the liver. The Board found that the veteran's service treatment records, which included a 44-day hospitalization for infectious hepatitis in 1971, established the in-service disease element. The veteran consistently reported symptoms of hepatitis since service and provided lay statements, including from his brother, detailing his belief that he contracted hepatitis C through needle sticks while handling contaminated medical linens during his service. Despite the absence of a hepatitis C diagnosis in service, as the virus was not identifiable at that time, the Board found the veteran's consistent lay testimony regarding in-service exposure and subsequent symptoms, coupled with private medical opinions, provided sufficient evidence for service connection. The private opinions, which considered the service records, lay statements, and VA treatment records showing progression to cirrhosis, concluded that the hepatitis C was more likely related to the in-service hepatitis diagnosis. The Board found the VA medical opinions inadequate because they mischaracterized evidence, failed to consider the veteran's lay statements, and relied on ambiguous notations. The Board resolved the equipoise in the evidence in the veteran's favor, granting service connection for hepatitis C. Subsequently, the Board granted secondary service connection for cirrhosis of the liver, finding it proximately due to the service-connected hepatitis C, also resolving reasonable doubt in the veteran's favor.

Rationale

In-service diagnosis and treatment of hepatitis; Veteran's consistent lay statements of exposure and symptoms; Private medical opinions linking hepatitis C to in-service hepatitis; Equipoise in evidence resolved in veteran's favor

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210420-154132

Full Decision Text

Citation Nr: A26027639
Decision Date: 03/26/26 Archive Date: 03/26/26

DOCKET NO. 210420-154132
DATE: March 26, 2026

ORDER

Entitlement to service connection for hepatitis C is granted.

Entitlement to service connection for cirrhosis of the liver, secondary to now service-connected hepatitis C, on a causation basis, is granted.

FINDINGS OF FACT

1. The evidence is at least evenly balanced as to whether the Veteran's hepatitis C is related to his in-service diagnosis and treatment of hepatitis.

2. The evidence is at least evenly balanced as to whether the Veteran's cirrhosis of the liver is caused by his now service-connected hepatitis C.

CONCLUSIONS OF LAW

1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for hepatitis C have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for cirrhosis of the liver, secondary to hepatitis C, on a causation basis, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from March 1970 to March 1972.

This case comes before the Board of Veterans' Appeals (Board) from an April 2020 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Prior to that decision, the RO denied entitlement to service connection for hepatitis C in rating decisions dated July 1994, July 2002, January 2010, and March 2019, with the Board remanding the issue three times between January 2010 and March 2019. The Veteran filed a supplemental claim in February 2020, and in the rating decision on appeal, the RO continued the previous denials of entitlement to service connection for hepatitis C, finding that new and relevant evidence had been received warranting readjudication of the claim. The Board is bound by this favorable finding and will adjudicate the merits of the claim. 38 U.S.C. § 5104(b)(4); 5104A; 38 C.F.R. § 20.801(a).

In the April 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket and identified the April 2020 rating decision and the specific issue of service connection for hepatitis C. A Board hearing was held on December 3, 2024 and a copy of the transcript has been associated with the Veteran's claims file.

Therefore, the Board may only consider the evidence of record at the time of the April 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

As for characterization of the issues on appeal, the evidence reflects that the Veteran was diagnosed with cirrhosis of the liver associated with his hepatitis C for which service connection is being claimed. 38 C.F.R. § 3.155(d)(2) requires that, when entitlement to secondary service connection is raised, a formal claim for secondary service connection need not be filed, rather, VA must consider those "complications" in connection with the claim on appeal. This rule applies in the service connection context as well as the rating context. Grimes v. McDonough, 34 Vet. App. 84,
considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

As for characterization of the issues on appeal, the evidence reflects that the Veteran was diagnosed with cirrhosis of the liver associated with his hepatitis C for which service connection is being claimed. 38 C.F.R. § 3.155(d)(2) requires that, when entitlement to secondary service connection is raised, a formal claim for secondary service connection need not be filed, rather, VA must consider those "complications" in connection with the claim on appeal. This rule applies in the service connection context as well as the rating context. Grimes v. McDonough, 34 Vet. App. 84, 89 (2021) (a claim for service connection can include all diagnoses found during the claim's development that relate to the symptomatology asserted by the veteran). Therefore, the Board has expanded the appeal to include the separate issue of entitlement to service connection for cirrhosis of the liver secondary to hepatitis C.

Entitlement to service connection for hepatitis C is granted.

Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

As favorably found by the AOJ, VA treatment records show treatment and diagnosis for hepatitis C. The Board is bound by this favorable finding, 38 C.F.R. § 3.104(c), and the current disability requirement has thus been met.

The Veteran's service treatment records show that he was diagnosed with hepatitis during service. Specifically, the Veteran was hospitalized from April 14, 1971 to May 26, 1971. Despite this 44-day hospitalization, and the Veteran and his brother recalling that the Red Cross contacted the Veteran's mother because of the severity of the disease, service treatment records do not document the Veteran's symptoms prior to hospitalization that warranted intake, testing and diagnosis, the progression of the symptoms during the 44 days, the type of treatment, or the Veteran's response to treatment. Only two service records document the hospitalization: a discharge statement and a medical condition - physical profile record that placed the Veteran on temporary physical limitation after hospital release. The May 26, 1971 discharge statement reads, "dx - infectious Hepatitis, Au+, treatment improved." Following his hospitalization, service treatment records reflect that the Veteran reported low back pain in September 1971, insomnia in November 1971, and fatigue with blood in his urine in November 1971. Based on the service treatment records showing a 44-day hospitalization for hepatitis, the in-service disease or injury element has been met.

The Veteran initially filed a claim for entitlement to service connection for hepatitis in February1994, prior to his hepatitis C diagnosis. VA treatment records show that the Veteran was diagnosed with hepatitis C in September 2000, with blood tests also showing the presence of antigens for hepatitis B. A March 2001 liver biopsy showed moderate to severe hepatitis C. The Veteran reported to VA physicians that he believed his hepatitis C began during service in 1971.

Following the diagnosis, the Veteran again filed for entitlement to service connection for hepatitis C in April 2001. In August 2001, the Veteran submitted a statement, in which he explained that while he was stationed in Texas, he worked for Brook General Hospital, primarily performing laundry duties. The Veteran would collect items to be laundered, including bed sheets, which were often rolled into bundles, and sometimes contained hazardous materials including needles and blood. The Veteran stated that in loading and unloading the used medical linens, he was stuck by used needles on multiple occasions, which he contends led to his in-service contraction of hepatitis C. In a March 2002 statement, the Veteran recalled that he was diagnosed with serum hepatitis while he was hospitalized. The Veteran made similar reports and statements submitted in September 2008. In October 2008, the Veteran's brother submitted a statement recalling his brother's account of being stuck by used and dirty needles when handling medical linens.
Hospital, primarily performing laundry duties. The Veteran would collect items to be laundered, including bed sheets, which were often rolled into bundles, and sometimes contained hazardous materials including needles and blood. The Veteran stated that in loading and unloading the used medical linens, he was stuck by used needles on multiple occasions, which he contends led to his in-service contraction of hepatitis C. In a March 2002 statement, the Veteran recalled that he was diagnosed with serum hepatitis while he was hospitalized. The Veteran made similar reports and statements submitted in September 2008. In October 2008, the Veteran's brother submitted a statement recalling his brother's account of being stuck by used and dirty needles when handling medical linens. He remembered the Veteran's medical condition deteriorating, despite the Veteran seeking treatment, until he became seriously ill; at that time, Red Cross contacted his mother to see the Veteran because of his condition.

Finally, the Veteran has testified at two Board hearings, the first in April 2016 and the second in December of 2024. During the first hearing, the Veteran recounted handling medical linens that contained blood and being stuck by needles several times without being provided gloves or any protective equipment. He stated that following separation from service, he continued to experience fluctuating symptoms from hepatitis but did not have insurance or financial means to seek treatment. He sought treatment from VA only when the symptoms had increased in severity, and at that time was diagnosed with hepatitis C. In a statement submitted in January 2018, the Veteran stated that he experienced fever, lightheadedness, dizziness, muscle spasms and insomnia before his infectious hepatitis was diagnosed; when he was discharged, he continued to experience fever, nausea, vomiting and stomach pains. During his second Board hearing, 23 years after he submitted his first statement explaining how he contracted hepatitis in service, the Veteran again recounted that he was stuck by needles while performing laundry services, and that they referred to his in-service diagnosis as serum hepatitis.

The remaining issue is thus whether there is a relationship between the Veteran's hepatitis C and the in-service disease of infectious hepatitis. There are conflicting medical opinions on this question.

Before discussing the medical opinions of record, it is important to note that in April 1971, when the Veteran was hospitalized and diagnosed with hepatitis, viral hepatitis was believed to consist only of two types: infectious or type A hepatitis and serum or type B hepatitis. See The history of the "natural history" of hepatitis C (1968-2009), available at https://pmc.ncbi.nlm.nih.gov/articles/PMC4373556/). A November 1998 VA Fast letter, which was rescinded with summaries incorporated into VA's Adjudication Procedures Manual, M21-1, states that hepatitis C was identified in 1989, with a reliable second generation test for the C virus becoming available in 1992. While the Adjudication Manual is not binding on the Board, DAV v. Sec'y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) ("The M21-1 Manual is binding on neither the agency nor tribunals"), it "is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases." Overton v. Wilkie, 30 Vet. App. 257, 264 (2018). Given that hepatitis C could not be diagnosed in service, the absence of this diagnosis does not create substantive negative evidence against the Veteran. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (stating that "[w]hen assessing a claim, the Board may not consider the absence of evidence as substantive negative evidence.").

Moreover, the records are unclear whether the Veteran was diagnosed with hepatitis A or hepatitis B during service, with the records referring to "infectious hepatitis," but the Veteran recalling a diagnosis of serum hepatitis, the hospital discharge noting "Au+", with Au likely referencing a test for the detection of the Australian (Au) antigen used to diagnose hepatitis B. the presence of hepatitis B antibodies. See Subspecificities of the Australia Antigen Complex, (available at https://jamanetwork.com/journals/jamapediatrics/fullarticle/504521). However, a finding that the Veteran was diagnosed with hepatitis B in service may substantiate the Veteran's claim regarding in-service contraction. As stated in the M21-1, while hepatitis B and hepatitis C are different diseases, they nevertheless share the same type of transmission risks, including contact with blood and blood products, such as accidental exposure to blood products as a healthcare worker, combat medic, or corpsman by percutaneous (through the skin)
a test for the detection of the Australian (Au) antigen used to diagnose hepatitis B. the presence of hepatitis B antibodies. See Subspecificities of the Australia Antigen Complex, (available at https://jamanetwork.com/journals/jamapediatrics/fullarticle/504521). However, a finding that the Veteran was diagnosed with hepatitis B in service may substantiate the Veteran's claim regarding in-service contraction. As stated in the M21-1, while hepatitis B and hepatitis C are different diseases, they nevertheless share the same type of transmission risks, including contact with blood and blood products, such as accidental exposure to blood products as a healthcare worker, combat medic, or corpsman by percutaneous (through the skin) exposure or on mucous membrane. Because "there are certain risk factors that are plausible as a cause of hepatitis B or C," including "employment in a health care occupation," a "claim that hepatitis B or C infection resulted from one of these in service would be plausible nexus information." See M21-1, November 30, 1998 Fast Letter (98-110). In contrast, a hepatitis A infection is caused by the hepatitis A virus and is spread by oral or fecal contamination of food or water, usually because of poor sanitation. Id. This acute infection produces lifelong immunity to re-infection, heals without residual disability and does not result in chronic hepatitis infection or liver damage. Id.

Therefore, the question is not whether the Veteran was diagnosed with hepatitis C during service, a diagnosis that did not exist at that time, but whether lay and medical evidence supports a finding that the Veteran's in-service hepatitis is related to his diagnosed hepatitis C. To this point, a finding that the Veteran contracted hepatitis B during service would further support the Veteran's contention that he was exposed to blood and incurred accidental percutaneous exposure to blood products in his employment in a health care facility.

Regarding the continuity of symptoms from service to his 2000 diagnosis of hepatitis C, the Veteran is competent to report the onset and persistent nature of his observable hepatitis symptoms, including fatigue, jaundice, lack of appetite, and back pain. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a layperson is competent to report observations). The Veteran's lay evidence concerning his continuity of symptoms following his 1971 treatment and 1972 discharge is competent regardless of the lack of treatment records further discussing the frequency or severity of the symptoms until diagnosis of hepatitis C in 2000. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006) (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). Notably, post May 1971 service treatment records reflect that the Veteran sought medical treatment for back pain and fatigue, and the Veteran stated that he did not have insurance or other means to seek treatment for his continued symptoms after service until 2000. The Veteran filing a 1994 claim for entitlement to service connection for hepatitis indicates that the Veteran continued to experience chronic hepatitis symptoms following service.

The Veteran attended a VA examination in May 2002, during which he recounted his work in the laundry room. The physician recorded that the Veteran "possibly got stuck by a needle," and provided a negative opinion based on the 2000 diagnosis of hepatitis C, 28 years after separation, the Veteran's pre-service tattoo and intravenous drug use prior to, during and after service.

The Veteran attended a hepatitis, cirrhosis and other liver conditions VA examination in September 2016. The physician referenced a statement from the Veteran's brother and the hospital discharge note for "infectious hepatitis, A+, treated, improved." At that time, per the Veteran's report, he had fatigue, jaundice of eyes and fingernails, itching and decreased appetite, with no supporting medical documentation of these symptoms. The Veteran recorded that there were no subsequent in-service visits for symptoms related to hepatitis. The physician recorded that at the time of the Veteran's separation physical in 1972, "the examiner made a notation of 'hepatitis, Fort Sam Houston, Brock General Hospital, from drinking dirty well water'" and "no current medical problems."

In the accompanying opinion, the physician stated that the symptoms the Veteran reported at diagnosis were consistent with hepatitis A and relied on the examiner's notation that the hepatitis was due from dirty drinking water, consistent with the way that hepatitis A can be spread. The physician concluded that the Veteran was diagnosed with hepatitis A during service and "Hepatitis A does not lead to or cause Hepatitis C." Moreover, while the Veteran "maintains that an event occurred, there is no medical documentation in the records reviewed that can be used to verify the occurrence of the reported event of the alleged needle sticks while handling laundry and subsequent Hepatitis C. Without definitive medical documentation of the occurrence of the injury event and associated details of the injury that occurred, it is impossible to verify that such an injury occurred during military service." Based on the lack of definitive medical documentation that the Veteran was pricked with used needles during service, the physician opined that "it is less likely than not that the risk factor of handling soiled hospital linens caused the hepatitis C diagnosed during the course of the Veteran's claim, as this is not a mode of transmission for Hepatitis C."

In February 2019, the same VA physician provided a similar opinion based on an in-service diagnosis of hepatitis A not causing hepatitis C, and the Veteran's post-service risk factors being more likely the cause.

For several reasons, the May 2002, September 2016 and February 2019 VA opinions are inadequate and not entitled to substantial probative value in determining whether a relationship exists between the Veteran's diagnosed hepatitis C, and his hepatitis diagnosis in service. First, the later VA physician determined that the Veteran had been diagnosed with hepatitis A in service based on a mischaracterization of the evidence, specifically referring to "A+" found in the records, when the records reference "Au+," important here as Au may refer to hepatitis B antigen testing. The physician also did not consider 2000 testing showing the presence of hepatitis B antibodies. Moreover, the physician relied on an examiner's notation that hepatitis was due to drinking dirty well water on the Veteran's report of medical history at separation; however, the Veteran himself wrote this statement at discharge and given the absence of medical records, the origin of this statement is unclear. Moreover, the Veteran has consistently stated that he was diagnosed with serum hepatitis in service, also known as hepatitis B. While the determination that the Veteran was diagnosed with hepatitis A in service does not bear on the question of service connection, it reflects the VA opining physicians misciting the limited facts available, and further discounting the Veteran's statements of in-service exposure, even when supported by medical evidence.

For 23 years, the Veteran reported that he was pricked by used needles while collecting and unloading used linens at a medical hospital, and that despite treatment during his 44-day hospitalization, he experienced fluctuating symptoms of hepatitis prior to his ultimate diagnosis of moderate to severe hepatitis C. Despite the Veteran providing competent and credible statements regarding his hepatitis symptoms from the time of his 1971 hospitalization to his 2000 diagnosis of hepatitis C, his accounting for the gap in treatment, and his consistent explanation of in-service exposure that is a recognized type of hepatitis C transmission, the physicians providing the opinions in May 2002, September 2016 and February 2019 provided negative opinions based on the absence of medical evidence that the Veteran was pricked by needles during service, with the May 2002 physician recognizing only "a possibility" but not considering it in his opinion, and the later VA physician only considering whether the Veteran touched soiled linen. See Fountain v. McDonald, 27 Vet. App. 258, 272 (2015) (stating that the Board must first establish a proper foundation for drawing inferences against a claimant from an absence of documentation). As the physicians did not consider the Veteran's lay statements of injuries during service or his report of continuing symptoms until his later diagnosis, the opinions are inadequate and not entitled to substantial probative weight. See Buchanan, 451 F.3d at 1336 (VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the Veteran's] disability such that his claim for service connection could be proven without contemporaneous medical evidence"); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (finding that an examiner impermissibly ignored the appellant's lay assertions that he
absence of documentation). As the physicians did not consider the Veteran's lay statements of injuries during service or his report of continuing symptoms until his later diagnosis, the opinions are inadequate and not entitled to substantial probative weight. See Buchanan, 451 F.3d at 1336 (VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the Veteran's] disability such that his claim for service connection could be proven without contemporaneous medical evidence"); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (finding that an examiner impermissibly ignored the appellant's lay assertions that he had sustained a back injury in service).

In February 2020, the Veteran submitted two opinions from separate private physicians. The first opinion, dated September 2019, states that the physician reviewed the May 1971 service treatment records reflecting the Veteran's hospitalization for infectious hepatitis, the Veteran's development of jaundice and liver cirrhosis as shown through VA treatment records, and VA treatment for hepatitis C in 2015. The physician opined that the Veteran's hepatitis C is more likely related to the in-service May 1971 infectious hepatitis diagnosis. A separate physician provided an opinion dated December 2019, which also recounted the Veteran's service treatment records, and VA treatment records showing diagnosis and treatment of hepatitis C. The physician opined that after review of the pertinent records, it is highly likely that the Veteran's hepatitis C and liver disease are related to the infectious hepatitis incurred while on military active duty.

The physicians providing these opinions considered the service treatment records, the Veteran's lay statements, and VA treatment records documenting the progression and treatment of his hepatitis C to reach their opinions. For this reason, the opinions are adequate and afforded substantial probative weight in finding that the Veteran's hepatitis C is related to his in-service diagnosis of hepatitis. See Nieves-Rodriguez, 22 Vet. App. at 304 ("The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion."); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record).

For the above reasons, the evidence is at least evenly balanced as to whether the Veteran's hepatitis C is related to service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for hepatitis C is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Entitlement to service connection for cirrhosis of the liver, secondary to now service-connected hepatitis C, on a causation basis, is granted.

Secondary service connection under 38 C.F.R. § 3.310(a) is warranted for disability proximately due to or the result of a service-connected disease or injury. Historically, "secondary service connection was considered a product of regulation, rather than statute." Adams v. Collins, 38 Vet. App. 273, 286 (2025) (citing Frost v. Shulkin, 29 Vet. App. 131, 137 (2017) ("Secondary service connection for VA benefit purposes is not addressed in any statute")). However, 38?U.S.C. § 1110 "plainly requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability." Spicer v. McDonough, 61 F. 4th 1360, 1366 (Fed. Cir. 2023). Moreover, "[t]he but-for causation standard is not limited to a single cause and effect, but rather contemplates multi-causal links." Id. at 1364.

A December 2009 VA infectious disease consultation report, under disease progression, states that 10 to 15 percent of hepatitis C infected persons will develop cirrhosis over a 20 to 30 year period. The general progression of hepatitis C liver disease is fibrosis, then cirrhosis, then advanced liver disease.

VA treatment records reflect that in March 2012, the Veteran was referred to VA hepatology based on his unspecified viral hepatitis C. In March 2012, VA hepatology ordered an ultrasound and additional blood tests. An October 2013 ultrasound showed cirrhotic liver without focal mass. In an August 2013, VA hepatology note, the physician recorded that the Veteran has advanced liver disease/cirrhosis,
disease consultation report, under disease progression, states that 10 to 15 percent of hepatitis C infected persons will develop cirrhosis over a 20 to 30 year period. The general progression of hepatitis C liver disease is fibrosis, then cirrhosis, then advanced liver disease.

VA treatment records reflect that in March 2012, the Veteran was referred to VA hepatology based on his unspecified viral hepatitis C. In March 2012, VA hepatology ordered an ultrasound and additional blood tests. An October 2013 ultrasound showed cirrhotic liver without focal mass. In an August 2013, VA hepatology note, the physician recorded that the Veteran has advanced liver disease/cirrhosis, with bridging fibrosis shown on the liver biopsy in 2001. The physician recorded that the Veteran continued to drink alcohol and his hepatitis C is "not fully treated thus likely [the Veteran] has advanced to cirrhosis." Prior to this report, VA treatment record shows the Veteran stating that he did not drink alcohol.

To the date of the rating decision on appeal, VA treatment records continued to reflect a diagnosis of cirrhosis, which, based on VA hematology's note, was a progression of the Veteran's hepatitis C, with the advancement of disease caused by the Veteran's untreated hepatitis C. Moreover, the physician providing the December 2019 opinion detailed above opined that the Veteran's "liver disease is related to the infectious hepatitis incurred while on military active duty." To the extent that other factors may have contributed to the Veteran's cirrhosis, such as alcohol consumption, the presence of this factor would not negate the but-for causal relationship established between his service-connected hepatitis C and his cirrhosis. See Gajeski v. Collins, No. 24-4992, 2025 U.S. App. Vet. Claims LEXIS 942, *10-11 ("A veteran is entitled to compensation for a 'disability resulting from personal injury suffered or disease contracted' in or related to service. 38 U.S.C. § 1110. And 'the causation standard of § 1110 is simply standard but-for causation.' Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023). But-for causation is a broad standard that 'is not limited to a single cause and effect, but rather contemplates multi-causal links.' Id. This means that establishing one factor as a but-for cause does not necessarily eliminate all other factors as but-for causes.") (citing Bostock v. Clayton Cnty., Ga., 590 U.S. 644, 656 (2020) (explaining that, in the context of Title VII, but-for causation means that a defendant cannot avoid liability 'just by citing some other [non-discriminatory] factor that contributed to its challenged employment decision'"). See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain).

For the above reasons, the evidence is approximately evenly balanced as to whether the Veteran's cirrhosis of the liver was caused by his now service-connected hepatitis C. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for cirrhosis of the liver, secondary to now service-connected hepatitis C, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102

Jonathan Hager

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board H. T. Mowell, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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