LIVER CIRRHOSIS OF

Summary

The Veteran served from November 1992 to February 1993 and January 2002 to February 2006. The Veteran appeals the denial of service connection for Non-Alcoholic Fatty Liver Disease (NAFLD), including Non-Alcoholic Steatohepatitis (NASH). The Veteran's service records show weight gain during service, particularly after being prescribed anti-depressants for PTSD. A private medical opinion in December 2018 opined that the Veteran's weight gain and obesity were at least as likely as not related to his PTSD, ankle injury, and neuropathy. Medical literature submitted by the Veteran linked diets high in fat to NAFLD and noted that most NAFLD patients were overweight or obese. A May 2024 VA examination diagnosed NASH but opined that NAFLD was less likely than not proximately due to service-connected Obstructive Sleep Apnea (OSA), failing to adequately address weight gain as an intermediate step. Another October 2024 VA opinion found NAFLD not likely caused by toxic exposure risk activities. The Board found the May 2024 VA opinion inadequate for failing to address weight gain as an intermediate step for secondary aggravation. However, the Board found the evidence sufficient to decide the claim, concluding that the Veteran's service-connected PTSD led to weight gain, which is a risk factor for NAFLD, thus establishing obesity as an intermediate step. Resolving reasonable doubt in the Veteran's favor due to approximate balance of evidence, the Board granted service connection for NAFLD.

Rationale

Service-connected PTSD led to weight gain.; Weight gain is a risk factor for NAFLD.; Obesity served as an intermediate step between PTSD and NAFLD.

Full Decision Text

Citation Nr: A26037270
Decision Date: 04/21/26	Archive Date: 04/21/26

DOCKET NO. 250627-558764
DATE:  April 21, 2026

ORDER

Entitlement to service connection for a non-alcoholic fatty liver disease (NAFLD), to include non-alcoholic steatohepatitis (NASH), is granted.

FINDING OF FACT

Resolving reasonable doubt in favor of the Veteran, his NAFLD is proximately caused by his service-connected posttraumatic stress disorder (PTSD), to include resultant obesity as an intermediate step.

CONCLUSION OF LAW

The criteria for service connection for NAFLD, to include NASH, are met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2025).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active miliary service from November 1992 to February 1993 and from January 2002 to February 2006. 

This case comes before the Board of Veterans' Appeals (Board) on appeal of a March 2025 Higher-Level Review (HLR) rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Originally, the Veteran was denied entitlement to service connection for NAFLD in a December 2024 rating decision. In December 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR, requesting a review of the December 2024 rating decision. The March 2025 HLR rating decision on appeal was issued in response to that request. 

In the June 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the December 2024 agency of original jurisdiction (AOJ) rating decision, which was subsequently subject to HLR. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the December 2024 rating decision, that was subsequently subject to HLR, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 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. 

Service Connection - NAFLD

The Veteran's service treatment records (STRs) reveal that he weighed 153 pounds at the time of his medical examination for enlistment in October 1992. Additionally, a Report of Medical Examination, from January 2002, documented that the Veteran weighed 168 pounds. Later, an October 2003 treatment note revealed that the Veteran was feeling down and depressed related to his deployment; at that time, his weight was 188 pounds. Further, a June 2005 treatment note documented that the Veteran was overweight and counseled pertaining to his obesity, at that time he weighed 193 pounds.

An August 2006 treatment note documented the Veteran's report that he began to gain weight after being put on anti-depressants for PTSD upon his first return trip from Iraq. 

In a December 2018 private medical opinion, an advanced practice registered nurse, G.U., opined that it was at least as likely as not that the Veteran's weight gain and obesity were due to or related to his PTSD, left ankle osteochondral injury, and peripheral neuropathy of the left foot. G.U. referenced several excerpts from medical articles and/or studies to support their conclusion. 

In May 2024, the Veteran submitted medical literature which revealed, amongst other things, that diets (specifically those high in fat) were an independent risk factor for the development of NAFLD. Additionally, other medical literature associated with the claims file noted that among NAFLD about 75 percent of patients were overweight and 90 to 95 percent of patients were morbidly obese. 

During a May 2024 VA examination, a VA examiner assessed that the Veteran had a diagnosis of NASH. At that time, the examiner opined that the Veteran's NAFLD was less likely than not proximately due to or the result of his service-connected
 referenced several excerpts from medical articles and/or studies to support their conclusion. 

In May 2024, the Veteran submitted medical literature which revealed, amongst other things, that diets (specifically those high in fat) were an independent risk factor for the development of NAFLD. Additionally, other medical literature associated with the claims file noted that among NAFLD about 75 percent of patients were overweight and 90 to 95 percent of patients were morbidly obese. 

During a May 2024 VA examination, a VA examiner assessed that the Veteran had a diagnosis of NASH. At that time, the examiner opined that the Veteran's NAFLD was less likely than not proximately due to or the result of his service-connected OSA. The VA examiner noted that the risk factors for NAFLD included obesity and metabolic syndrome, insulin resistance, and high levels of triglycerides. 

Additionally, in an October 2024 VA medical opinion, a VA examiner found that Veteran's NAFLD was not at least as likely as not caused by toxic exposure risk activities (TERA) during his deployments. 

The Board finds that the May 2024 VA medical opinion is inadequate for adjudication purposes. In this regard, the VA examiner failed to adequately address secondary aggravation, to include an intermediate step of weight gain, as they noted that obesity was a risk factor but failed to address the Veteran's weight gain during service and his lay statements of weight gain due to his service-connected PTSD. See Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018) (holding that, in claims involving service connection on a secondary basis, VA medical opinions must provide separate findings and rationales regarding both cause and aggravation); see also El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (a medical opinion is inadequate when it fails to adequately address the question of aggravation). 

Nonetheless, in this case, the Board finds that another remand is not necessary as the evidence is sufficient to decide the claim. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

Based on the evidence above, the Board finds that the objective medical evidence, the December 2018 opinion and medical literature related to NAFLD, supports that the Veteran's service-connected PTSD resulted in weight gain and that weight gain is a risk factor for the development of NAFLD. Thus, the evidence demonstrates that the Veteran's obesity was an intermediate step between his service-connected PTSD and NAFLD. See Walsh v. Wilkie, 32 Vet. App. 300 (2020).

Accordingly, the Board finds that the evidence for and against the claim is in approximate balance. Therefore, the benefit of the doubt must be resolved in favor of the Veteran and entitlement to service connection for NAFLD, to include NASH, is warranted. 38 U.S.C. § 5107(b) (2018); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

 

 

Kristin Haddock

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Randall

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.