Citation Nr: 0909396 Decision Date: 03/13/09 Archive Date: 03/26/09 DOCKET NO. 06-26 441 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee ISSUES 1. Whether the reduction in rating from 100 percent to 60 percent effective June 1, 2005, for status post kidney transplant due to polycystic kidney disease was proper. 2. Entitlement to a rating in excess of 60 percent beginning June 1, 2005, for status post kidney transplant due to polycystic kidney disease. 3. Entitlement to special monthly compensation benefits beginning June 1, 2005. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD P. Childers, Associate Counsel INTRODUCTION The Veteran had active military service from November 1966 to January 1973, including service in Vietnam during the Vietnam conflict; and from September 1990 to June 1991, including service in the Southwest Asia Theater of Operations from October 1990 to May 1991 in support of Operation Desert Shield/Desert Storm. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In August 2005 the Veteran appeared and testified at an RO hearing in Nashville, Tennessee. The transcript of that hearing is of record. FINDINGS OF FACT 1. The rating for the Veteran's service-connected kidney transplant disability was reduced in compliance with VA regulations. 2. The Veteran's status post kidney transplant disability is not productive of persistent albuminuria; BUN of at least 40; or creatinine level of at least 4, and does no require regular dialysis, but it is productive of generalized poor health characterized by lethargy, weakness, and limitation of exertion. 3. The Veteran is not service-connected or entitled to service connection for blindness in both eyes demonstrated by visual acuity of 5/200 or less, is not service-connected or entitled to service connection for anatomical loss or loss of use of both hands; is not 65 years of age; does not have a single disability rated at 100 percent disabling; does not require the regular aid and attendance of another person; and is not housebound. CONCLUSIONS OF LAW 1. The March 2005 reduction in rating for the Veteran's service-connected status post kidney transplant disability was properly executed. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 3.105 (2008). 2. The criteria for a rating of 80 percent beginning June 1, 2005, for status post kidney transplant due to polycystic kidney disease are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 4.115a, 4.115b, Diagnostic Code 7531 (2008). 3. The criteria for special monthly compensation beginning June 1, 2005, are not met. 38 U.S.C.A. §§ 2101(b), 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.351, 3.352 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Kidney transplant disability rating On May 7, 2003, the Veteran was hospitalized and underwent a "living renal transplant." In a rating decision dated in July 2003 he was granted an evaluation of 100 percent effective May 7, 2003, under the provisions of Diagnostic Code 7531. 38 C.F.R. § 4.115b. A mandatory post-transplant VA genitourinary examination was done in May 2004, and in September 2004 the RO issued a rating decision in which it proposed to decrease the disability rating for the Veteran's service-connected kidney transplant disability from 100 percent to 60 percent based on improvement in the condition. The Veteran has appealed this reduction. Diagnostic Code 7531 provides that any change in evaluation based upon the mandatory VA examination done one year following hospital discharge or any subsequent examination shall be subject to the provisions of §3.105(e). 38 C.F.R. § 4.115b, Diagnostic Code 7531, Note. Where a reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefore, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. Id. Unless otherwise provided in paragraph (i) of this section, if additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. Id. In this case the notice requirements of 38 C.F.R. § 3.105(e) are clearly met. In its September 2004 rating decision the RO set forth all material facts and reasons for the proposed reduction in compensation for the Veteran's service-connected kidney transplant disability from 100 percent to 60 percent. The rating decision informed the Veteran that the proposed reduction in rating was based on improvement in the Veteran's condition, and provided the Veteran with the applicable facts that existed at the time of the decision. The RO also sent a letter dated October 14, 2004, to the Veteran's last address of record which advised him of the proposed decrease in rating for his service-connected kidney transplant disability from 100 percent to 60 percent (and of a corresponding decrease in his combined rating from 100 percent to 90 percent). The letter also notified him that the effective date of the proposed reduction would be the "first day of the third month following [notice] of the final decision; and notified him that he had 60 days within which to provide evidence that would support continuation of his compensation payments at their then present level. Notice requirements having been met, the Board will therefore consider whether a rating in excess of 60 percent beginning June 1, 2005, for status post kidney transplant due to polycystic kidney disease is warranted. Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C.A. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. While the Veteran's entire history is reviewed when assigning a disability evaluation (38 C.F.R. § 4.1), where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the United States Court of Appeals for Veterans Claims (Court) has recently held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, (2007). Diagnostic Code 7531 provides for a 100 percent disability rating following kidney transplant surgery from the date of hospital admission for transplant surgery. 38 C.F.R. § 4.115b, Diagnostic Code 7531. The regulations further provide that a mandatory VA examination shall be performed one year following hospital discharge, and require that any transplant residuals shall be evaluated under the renal dysfunction provisions of 38 C.F.R. § 4.115a. 38 C.F.R. § 4.115b, Diagnostic Code 7531, Note. Pursuant to 38 C.F.R. § 4.115a, a 60 percent disability rating is warranted for renal dysfunction characterized by constant albuminuria with some edema; or, where there is a definite decrease in kidney function; or, where hypertension is at least 40 percent disabling under Diagnostic Code 7101. An 80 percent disability rating is warranted where there is persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. The highest disability rating of 100 percent is warranted where the renal dysfunction requires regular dialysis, or precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or, where BUN is more than 80mg%; or, creatinine more than 8mg%; or, where there is markedly decreased function of kidney or other organ systems, especially cardiovascular. 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.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Preliminarily, the Board notes that since the Veteran was in receipt of the highest possible rating of 100 percent until June 1, 2005, the evidence under review in this decision will be limited to that dated approximate to June 1, 2005, and thereafter. VA treatment records dated in November 2004 include the following comments: "renal insufficiency though improved from pre-transplant status has never returned to within normal limits. His level of proteinuria needs to be clarified. I have added a microalbumin level to his labs today. Significant microalbuminuria likely reflects diabetic changes in the transplanted kidney." In a letter dated in April 2005 a VA physician wrote as follows: [The Veteran] is s/p renal transplant for polycystic kidney disease with resultant renal failure. Since his transplant he has never returned to normal renal function. He is diabetic and is on chronic immunosuppressive therapy making his diabetes more difficult to control. He also has a history of recurrent shingles, morbid obesity, degenerative disc disease with chronic pain, gout and peripheral neuropathy and chronic lower extremity edema. He is on [medication] for chronic immunosuppressive/antirejection therapy for his kidney transplant. This will obviously make him very susceptible to developing infections. His Bun has varied any were from 22 to 36 post transplant with [creatinine] varying from 1.8 to 2.2 and there have also been problems with hyperkalemia. Due to his multiple continuing medical problems, it is felt [that the Veteran] is unemployable and despite transplant has not shown any significant improvement in functioning. In May 2005, the Veteran was accorded another VA genitourinary examination. The examiner noted that the Veteran had a renal transplant in 2003. He also noted that the Veteran had severe diabetes mellitus, for which he would take at least five injections a day of insulin. During the examination the Veteran reported that he: "basically sits in a recliner all day at home, plus takes a nap in the afternoon at least two hours. He only walks to the mailbox, which is a short distance, and he can only walk about 100 yards without stopping because of dyspnea and back pain. He occasionally leaves the house several days a week and drives, with his wife in attendance, to go to the grocery store and back for an hour. When he returns, he is very fatigued and must go to bed. . . . His only activity, other than the aforementioned, he does attempt to cook his breakfast each morning. He must rest several times during this endeavor. He is otherwise completely taken care of by his wife, who does all the housework and manages all the affairs." The examiner also noted that the Veteran had "modest prostatism with nocturia x2 or 3 and hesitancy, but is not incontinent." Review of medical records revealed that "over the last two years, serum creatinine has gone from 1.5 to 1.9, which is a gradual deterioration of renal function, as understood generally. BUN and other renal function tests in the same period of time show an up and down propensity." The examiner added that "two years ago it was 23, which is abnormal, and last month was 25, which is a slight increase." Physical examination revealed a well developed, well nourished individual in no acute distress. Abdomen was "extremely obese without percept[ible] organomegaly." Femoral pulsations were 2+ and equal bilaterally. Distal pulses were not found on palpation "secondary to 3+ edema of the feet, four feet posterior tibial areas to the knees." Diagnoses were as follows: 1. Diabetes mellitus, severe and complicated. 2. Status post renal transplant, secondary to renal disease 2003 with progressive general poor health, progressive weakness, lethargy, limitation of activities and, though not impressive, there is some evidence of slightly diminishing renal function over the last two years. According to the examiner, the Veteran was in "general very poor health," and his "medical history is positive for lethargy and weakness." He noted that the Veteran has had no weight loss or anorexia, but reiterated that he had "profound weakness, lethargy and lack of exercise capacity." He further stated as follows: "I do feel he has generalized poor health with impressive lethargy weakness and limitation of activities and is unable to care for himself except for dressing and his activities of daily living and occasionally helps with a meal." Physical examination in June 2005 found the abdomen to be soft, non-tender, and non-distended, with "normoactive bowels sounds x 4 quads, no masses, and no organomegaly." Extremities were described as follows: Right knee - normal ROM [range of motion], no deformities, no cyanosis, mild diffuse swelling-erythema-warm-very TTP [tender to palpation]. No open lesions. In a letter dated in July 2005 a VA physician said that the Veteran was on certain medications, and wrote that the Veteran "must remain on these antirejection/immuomudalting medications to prevent rejection of his transplanted kidney." In August 2005 the Veteran testified at an RO hearing. During the hearing he asserted that he had to fix his breakfast in the mornings so that he could take his pills and insulin shots. He testified that he then had to rest to get his breakfast to settle down. He testified that at 9:30 he would take a "big shot," and said that "at that time, I'm tired and I have to sit down and rest about an hour or two." He then testified that he is able to go to town. He testified that if he would go to town to go to the store, he would drive to town, sit and rest, then go to the grocery store, walk a little bit, and then sit down. He next stated: "when I get the rest of my stuff, I'm tired[.] So, I go back home and I'm tired. . . . I've tried to get out and walk, but I can't walk too far, because my back gets to - my spine gets to hurting and I get tired, so I just turn around and go back home. I just sit down and rest." Upon query from his representative he testified that the most disabling symptom of his disability was "the tiredness," such as when he would shop. The Veteran's wife added that: "When he comes back, sometimes it takes a while for him to rest up. Because I don't get out and go. He does it. I try to get out, but he tries to do the grocery shopping. And, he just goes and gets a few things. It's not like he goes down every aisle and shops for an hour or two, it's just going in and getting what we need and coming back out." In addition, the Veteran and his wife stated that he would drive himself and his wife to their doctor appointments. The Veteran further testified that he would visit with relatives "across the street or down at the corner," and attend church. He added that he would drive to church, and that the church was "just a quarter of a mile" away. He also testified that he was still taking antirejection drugs, and was not aware of any worsening of his kidney condition. VA treatment records dating from August 2005 to May 2006 show continued use of anti-rejection medications. Physical examination in August 2005 at the Nashville Renal Transplant Clinic found the abdomen with positive bowel sounds and no masses, tenderness or organomegaly; no bruits or tenderness of the right lower quadrant, and no edema or cyanosis of the extremities. During the examination the Veteran reported good fluid intake and urine output, and denied "f/c/n/v/d/dysuria or hematuria." Laboratory work found BUN of 24 and Creatinine of 1.7. Urinalysis was negative for blood and protein. Impression was "s/p renal transplant: s/p living unrelated transplant approx 2 years ago. Good allograft function. Scr 1.7." The Veteran was scheduled to return to the clinic in 4 months. In December 2005 the Veteran returned to the Renal Transplant Clinic for routine status post renal transplant follow up visit. During the examination he complained of multiple bouts of gout in September and November, plus outbreaks of shingles in October and November. He also complained of swelling in the lower extremities, but denied "f/c/n/v/d/diarrhea." Physical examination found the abdomen with normal bowel sounds and no masses, tenderness or organomegaly, and no bruits or tenderness in the right lower quadrant, but there was 2+ edema in the lower extremities. Gait was steady and the Veteran was alert and oriented times 3. BUN was 17 and creatinine was 1.5. Impression was "s/p renal transplant: 58 y/o male with ESRD [end stage renal disease] . . . LUR txp [living-unrelated donor transplant] on 5/7/03 with good allograft function, uop [urinary output] & stable scre 1.5." The Veteran was scheduled to return to the clinic in 4 months. In April 2006 the Veteran returned to the Renal Transplant Clinic as scheduled. During the examination he reported a good appetite and urinary output, and denied any "f/c/n/v/diarrhea." Physical examination found the abdomen with normal bowel sounds and no masses, tenderness or organomegaly, and no bruits or tenderness in the right lower quadrant, but there was 2+ edema or cyanosis in the extremities. Gait was steady and the Veteran was alert and oriented times 3. BUN was 20 and creatinine was 1.6. Urine was clear. Impression was status post renal transplant: 58 year old male with a history of end stage renal disease . . . received a living-unrelated donor renal transplant on 5/7/03 with good allograft function, stable scre 1.6 and urinary output. During this same timeframe (August 2005 to May 2006) the Veteran received medical care at another Veterans' Affairs Medical Center (VAMC). An August 2005 physical examination at the other VAMC found the Veteran with a steady gait and alert and oriented times 3. Abdomen was soft and non tender, with normoactive bowel sounds "x 4 quads." There was full range of motion in all extremities, and no clubbing or cyanosis. A physical examination was also done in November 2005. During the examination the Veteran complained of excessive daytime somnolence, fatigue, frequent awakenings, excessive snoring. Physical examination found abdomen to be soft and non tender, and no clubbing, cyanosis, or edema in the extremities. Physical examination in December 2005 found "no breathing problems - no wheezing or hemoptysis. Appetite good, wt stable, BM nl. No gross hematuria or dysuria. No myalgias. No TIA sxs." Bowel sounds were normal, and abdomen was non- tender. Edema of the lower extremities of 1 -2+ was noted, but there was no "c/c" or signs of breakdown. A January 2006 treatment note documents the Veteran as reporting that he goes to a VAMC Transplant Clinic every 4 months and is supposed to see a nephrologist every two months. Analysis Although the evidence does show treatment for edema since June 1, 2005, there is no report of any persistent albuminuria. There is also no record since June 1, 2005, of BUN of at least 40, or creatinine level of at least 4. However, VA medical records (including the April 2005 physician's letter; the report of the May 2005 VA examination; and VA treatment records) and the Veteran's August 2005 testimony indicate that the Veteran is in generalized poor health characterized by lethargy, weakness, and limitation of exertion. Although the Board notes that the Veteran has a multitude of other debilitating disabilities that could account for these symptoms, the Board is mindful of the Court's decision in Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008), which held that claims involving overlapping symptoms must be considered independently because they rest on distinct factual bases. Therefore, and according the Veteran every reasonable doubt, the Board finds that a disability rating of 80 percent effective June 1, 2005, for status post kidney transplant due to polycystic kidney disease is warranted. 38 C.F.R. §§ 3.102, 4.115a. The highest rating of 100 percent is not warranted since the Veteran is not on regular dialysis; since the Veteran is ambulatory; since BUN is less than 80mg% and creatinine is less than 8mg%; and since there is no report of a marked decrease in kidney or other organ system function. In accordance with Hart v. Mansfield, the Board has considered whether a staged rating is appropriate. However, in the present case, the Veteran's symptoms remained constant throughout the course of the period on appeal and as such staged ratings are not warranted. The assignment of an extra-schedular rating was duly considered under 38 C.F.R. § 3.321(b)(1); however, VA regulations mandate that any post transplant kidney residuals be evaluated under the schedular provisions of 38 C.F.R. § 4.115a. Referral by the RO to the Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is thus not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). Special monthly compensation In a rating decision dated in November 2003 the Veteran was granted special monthly compensation on account of being housebound effective May 8, 2003. In a rating decision dated in March 2005 the RO reduced the rating decision for the Veteran's service-connected kidney transplant disability from 100 percent to 60 percent, which in turn ended the Veteran's eligibility for special monthly compensation. The Veteran's special monthly compensation was accordingly terminated effective June 1, 2005. The Veteran has appealed. Special monthly compensation is payable to a Veteran who is, as a result of his service-connected disabilities, so helpless as to need or require the regular aid and attendance of another person. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b)(3). A Veteran will be considered in need of regular aid and attendance if he or she: (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to five degrees or less; (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.351(c). The following criteria will be considered in determining whether the Veteran is in need of the regular aid and attendance of another person: the inability of the Veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without such aid; the inability of the Veteran to feed himself through the loss of coordination of upper extremities or through extreme weakness; the inability to attend to the wants of nature; or an incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). In Turco v. Brown, 9 Vet. App. 222 (1996), the Court held that it was not required that all of the disabling conditions enumerated in the provisions of 38 C.F.R. § 3.352(a) be found to exist to establish eligibility for aid and attendance and that such eligibility required at least one of the enumerated factors be present. The Court added that the particular personal function which the Veteran was unable to perform should be considered in connection with his or her condition as a whole and that it was only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. In this case, no medical evidence indicates that the Veteran is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to five degrees or less; or that he is a patient in a nursing home because of mental or physical incapacity. In fact, the Veteran testified during his August 2005 hearing that he drives, and treatment records dated in September 2005 inform of 20/30 vision bilaterally. The Veteran also testified that he lives in his home with his wife. It thus appears that the Veteran's claim is based solely on a factual need for aid and attendance of another person under the criteria set forth in 38 C.F.R. § 3.352(a). Unfortunately, these criteria have not been met. The Veteran's service-connected disabilities are as follows: * gouty arthritis, multiple joints associated with status post kidney transplant due to polycystic kidney disease, rated as 60 percent disabling; * status post kidney transplant due to polycystic kidney disease associated with diabetes mellitus, now rated as 80 percent disabling; * cataracts associated with diabetes mellitus, rated as 30 percent disabling; * diabetes mellitus, rated as 20 percent disabling; * dysthymic disorder with generalized anxiety disorder associated with status post kidney transplant due to polycystic kidney disease, rated as 10 percent disabling; * peripheral neuropathy, right upper extremity, associated with diabetes mellitus, rated as 10 percent disabling; * peripheral neuropathy, left upper extremity, associated with diabetes mellitus, rated as 10 percent disabling; * peripheral neuropathy, left lower extremity, associated with diabetes mellitus, rated as 10 percent disabling; * peripheral neuropathy, right lower extremity, associated with diabetes mellitus, rated as 10 percent disabling; * degenerative joint disease, bilateral knees and wrists, associated with status post kidney transplant due to polycystic kidney disease, rated as 10 percent disabling; * degenerative joint disease, lumbar spine, associated with status post kidney transplant due to polycystic kidney disease, rated as 10 percent disabling; * residuals, pilonidal cyst, rated as 0 percent disabling; fatty infiltrate of liver associated with diabetes mellitus, rated as 0 percent disabling; * peripheral vascular disease, left lower extremity, associated with diabetes mellitus, rated as 0 percent disabling; * peripheral vascular disease, right lower extremity, associated with diabetes mellitus, rated as 0 percent disabling; * herpes zoster (claimed as shingles and zoster outbreaks), associated with status post kidney transplant due to polycystic kidney disease, rated as 0 percent disabling; and * actinic keratosis associated with diabetes mellitus, rated as 0 percent disabling. None of these service-connected disabilities warrants a finding that the Veteran required the aid and attendance of another person. According to the Veteran, he arises each morning and fixes his breakfast. He also drives to the store and goes grocery shopping; drives himself and his wife to their doctor appointments (his wife testified that she does not drive); drives himself to church; and visits with nearby relatives in their homes. Treatment records dated in August 2005 describe him as ambulatory and unaccompanied. The 2005 VA joints examiner informs that while he is unable to stand for more than a few minutes and unable to walk more than a few yard, he walks with only "one cane." According to the 2005 C&P spine examiner, activities of daily living were affected as follows: TRAVELING: moderate CHORES: moderate FEEDING: none SHOPPING: moderate BATHING: moderate EXERCISE: moderate DRESSING: moderate SPORTS: prevents TOILETING: mild RECREATION moderate GROOMING: none Based on this evidence the Veteran is not limited in any activity except sports. Of particular relevance, there is no evidence which shows that any of the Veteran's service- connected disabilities prevented him from dressing or undressing himself, keeping himself ordinarily clean and presentable; frequently needing adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without such aid; feeding himself through the loss of coordination of upper extremities or through extreme weakness; and attending to the wants of nature. There is also no evidence of incapacity, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment, as a result of his service-connected disabilities. In that regard the Board notes the May 2005's comments that the Veteran "has generalized poor health with impressive lethargy weakness and limitation of motion, and is unable to care for himself," however, the examiner went on to state "except for dressing and his activities of daily living and occasionally helps with a meal." Based on this evidence alone there is no indication that the Veteran is so helpless as to need regular aid and attendance as contemplated by VA regulations. If a veteran does not qualify for increased benefits for aid and attendance, increased compensation benefits may still be payable if he has a single permanent disability rated 100 percent disabling, and has either additional service- connected disability or disabilities independently ratable at 60 percent or more, or is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.351(d). In addition, a wartime veteran may be awarded a special monthly pension if, in addition to being at least 65 years old, he possesses a minimum disability rating of 60 percent or is considered permanently housebound as defined under statute. Hartness v. Nicholson, 20 Vet. App. 216 (2006). A veteran is "permanently housebound" when he is substantially confined to his house (ward or clinical areas, if institutionalized) or immediate premises due to service- connected permanent disability or disabilities. 38 C.F.R. § 3.350(i)(2). In this case the Veteran (born in the year 1947), has not attained the age of 65, and he does not have a single service- connected disability rated as 100 percent disabling. There is also no medical evidence that he is "permanently housebound" by reason of his service-connected disabilities. 38 C.F.R. § 3.351(d). Indeed, in April 2005 the Veteran wrote that he would be attending a weeklong family reunion in another state. What's more, during his August 2005 hearing he and his wife testified that the Veteran drives about on errands and to church. In addition, medical records dated in 2005 document the Veteran as ambulatory and unaccompanied, and there is no medical evidence which suggests that the Veteran is housebound. In this regard the Board notes that while the Veteran has been described by VA physicians as "unemployable," and while the May 2005 VA examiner opines that the Veteran functioning is limited to dressing himself, activities of daily living, and occasional cooking, by the Veteran's own words he is clearly mobile and engages in business and recreational activities beyond the immediate premises of his house. In sum, the Veteran is not blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to five degrees or less. He also is not a patient in a nursing home because of mental or physical incapacity; is not 65 years old; does not have a single permanent disability rated as 100 percent disabling; does not require the regular aid and attendance of another person, and is clearly not housebound. Accordingly, his claim of entitlement to special monthly compensation must be denied. Duty to Notify and Assist 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, 5106, 5107, 5126 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2008). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information and 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) (2008); 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. VCAA notice should be provided to the claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). Notice which informs the Veteran of how VA determines disability ratings and effective dates should also be provided. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a recently issued decision the Court also held that with regard to claims for increased-compensation, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement as well. Id. In a letter dated in May 2003 the Veteran was apprised of the evidence necessary to establish entitlement to special monthly compensation. In a letter dated in August 2005 the Veteran was notified of the information and evidence necessary for a higher rating for his kidney transplant disability. Although the letter does not satisfy the criteria set forth in Vazquez, the Board notes that the Veteran has written at length regarding his disability and testified in an RO hearing as to why he feels that a higher rating for his kidney transplant disability is warranted; and this evidence was considered by the Board in its increase of the Veteran's rating for his service-connected kidney transplant disability from 60 percent to 80 percent. The Board further notes that during the August 2005 hearing the Decision Review Officer informed the Veteran of the criteria necessary for a rating in excess of 60 percent, and the Veteran testified that he understood this information. In addition, the Veteran was provided with the applicable rating criteria in the July 2006 statement of the case. Moreover, the Veteran has been zealously represented by a Veterans' service organization throughout the appeal period. Based on the various communications from VA with respect to the applicable criteria and the types of information and evidence that the Veteran could submit to VA; as well as the various communications between the Veteran and the Veteran's representative and VA, the Veteran is reasonably expected to understand the types of evidence that would support his claims for a higher rating. Regarding the duty to assist, VA treatment records have been associated with the claims file. The Veteran has also been accorded numerous VA examinations; the reports of which are of record. He (and his wife) also testified at length during a local RO hearing; the transcript of which is of record. There is no indication in the record that additional evidence relevant to the issue decided herein is available and not part of the claims file. The Board is satisfied that VA has sufficiently discharged its duty in this matter. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER The March 2005 reduction in rating of the Veteran's service- connected kidney transplant disability was properly executed. A disability rating of 80 percent beginning June 1, 2005, for status post kidney transplant due to polycystic kidney disease is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to special monthly compensation after June 1, 2005, is denied. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs