Citation Nr: 1335913 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 07-31 821 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for a disorder manifested by paraplegia. 2. Entitlement to special monthly compensation (SMC) due to the need for the aid and attendance of another person or on the basis of being housebound. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARINGS ON APPEAL The Veteran and E. M. ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to November 1970. He had service in the Republic of Vietnam, where his decorations included the Silver Star medal and two awards of the Purple Heart medal. This case has been before the Board of Veterans' Appeals (Board) in April 2011 and February 2013. Each time, it was remanded for further development to the VA Appeals Management Center (AMC) in Washington, D.C. The Board directed the AMC to 1) obtain the Veteran's Social Security records; 2) ask the Veteran for additional information which would allow the AMC to obtain evidence in support of his claims; and 3) examine the veteran to determine the nature and etiology of any neurologic disorder found to be present. Following the requested development, the AMC confirmed and continued the RO's denials of entitlement to compensation under 38 U.S.C.A. § 1151 for paraplegia and entitlement to SMC due to the need for the aid and attendance of another person or on the basis of being housebound. Thereafter, the case was returned to the Board for further appellate action. In February 2010, during the course of the appeal, the Veteran had a hearing before the Veterans Law Judge whose signature appears at the end of this decision. FINDINGS OF FACT 1. The preponderance of the competent evidence of record shows that the Veteran does not have additional disability, claimed as paraplegia, as the result of VA medical treatment. 2. Service connection is in effect for the following disorders: posttraumatic stress disorder (PTSD), evaluated as 70 percent disabling; the residuals of a shell fragment wound of the left thigh, evaluated as 20 percent disabling; tinnitus, evaluated as 10 percent disabling; and a bilateral hearing loss disability, evaluated as noncompensable. 3. The Veteran's service-connected disabilities, by themselves, do not render him unable to care for his daily needs or to protect himself from the hazards of his environment, such that he requires the regular aid and attendance of another person. 4. The Veteran does not have a single disability evaluated as 100 percent disabling. CONCLUSIONS OF LAW 1. The criteria have not been met for compensation for a neurologic disorder, claimed as paraplegia, pursuant to 38 U.S.C.A. § 1151. 38 U.S.C.A. §§ 1151, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.159, 3.361 (2013). 2. The criteria have not been met for SMC based on the need for the regular aid and attendance of another person or on the basis of being housebound. 38 U.S.C.A. § 1114, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.350, 3.351, 3.352 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Prior to consideration of the merits of the Veteran's appeal, the Board must determine whether VA has met its statutory duty to assist him in the development of the issues of entitlement to a disorder, manifested by paraplegia, pursuant to 38 U.S.C.A. § 1151 and entitlement to SMC. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. After reviewing the record, the Board finds that VA has met that duty. In September 2004, VA received the Veteran's claims, and there is no issue as to providing an appropriate application form or completeness of the applications. Following the receipt of those applications, VA notified the Veteran of the information and evidence necessary to substantiate and complete his claims, including the evidence to be provided by him, and notice of the evidence VA would attempt to obtain. VA informed him of the criteria for entitlement to compensation under 38 U.S.C.A. § 1151 for a disorder manifested by paraplegia and entitlement to SMC. 38 U.S.C.A. § 5103(a). Following the notice to the Veteran, VA fulfilled its duty to assist him in obtaining identified and available evidence necessary to substantiate his claims. VA obtained or ensured the presence of the Veteran's service treatment records; records reflecting his VA treatment from September 1995 through August 2007; his Social Security records; statements from D. M. and E. M., dated in February and March 2006, respectively; the transcript of the Veteran's May 2007 hearing before a VA Decision Review Officer; statements from A. M. K., M.D., dated in January and April 2008; and the transcript of the Veteran's February 2010 hearing before the undersigned Veterans Law Judge. The February 2010 hearing transcript shows the presiding Veterans Law Judge conducted the proceeding in accordance with the mandates of 38 C.F.R. § 3.103(c)(2) insofar as 1) explaining fully the issue and 2) suggesting the submission of evidence that the claimant may have overlooked and that would be advantageous to his position. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Specifically, the transcript of the hearing shows the presiding Veterans Law Judge identified the material issues, accepted additional evidence from the Veteran, gave the Veteran's representative an opportunity to question the Veteran and his witness, questioned the Veteran and his witness himself, made sure that all potential evidence had been identified, and at the end of the hearing asked the Veteran if he had anything to add. For these reasons, there was no prejudice to the Veteran's claim as a result of the conduct of his hearing. See Bryant, 23 Vet. App. at 498 (citing to 38 U.S.C. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). In September 1995, May 1997, February 2000, April 2002, August 2005, and April 2006, the VA examined the Veteran, in part, to determine the nature and etiology of the residuals of cervical spine surgery in August 2004 and whether or not the Veteran was housebound or required the regular aid and attendance of another person due to his service-connected disabilities. In June 2013, a VA examiner also reviewed the Veteran's claims file and the medical literature and rendered an opinion with respect to the foregoing questions. The VA examination reports show, generally, that the examiners reviewed the Veteran's medical history, interviewed and examined the Veteran, documented his medical conditions, and rendered diagnoses and opinions consistent with the remainder of the evidence of record. Therefore, the Board concludes that the VA examinations are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2009); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In sum, the Veteran has been afforded a meaningful opportunity to participate in the development of his appeal. He has not identified any outstanding evidence which could support either of his claims; and there is no evidence of any VA error in notifying or assisting the Veteran that could result in prejudice to him or that could otherwise affect the essential fairness of the adjudication. Accordingly, the Board will proceed to the merits of the appeal. The 1151 Claim VA compensation shall be awarded for a qualifying additional disability in the same manner as if such additional disability were service- connected. For purposes of this section, a disability is a qualifying additional disability if the disability or death was not the result of the veteran's willful misconduct and (1) the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by VA and the proximate cause of the disability was (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (B) an event not reasonably foreseeable. 38 U.S.C.A. § 1151. In determining whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran's additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. Whether the proximate cause of a veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). Schertz v. Shinseki, No. 11-2694 (USCAVC Sept. 26, 2013) (merely because a treating physician, expert, or other health care provider actually foresaw certain risks does not mean that a reasonable health care provider with primary care for the patient would have disclosed these risks. The standard is not actual foreseeability or possible foreseeability, but that the test is driven wholly by how a "reasonable health care provider" would behave if asked to perform a certain procedure on a veteran with the same characteristics as the veteran in a given case.) Generally, all patient care furnished by VA shall be carried out only with the full and informed consent of the patient or, in appropriate cases, a representative thereof. In order to give informed consent, the patient must have decision- making capacity and be able to communicate decisions concerning health care. 38 C.F.R. § 17.32(b). The informed consent process must be appropriately documented in the medical record. 38 C.F.R. § 17.32(d). Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). During the Veteran's February 2010 hearing, the Veteran and E. M. testified that in August 2004, he underwent cervical spine surgery at the Houston VA Medical Center to determine the nature of a lesion at C3-C4. They noted that it was unclear whether the surgery was even necessary and that it left the Veteran with additional disability, manifested by paraplegia and bowel and bladder incontinence. Therefore, they maintained that compensation was warranted for those manifestations, pursuant to 38 U.S.C.A. § 1151. In September 2012, the Veteran reported that at the time he made his decision to have a surgery and biopsy in August 2004, he had not had all the information that had been available to the surgeon and his treating physician. He stated that he was unaware that the physicians were uncertain as to the value of the procedure. He further stated that he had been unaware that a 2003 cervical spine laminectomy made it riskier to perform the August 2004 surgery and biopsy. He noted that had he been aware of the risk, he would not have agreed to the surgery. In addition, he suggested that the surgeon had pressured him to have the surgery as the only way to determine the nature and etiology of his cervical cord lesion. He stated that in view of the doubt and risks surrounding the procedure, it was careless, if not negligent of VA, to proceed. For the foregoing reasons, the Veteran maintains that pursuant to 38 U.S.C.A. § 1151, compensation is warranted for the residuals of his August 2004 surgery and biopsy. However, after carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against that claim. Accordingly, the appeal with respect to that issue will be denied. A review of the evidence, such as a report of the Veteran's VA hospitalization from August to October 2004 and the report of the January 2013 VA physician's opinion shows that in 1995, the Veteran was involved in an all-terrain vehicle accident. Thereafter, he began to experience weakness in his left hand, as well as, progressive lower extremity weakness and spasticity. In 1998, he went to a private physician who diagnosed multiple sclerosis, a disorder for which he was granted Social Security disability benefits. In 2002, he was involved in a motor vehicle accident during which he experienced a brief period of quadriplegia. An MRI revealed a stenotic cervical canal, and in March 2003, the Veteran underwent a decompressive laminectomy from C3 to C5. After about two months of improvement, he began to reexperience weakness and spasticity in his upper and lower extremities and bowel and bladder problems, manifested by constipation and urgency and frequency. Workups by the VA Neurology service showed a medullary lesion in the area of C3-C4. It's nature and etiology were unclear; so in August 2004, at the Houston VA Medical Center (MC), the Veteran underwent a surgical biopsy to clarify the nature of the lesion, neoplastic versus myelitis/a residual of old trauma. The biopsy revealed axonal spheroids, Rosenthal fibers, and mild gliosis. Further workup was negative for any findings of multiple sclerosis, and at the Veteran's October 2004 hospital discharge, the diagnosis was T1 ASIA (American Spinal Injury Association) D paraplegia (incomplete spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of three or more). Since his discharge from the hospital, the Veteran has continued to report increasing weakness and numbness in his upper and lower extremities, as well as difficulty ambulating, spasticity, and bowel and bladder problems. In January and April 2008, following an examination and review of the Veteran's records, A. M. K., M.D., the Veteran's treating neurologist, acknowledged that the recent evidence did not show a definitive diagnosis. However, he found the additional neurologic deficits, including numbness and quadriparesis with loss of bowel and bladder function, secondary to cervical myelopathy of unknown etiology. He opined that such manifestations were precipitated by the August 2004 surgery and biopsy of the Veteran's cervical lesion. In considering Dr. K's opinion, the Board notes that VA treatment records dated in February and May 2004, an August 2, 2004 report from a VA physician, and an August 19, 2004 report of an Aid and Attendance examination, show that the Veteran he had a long history of progressive cervical myelopathy with lower extremity weakness and bowel and bladder problems manifested by constipation and straining at the stool, as well as a neurogenic bowel and bladder. Following a period of VA hospitalization in February 2004, his diagnosis was cervical myelopathy of unknown etiology. The VA treatment records the day before the Veteran's August 2004 surgery show that he was so severely myelopathic that he was unable to perform simple motor tasks with his hands, that he was scooter bound, and that he had difficulty voiding. On admission to the hospital in July 2004, the diagnosis was T1 ASIA D paraplegia. In October 2004; at the time of his discharge, the diagnosis was also T1 ASIA D paraplegia due to cervical myelopathy, etiology unknown. In addition, it was noted that he had a neurogenic bowel and bladder, spasticity, and neuropathic pain. Such evidence strongly suggests that the that the symptoms the Veteran experienced following his discharge from the hospital were in place prior to his August 2004 VA surgery and biopsy. The salient question then is whether those symptoms worsened as a result of the surgery and biopsy. In April 2006, a board-certified VA neurosurgeon examined the Veteran to determine the nature and etiology of any neurologic disorder found to be present; and in June 2013, the VA neurosurgeon, again, reviewed the Veteran's claims file to determine whether the Veteran had sustained additional disability as a result of his August 2004 surgery and biopsy. Following the examination and subsequent review, the VA physician opined that it was less likely than not that the Veteran's manifestations were due to the biopsy and surgery. The physician felt that at the time of the Veteran's admission to the hospital in July 2004, the Veteran was already suffering from a progressive neurologic disorder. Unlike Dr. K., he provided substantial rationale for his opinions and cited multiple treatment records showing that the current manifestations had been present prior to the surgery. The April 2006 examiner noted that the Veteran had some additional sensory deficits and bowel and bladder incontinence which could possibly be the result of the surgery. However, he noted that prior to the surgery, the Veteran was having some urinary frequency and a decreased force of stream. He stated that the increased neurologic deficits were not outside those outlined in the consent form nor were those outside those which could be encountered given appropriate surgical care and technical intervention. He further noted that there did not appear to be any gross errors in the decision to operate or in the procedure itself. The April 2006 examiner stated that the additional manifestations appeared to be known complications of the procedure. In June 2013, following his review of the Veteran's claims file, the VA neurosurgeon noted that since 1998, the Veteran had had a known enhancing cervical cord lesion. He cited a February 2004 report of consultation with the VA Neurology Service which showed that the Veteran had experienced spastic paraparesis and later quadriparesis which was exacerbated by a December 2002 neck injury. Therefore, the VA neurosurgeon concluded that the paraparesis and quadriparesis had existed prior to the August 2004 surgery and biopsy. He noted that such manifestations were progressive in nature before the surgery and that the progression likely continued after the surgery. The VA neurosurgeon stated that had the changes been due to the surgery, they would have more likely than not been shown during the acute postoperative period. He noted that the evidence was negative in that regard and opined that it was less likely than not that the changes cited by Dr. K. represented additional disability resulting from the August 2004 surgery. Even if the changes cites by Dr. K. had constituted additional disability, the VA neurosurgeon opined that it was less likely than not that they were caused by VA carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA with respect to the August 2004 surgery and biopsy. The VA neurosurgeon acknowledged Dr. K.'s concerns as to why VA chose to proceed and recognized VA discussion prior to surgery that it might not yield a diagnosis to affect therapy. However, he noted that such a question was best answered by the physician who performs the surgery. In this case, the decision to proceed was made after much review and discussion by three participating neurosurgeons, including two attending neurosurgeons from Baylor University. It was felt that because of the Veteran's progressive symptoms, likely pathology that the cervical lesion was a low grade neoplasm, and current lack of diagnosis, it was not an careless, negligent, or error in judgment to proceed. In addition, the VA neurosurgeon noted that the surgical report showed the difficulty in approaching the lesion because of the previous laminectomies and the consequent care taken in the approach. Moreover, the VA neurosurgeon stated that the surgical report was negative for any intraoperative complications. Indeed, the surgical report noted that the Veteran tolerated the procedure well. Finally, the VA neurosurgeon considered whether the Veteran's post-operative manifestations noted by Dr. K. were the result of an unforeseeable event. In this regard, it was noted that prior to the surgery, the Veteran had been well aware of the possible complications of the surgery. On July 30, 2004, he signed a consent form which informed him that he would be undergoing a cervical myelotomy, biopsy of a surgical cord lesion, possible resection of the lesion, and possible laminectomy of the cervical vertebrae. He and the surgeon discussed the relevant aspects of the treatment/procedure in language the Veteran could understand, discussed the indications and benefits of the procedure, and discussed alternatives including not performing the treatment/procedure. The Veteran was given an opportunity to ask questions and to indicate that he understood the discussion. The surgeon and the Veteran also discussed the potential risks and complications of the procedure, including bleeding, infection, pain, a spinal cord injury, spinal instability, paresthesias, numbness, a cervical spinal fluid leak, dependence on a ventilator, paralysis, quadriplegia, death, a failure to diagnose the problem, and the need for further procedures. The Veteran consented to the treatment/procedure without threat, distress, deceit, or coercion. The Veteran stated that he had no further questions and requested that VA proceed with the surgery. The Veteran contends that had he known that a cervical spine laminectomy which had been performed in 2003 increased the riskiness of the procedure, he would have declined to proceed. However, on August 2, 2004, the pre-operative note stated that the Veteran had previous laminectomies from C3 to C5, making surgery riskier than in an unoperated spine. In the next sentence, it was noted that the risks and benefits of the procedure were explained in detail to the Veteran and his wife. This strongly suggests that the risk posed by the prior laminectomies was explained to the Veteran. Later, in the note, the Veteran and his wife affirmed that they clearly understood the nature of the procedure, as well as the risks and alternatives set forth in the consent form. They had their questions answered, reportedly to their satisfaction, and understood that no guarantees could be made as to the outcome of the procedure. They reportedly understood that it was unlikely that the cervical lesion would be excised completely or that the Veteran would improve neurologically following the surgery. Furthermore, the Veteran and his wife understood that even if an exact diagnosis was made, the pathology might not be treatable and that the nature of the Veteran's symptoms could progress as before. For these reasons, the VA neurosurgeon concluded that it was less likely than not that the Veteran's manifestations following his August 2004 surgery and biopsy were the result of an unforeseeable event. The Board finds no evidence that a reasonable health care provider would not have foreseen the risks. In fact, the consent form shows that not only were the risks explained to the Veteran by the physicians caring for him, they were explained in language that a layman could understand. Schertz. In light of the foregoing discussion, the Board finds that the preponderance of the competent evidence of record is against a finding that the Veteran developed additional disability as a result of his VA surgery and biopsy on August 3, 2004. The Board finds the April 2006 and June 2013 opinions of the VA neurosurgeon to be more probative than that of Dr. K. Although both physicians are specialists in neurology or neurosurgery and both reviewed the Veteran's records, the reports from the VA neurosurgeon provide a detailed rationale and citation to medical literature, thus rendering his opinions more full and complete than those of Dr. K. Moreover, the Board finds that the Veteran decided to proceed with the surgery, after the VA physicians who performed the surgery had substantially complied with their duty to inform him and E. M. of the possible benefits and risks of the surgery including the residual problems he currently experiences. Therefore, the Board concludes that the manifestations currently experienced by the Veteran are not the result of fault on the part of the VA. As such, he does not meet the criteria for compensation pursuant to 38 U.S.C.A. § 1151. Accordingly, compensation is not warranted, and that portion of the appeal is denied. SMC SMC is payable where a veteran has service-connected disabilities that render him so helpless as to be in need of the regular aid and attendance of another person. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). The veteran will be considered in need of regular aid and attendance if he 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 5 degrees or less; or 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). A veteran shall be considered to be in need of regular aid and attendance, if he is bedridden or establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). Determinations as to the need for aid and attendance are based on the actual requirements of personal assistance from others. In determining the need for regular aid and attendance, consideration is given to the inability of the Veteran to dress or undress himself, or to keep himself clean; the frequent need of adjustment of any prosthetic which by reason of the disability cannot be done without aid; the Veteran's inability to feed himself; his inability to attend to the wants of nature; or physical or mental incapacity, which requires care or assistance on a regular basis to protect him from the hazards or dangers of his daily environment. Bedridden will be that condition which, through its essential character, actually requires that the Veteran remain in bed. 38 C.F.R. § 3.352(a) . SMC is also payable where the veteran has a single service-connected disability rated as 100 percent and is permanently housebound by reason of his service-connected disability or disabilities. This requirement is met when the veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). During his February 2010 hearing, the Veteran and E. M. testified that his service-connected disabilities, by themselves, were so severe that they rendered him unable perform his daily activities without the regular aid and attendance of another person. He also testified that those disorders effectively caused him to remain housebound. Therefore, he maintained that he was entitled to SMC. Again, however, after carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against that claim. Accordingly, that appeal will also be denied. Service connection is in effect for the following disorders: posttraumatic stress disorder, evaluated as 70 percent disabling; the residuals of a shell fragment wound of the left thigh, evaluated as 20 percent disabling; tinnitus, evaluated as 10 percent disabling; and a bilateral hearing loss disability, evaluated as noncompensable. Although he also has a total rating due to individual unemployability (TDIU) caused by his service-connected disabilities, he does not have a single disability evaluated at 100 percent or more, and thus, does not meet the criteria for SMC on the basis of being housebound. Moreover, evidence such as the Veteran's Social Security records, the Veteran's VA treatment records do not show that the Veteran requires the regular aid and attendance of another person due to his service-connected disabilities. Rather, statements from the Veteran, E. M., and D. M., the transcripts of the Veteran's hearings, and the reports of August 2004 VA aid and attendance examinations/evaluations, show that the Veteran requires aid and attendance of another person due to the neurologic disorder, manifested primarily by paraplegia affecting his upper and lower extremities. Although variously diagnosed as multiple sclerosis and T1 ASIA D paraplegia, due to cervical myelopathy, a definitive diagnosis has not been confirmed. In any event, the Veteran does not receive compensation for that disability, either as a result of service connection or, as noted above, the result of additional disability pursuant to 38 U.S.C.A. § 1151. Therefore, the Veteran does not meet the criteria for a grant of SMC on the basis of the need for the regular aid and attendance of another person. Accordingly, SMC is not warranted, and the appeal is denied. Additional Considerations In arriving at the foregoing decisions, the Board has considered the doctrine of reasonable doubt. However, that doctrine is only invoked where there is an approximate balance of evidence which neither proves nor disproves a claim. In this case, however, the preponderance of the evidence is against the Veteran's claims. Therefore, the doctrine of reasonable doubt is not applicable. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013). ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 is denied for a disorder manifested by paraplegia. Entitlement to SMC due to the need for the aid and attendance of another person or on the basis of being housebound is denied. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs