Citation Nr: 1337379 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 07-02 366 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a liver disorder. 2. Entitlement to service connection for residuals of a groin muscle injury. 3. Entitlement to an increased initial rating for right median nerve, currently rated as 10 percent disabling. 4. Entitlement to an increased initial rating for left median nerve, currently rated as 10 percent disabling. 5. Entitlement to an increased rating for cervical spine disability, currently rated as 50 percent disabling. 6. Entitlement to adaptive automobile or other adaptive equipment. 7. Entitlement to specially adapted housing. 8. Entitlement to a special home adaptation grant. 9. Entitlement to special monthly compensation (SMC) based upon the need for aid and attendance and/or homebound status. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran served on active duty from August 1977 to March 1983. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In June 2007, the Veteran testified before the undersigned Veterans Law Judge Harvey P. Roberts at a Travel Board hearing held at the RO. The hearing transcript is associated with the record. In December 2007, and again in August 2010, the Board remanded the appeal, for additional development and/or RO review, and to afford the Veteran an additional requested hearing before a Veterans Law Judge at the Board. In April 2011, the Veteran was afforded that another Travel Board hearing before the undersigned Veterans Law Judge J. A. Markey. The hearing transcript is associated with the record. As the Veteran had now provided testimony for the issues on appeal to two different Veterans Law Judges, the appeal became subject to a Board panel after the second hearing. Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011); 38 C.F.R. §§ 19.3, 20.707. In June 2012, the Board panel remanded the issues currently on appeal for additional development. Based upon this development, the RO granted service connection for a lumbar spine disability in May 2013. As such rating action is a full grant of the benefit sought, this issue is no longer before the Board. The additional issues subject to the June 2012 Board panel remand have returned to the Board. The Veteran has changed representatives on several occasions throughout the pendency of the appeal. Initially, he was represented by the Disabled American Veterans. Effective January 12, 2006, Paralyzed Veterans of America assumed representation. On December 3, 2009, he changed his representative to Stetson University, College of Law, Veterans' Appellate Rights Clinic. Beginning February 1, 2012, he appointed The American Legion as his representative. They are recognized as the current representative. Review of the Virtual VA paperless claims processing system shows that updated VA treatment records are associated with the Veteran's electronic folder (efolder). The RO considered these updated VA treatment records in the May 2013 supplemental statement of the case (SSOC). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran has not demonstrated a current liver disorder at anytime during the claims period. 2. The Veteran has not demonstrated a current groin strain residual at anytime during the claims period. 3. Median nerve disability of each upper extremity is manifested by, at most, moderate incomplete paralysis of the median nerve, with subjective complaints of sensory impairment, clinical evidence of 4/5 motor strength and hyper-reflexes, but without tropic changes, muscle atrophy, or paralysis. 4. The Veteran's neck disability has not been characterized by ankylosis or incapacitating episodes or any associated neurologic impairment other than the separately rated myelopathy of each extremity. 5. The Veteran is currently service connected for the following disabilities: cerebral concussion with headaches, rated 70 percent; adjustment disorder, rated 50 percent; neck disability, rated 50 percent; right upper extremity neuropathy, rated as 30 percent; left upper extremity neuropathy, rated as 20 percent; lumbar back disability, rated 20 percent; myelopathy of lower extremities, rated 20 percent each; cataracts, rated 20 percent; neck scar, rated 10 percent; functional asplenia, rated 10 percent; glaucoma, rated 10 percent; renal insufficiency, anemia, adrenal insufficiency, hypertension, erectile dysfunction, and diabetes mellitus, Type II all rated noncompensable. He has a total combined rating. 6. Resolving reasonable doubt in the Veteran's favor, the Veteran has permanent and total service-connected disabilities that effectively result in the permanent loss of use of the feet and so affects the functions of balance or propulsion as to preclude locomotion without the aid of a cane, scooter, or wheelchair. 7. The Veteran filed a formal claim for special monthly compensation on September 2, 2005 and an informal claim for special month compensation on July 20, 2005. 8. Beginning July 20, 2005, the Veteran's service connected disabilities rendered him unable to care for his daily personal needs or protect himself from the hazards and dangers of daily living without care or assistance on a regular basis. 9. Prior to July 20, 2005, the evidence does not suggest that the Veteran had a factually ascertainable increase in any service connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a liver disorder are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection for a groin strain are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 3.303 (2013). 3. The criteria for a 30 percent rating, but no higher, for right upper extremity median nerve impairment are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.124a, Diagnostic Code 8515 (2013). 4. The criteria for a 20 percent rating, but no higher, for left upper extremity median nerve impairment are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.124a, Diagnostic Code 8515 (2013). 5. The criteria for a disability rating in excess of 50 percent for the manifestations of a cervical spine disability have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.71a, Diagnostic Code 5235 (2013). 6. The criteria for entitlement to a certificate of eligibility for purchase of automobile or adaptive equipment only have been met. 38 U.S.C.A. §§ 3901, 3902, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.808 (2013). 7. The criteria for eligibility for specially adapted housing have been met. 38 U.S.C.A. §§ 2101(a), (b), 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.809, 3.809a (2013). 8. The criteria for an effective date of July 20, 2005, but no earlier, for special monthly compensation based upon the need for regular aid and attendance have been met. 38 U.S.C.A. §§ 1114(l), 5107(b), 5110(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.400(o), 3.350, 3.352 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The Board grants certificates of eligibility for adaptive automobile and specially adapted housing. This constitutes a complete grant of these benefits sought on appeal and further discussion of VCAA with respect to these claims is not necessary. 38 C.F.R. § 3.159(d). 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 any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. 38 C.F.R. § 3.159(b)(1) (2013). The Veteran was notified about the information and evidence necessary to substantiate his service connection claims in the October 2005 and April 2006 notice letters. In May 2007, he was provided notice about the information and evidence necessary to substantiate his increased rating claim for his cervical spine disability. The May 2007 letter provided general notice of the evidence required to satisfy the increased rating claims for bilateral median nerve disorder. This is sufficient notice in an increased rating claim because the type of VCAA notice required to address rating claims is general notice of ratings for disabilities, not specific notice of all potentially applicable rating criteria. Dingess v. Nicholson, 19 Vet. App. 473 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the May 2007 letter included notification about how VA determines disability ratings and effective dates for ratings, which also satisfies the notification requirements for the earlier effective date claim. Id. Regarding the SMC claim, this claim has been substantiated. The appeal pertains to an earlier effective date, which is a downstream issue from the original grant. Additional notification is not necessary. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). To the extent of any notification deficiency, the U.S. Supreme Court has held that an error in VCAA notice should not be presumed prejudicial, and that the burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, the Veteran has not demonstrated any prejudicial or harmful error in VCAA notice and the Board has not identified any. A remand for notification about how to substantiate the claims is not necessary. The Veteran had June 2007 and April 2011 hearings by different Veterans Law Judges for the issues on appeal. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2013) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the two Board hearings conducted in this case, the Veterans Law Judges outlined the issues on appeal and suggested that any evidence tending to support the claims that had not yet been submitted should be, which necessarily includes evidence of greater severity of the Veteran's bilateral median nerve and neck disabilities. The judges' pre-hearing discussions with the Veteran and his authorized representative frequently address these issues - including particularly advice concerning the submission of additional evidence - to the extent they may not be fully discussed during the transcribed, testimonial portion of the hearing. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. In addition, VA law requires that the Veterans Law Judge (VLJ) who conducts a hearing on an appeal must participate in any decision made on that appeal. 38 U.S.C. § 7107(c) (West 2002); 38 C.F.R. § 20.707 (2013). When two hearings have been held by different VLJs concerning the same issue or issues, the law also requires that the Board assign a third VLJ to decide that issue or issues because a proceeding before the Board must be assigned either to an individual VLJ "or to a panel of not less than three members of the Board." 38 U.S.C. § 7102(a) (West 2002); 38 C.F.R. § 19.3 (2013). In Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011), the Court held that under § 20.707, a claimant must be afforded an opportunity for a hearing before all the Board members who will ultimately decide his appeal. Thus, if the claimant's appeal is assigned to a Board panel, the claimant must be afforded the opportunity for a hearing before every member of the panel that will ultimately decide his case. Id. In August 2011, the Veteran was offered the opportunity to schedule a hearing before a third Veterans Law Judge. He did not request a third hearing. The Arneson requirement is satisfied. The record does otherwise not suggest that any hearing request remains unfulfilled. VA's duty to assist the Veteran in the development of the claims includes assisting him in the procurement of service treatment records (STRs) and pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that the RO appropriately assisted the Veteran in obtaining indicated treatment and evaluation records, including both VA, private, and Social Security Administration (SSA) records. Service records were also associated with the claims file. The RO informed the Veteran, including in the appealed rating action, subsequent rating actions, and by the statement of the case (SOC) and supplemental statement of the case (SSOC), of records obtained, and thus by implication of records not obtained, in furtherance of his claims. It appears that the Veteran's STRs are incomplete. The RO made an additional STR request. In November 2005, the National Personnel Records Center (NPRC) responded that after a thorough search they could not locate any additional STRs and did not have any additional information about their whereabouts. In December 2005, the RO informed the Veteran about the missing portion of the STRs and invited him to submit any STRs in his possession. In April 2006, the RO issued a Formal Finding of Unavailability documenting the search efforts in locating the missing STRs. The Board finds that VA has complied with its duty to assist in searching for these records. 38 C.F.R. § 3.159(c)(2). When service records are missing, the Board has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). However, the case law does not lower the legal standard for proving a claim of service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (wherein the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in government control which would have required VA to disprove a claimant's allegation of injury or disease). VA's duty to assist the Veteran by providing examinations when necessary was also adequately fulfilled. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. He was afforded VA examinations over the course of appeal with the most recent being in February and April 2013. These examinations were appropriately followed by review of the claims by the RO, with the issuance of the May 2013 SSOC. These examinations, taken together with records of VA and service treatment, private records, and the Veteran's written statements and testimony, are adequate for the Board's adjudication. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication that the Veteran service connected disabilities materially increased in severity since the most recent VA examinations. Snuffer v. Gober, 10 Vet. App. 400 (1997). The Veteran has not been afforded a VA examination for his claimed groin disability. As detailed below, the medical and lay evidence does not suggest that the Veteran has a current residual from the in-service groin injury. He even affirmatively conceded that he recovered from the in-service groin injury at the April 2011 hearing. Without evidence of a current disability, a VA examination is not necessary for this claim. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Locklear v. Nicholson, 20 Vet. App. 410 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (discussing the circumstances when a VA examination and opinion are required). The Board also finds that requirements of the Board's prior remands in December 2007, August 2010, and June 2012 have been substantially fulfilled with regard to the claims on appeal. The RO issued a September 2012 letter providing an opportunity for another hearing and requesting the Veteran to submit any additional pertinent information or evidence in his possession. It obtained updated February and April 2013 VA examinations and updated VA treatment records. The RO issued a May 2013 SSOC based upon review of the newly generated evidence. For these reasons, the record is in substantial compliance with the prior remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). D'Aries v. Peake, 22 Vet. App. 97 (2008). In summary, there is no reasonable possibility that additional notification or evidentiary requests would further the appealed claims. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159. All notification and development actions needed to render a decision on the Veteran's claims on appeal have been accomplished. 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, supra. II. Service connection claims Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. However, the continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus."). The claimed disabilities are not shown to be chronic diseases within the meaning of 38 C.F.R. § 3.309(a). Notably, the claimed liver disorder is not shown to result in cirrhosis. For these reasons, the chronic disease presumption is not helpful to the Veteran. Service connection may also be granted 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). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Although a claimant is competent in certain situations to identify a readily observable condition, a lay person is generally not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. Layno v. Brown, 6 Vet. App. 465, 469 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). (i) Liver disorder The Veteran contends that he has a liver disorder related to service. He specifically cites being informed by a nurse that he had an enlarged liver. As explained below, a current liver disability has not been demonstrated, and the claim must be denied. Service treatment records (STRs) do not show the Veteran being treated for any liver problems. On his March 1983 Report of Medical History for separation, the Veteran denied having liver trouble, gallbladder trouble, and jaundice or hepatitis. Accordingly, no hepatological disorder was found upon contemporaneous clinical examination, including urinalysis. As noted, the STRs are incomplete and further search efforts to obtain these missing STRs would be futile. The Board notes that VA has heightened duties when the Veteran's STRs have been destroyed. See O'Hare, 1 Vet. App. at 365. However, the case law does not establish a heightened benefit-of-the-doubt standard, only a heightened duty of the Board to consider applicability of the benefit-of-the-doubt doctrine, to assist the claimant in developing the claim, and to explain its decision. See Cromer, 19 Vet. App. at 215. A VA examination which appears to have been taken in January 1994 reflects that the Veteran was found to have a history of severe alcohol abuse that was currently in remission. At the June 2007 hearing, the Veteran reported that a nurse recently informed him that he had an enlarged liver. He described it as being "malrotated" and argued that it was not congenital because it was only recently observed. A July 2008 VA CT scan showed a midline liver and multiple right-sided splenic moieties. The Veteran had a May 2009 VA spleen examination. He was noted to have injured his spleen in an in-service motor vehicle accident (MVA). The examiner reviewed the July 2008 CT scan. She commented that there were no signs of hepatomegaly. The Veteran was afforded a VA liver examination in February 2013. The examiner determined that the Veteran did not have cirrhosis or hepatitis. Radiograph studies showed cholelithiasis. She conducted pertinent laboratory diagnostic testing. She diagnosed gallstones. In an April 2013 addendum, she carefully reviewed the pertinent clinical history. She noted that liver function testing performed on multiple occasions from 2009 through 2013 was within normal limits, except for a June 2011 inpatient entry which showed slight elevations. She further observed that hepatitis test and imaging studies have been negative. Based upon the clinical evidence, she opined that the Veteran does not currently have liver disease. She noted the July 2008 CT scan showed abnormal liver location, but the above evidence did not show any abnormal liver function or liver disease. The finding of cholelithiasis was part of the gallbladder and not considered a liver disorder. Review of clinical records show that the Veteran has not been diagnosed with liver disease at any time during the appeals period. Although the Veteran is a licensed practical nurse, the question of whether his symptoms and diagnostic testing confirm liver disease is complex. The Board does not consider him competent to diagnose liver disease in this case. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). Any self diagnosis has no probative value. Id. In this case, competent evidence is required to diagnose a liver disorder. By "competent medical evidence" is meant in part that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). Here, the competent evidence includes numerous liver function tests within normal limits and a negative June 2009 hepatitis test. Imaging studies suggested an abnormal liver position; however, as explained by the April 2013 VA examiner these findings were not indicative of an underlying liver disease process. After careful review, he determined that a current liver disability was not demonstrated. In short, the competent evidence weighs against a finding of a current liver disease or disability at anytime during the claims period. See McClain v. Nicholson, 21 Vet. App. 319, 323 (2007). Without competent evidence of a current liver disability, the claim must fail. See id.; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The benefit-of-the-doubt doctrine, even under VA's heightened obligations, is therefore not helpful to the Veteran, and the claim for service connection for liver disease must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57; O'Hare, 1 Vet. App. at 367. (ii)Groin muscle injury The Veteran asserts that he has a residual injury due to an in-service groin injury. While STRs confirm an in-service groin injury, the lay and medical evidence weigh against a finding that he has a residual disability from the in-service groin injury at anytime during the claims period. STRs from December 1981 show that the Veteran had a "pulling sensation" in his groin area. The examiner noted the recent MVA resulting in a cervical spine injury. The examiner assessed a possible muscle strain or hernia. He was placed on profile for a week and advised not to lift any objects over 15 pounds. On his March 1983 separation examination, he was clinically examined and not found to have any hernia or associated groin muscle injury residual. In November 2005, the Veteran reported that he pulled his groin during military training exercises in November and December 1981. At the April 2011 hearing, he affirmed that he had recovered from his in-service groin injury. He did not identify any residual disorder. Review of VA treatment and private treatment records do not show that the Veteran has a current groin injury residual. In summary, the evidence does not show a residual from the in-service groin injury. The Veteran even affirmatively conceded that he healed from the in-service groin injury at the April 2011 hearing. The Board again finds that a current groin injury residual disability has not been demonstrated at anytime during the claims period. See McClain, 21 Vet. App. at 323. Without competent evidence of a current residual disability, the claim must fail. See id.; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The benefit-of-the-doubt doctrine, even under VA's heightened obligations, is therefore not helpful to the Veteran, and the claim for service connection for groin injury residuals must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57; O'Hare, 1 Vet. App. at 367. III. Increased ratings Disability evaluations are determined by the application of a schedule of ratings which is based upon an average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. §§ 3.102, 4.3, 4.7. In addition, the Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether or not they were raised by the appellant, as well as the entire history of the veteran's disability in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In the evaluation of service-connected disabilities the entire recorded history, including medical and industrial history, is considered so that a report of a rating examination, and the evidence as a whole, may yield a current rating which accurately reflects all elements of disability, including the effects on ordinary activity. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.41. In cases where the Veteran is challenging the initially assigned disability rating, it has been in continuous appellate status since the original assignment of service connection. The evidence to be considered includes all evidence proffered in support of the original claim. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. In such cases, staged ratings are appropriate when the factual findings show distinct time periods where the service- connected disability exhibits symptoms that would warrant different ratings for each such distinct time period. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). (i) Bilateral upper extremity neuropathy (median nerve) The Veteran is service connected for neurological disorders in both upper extremities as secondary to his service connected neck disability. He currently has separate 10 percent initial ratings under Diagnostic Code (DC) 8515 for neuropathy in each upper extremity. Under DC 8515, for mild incomplete paralysis of the median nerve of the major or minor hand, a 10 percent rating is assigned. For moderate incomplete paralysis of the median nerve of the major hand a 30 percent rating is assigned, and for the minor hand a 20 percent rating is assigned. For severe incomplete paralysis of the median nerve of the major hand a 50 percent rating is assigned, and for the minor hand a 40 percent rating is assigned. Finally, for complete paralysis of the median nerve of the major hand, which contemplates the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances, a 70 percent rating is assigned, and for the minor side a 60 percent rating is assigned. 38 C.F.R. § 4.124a, DC 8515. The Board notes that, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Additionally, the Board notes that, under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The schedule of ratings does not define the terms "moderate" and "severe;" rather than applying a mechanical formula to make a determination, the Board evaluates all of the evidence such that decisions are "equitable and just." 38 C.F.R. § 4.6. The term "incomplete paralysis," with respect to nerve injuries, indicates a degree of loss or impaired function substantially less than the type pictured for "complete paralysis" given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, Note. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See id. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating to be assigned for neuralgia, usually characterized by a dull and intermittent pain of typical distribution so as to identify the nerve, will be that equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Private medical records dated in March 2006 reflect that the Veteran had a slip and fall injury where he aggravated his neck and associated upper extremity disabilities. Neurological examination showed hypomatic reflexes for bilateral biceps and triceps. The Veteran also had a VA neurological examination in March 2006. The examiner recited the pertinent medical history, noting that the Veteran initially sought treatment for upper extremity weakness and tingling in 1994. Currently, the Veteran described being unable to perform fine motor movements with either hand. However upon clinical examination, the examiner remarked "[the Veteran's] fine motor movements are slow because of his effort but he appears to be able to perform fine motor movements." Sensory examination for the upper extremities was normal. The examiner assessed quadriparesis. She cited diffuse weakness related to cervical myelopathy. She commented that although the Veteran was occupationally disabled, he was able to perform activities of daily living. Private medical records from April 2006 show the Veteran complaining about bilateral numbness, weakness, in tingling in both upper extremities since his recent injury. He also reported having difficulty with fine motor skills. Clinical examination showed 3/5 strength for intrinsic hand muscles and 4/5 strength for additional muscles. He exhibited 3+/4 for triceps and bicep reflexes. He had a high amplitude postural tremor. He had diminished sensory perception on his hands to pinprick and light touch; however, vibration was intact. Pertinent diagnosis included cervical myeloradiculopathy. The Veteran was referred for further neurological evaluation. In July 2006, the Veteran had another private medical consultation. He continued to have bilateral upper extremity numbness and tingling. Clinical examination did not show an "obvious deformity" in either upper extremity. Palpation for both upper extremities was without tenderness and showed an intact pulse. He did not exhibit any restricted range of motion for either arm. Strength for both upper extremities was normal, except for grip 4 for both arms and deltoid 4, left arm. Sensation was abnormal with increased lateral forearm sensation for the right arm and abnormal increased sensation medial and dorsal for the left arm. Reflexes were triceps and biceps +3 bilaterally. The examiner diagnosed cervical fracture at C1-C4 with central cord syndrome. He characterized the Veteran as having severe neurological injury. At the June 2007 hearing, the Veteran described having numbness in his hands since the in-service MVA. Tampa General Hospital records show that the Veteran underwent a C3-4 laminectomy and fusion in June 2007. A postoperative VA treatment entry the following month reflects that he had full strength in both upper extremities and his sensation was grossly intact. He also reported that his right arm pain noticeably improved after the surgery. VA treatment records from October 2007 reflect that the Veteran's fine motor movements had improved following the surgery, but were not completely normal. He continued to have numbness and tingling in both hands. VA physical therapy records from December 2007 reflect that the Veteran had a restricted range of motion for both arms. He exhibited 3-4/ 5 arm strength bilaterally. He had decreased sensation. He complained that he was unable to propel his wheelchair due to pain. The examiner noted decreased upper extremity strength and range of motion. VA reexamined the Veteran in May 2009. She reviewed the claims folder and interviewed the Veteran. He complained about chronic diffuse numbness and weakness in his upper extremities that had been becoming progressively worse since 2005. Clinical examination showed 4/5 muscle strength for both upper extremities. Upper extremity reflexes were 3+. However, muscle atrophy, tremors, ticks, or abnormal movement was not observed. The examiner assessed bilateral upper extremity myelopathy secondary to service connected spine disability. She further commented that paralysis was absent, but neuritis and neuralgia were found. She opined that it had a moderate effect on most activities of daily living (ADLs) and a severe effect on chores and exercise. In December 2010, the Veteran had a neurology examination as part of his VA diabetes examination. Clinical examination showed his triceps reflexes to be normal and biceps to be hyperactive without clonus. Sensory examination showed vibration, position sense, and light touch to be normal for both upper extremities. Motor examination was 4/5 for both upper extremities. The examiner commented that there was a mild generalized reduction in motor power and that motor tone was normal. Muscle atrophy was not found. The Veteran had his most recent VA neurology examination in February 2013 as part of his cervical spine examination. He again demonstrated 4/5 muscle strength in both upper extremities. Muscle atrophy was not found. He had hypoactive reflexes without clonus in both upper extremities and decreased sensation in both hands and fingers. The examiner commented that the diminished upper extremity functioning was not equivalent to that expected of an amputation with prosthesis. The clinical evidence essentially shows that both upper extremities have very similar neurological symptoms. Although the Veteran had some improvement in symptoms following the June 2007 neck surgery, the symptoms did not materially change in the context of the applicable rating criteria over the course of the appeal. 38 C.F.R. § 4.124a, DC 8515. The symptoms demonstrated throughout the appeals period include pain, sensory disturbances, hyper reflexes, and slight motor weakness that have had episodes of intermittent improvement. (See March 2006 and December 2010 VA examinations with normal sensory findings; July 2007 VA treatment record reflecting post-operative improvement). The evidence generally demonstrates a level of only slight motor weakness (4/5 scaled), hyper-reflexes, and sensory disturbances for each extremity. Each extremity is separately rated. Given the evidence of slight muscle weakness and hyper-reflexes in addition to the sensory disturbances, the Board finds the criteria for a moderate incomplete paralysis is met for each extremity. 38 C.F.R. §§ 4.7, 4.124a, Note. The Board assigns a 20 percent rating for the left upper extremity as the minor hand and a 30 percent rating for the right upper extremity as the major hand. 38 C.F.R. § 4.124a, DC 8515. Although in July 2006 a private clinician characterized the Veteran's neurological impairment as "severe" and May 2009 examiner assessed it as having a moderate effect on ADLs, the symptoms do not include muscle atrophy, weakness beyond scaled 4/5 strength, trophic changes, or significantly restricted motion/ paralysis for either extremity. For these reasons, the Board declines to find that the criteria for a severe neurological disability are met for either upper extremity. See id. (ii) Cervical spine disability (residuals of fracture, odontoid process, with fracture to C5-C7) For historical purposes, the Veteran injured his neck during an in-service motor vehicle accident (MVA). His neck disability is currently rated as 50 percent disabling under Diagnostic Codes (DC) 5293-5235. The rating criteria for the evaluation of spine disorders were amended effective September 26, 2003. See 38 C.F.R. § 4.71a (DC 5285, 5286, 5287, 5288, 5289, 5290, 5291, 5292, 5293, 5294, 5295) (2002); 68 Fed. Regulation. 51454-58 (Aug. 27, 2003) (to be codified at 38 C.F.R. § 4.71a (Diagnostic Codes 5235, 5236, 5237, 5238, 5239, 5240, 5241, 5242, 5243)). The Veteran filed his claim for increase in June 2005, and the new criteria are applicable for the entire claims period. VAOPGCPREC 3-2000. With the possible exception of intervertebral disc syndrome, disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula for Diseases and Injuries of the Spine provide pertinent ratings as follows: 100% Unfavorable ankylosis of the entire spine; 50% Unfavorable ankylosis of the entire thoracolumbar spine; See 38 C.F.R. § 4.71a, DCs 5235 to 5243 (2013) (unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Here, the cervical spine disability is already rated as 50 percent disabling. A higher rating would require unfavorable ankylosis of the entire thoracolumbar spine. See 38 C.F.R. § 4.71a, DC 5293. Notably, he underwent June 2007 cervical surgery and he received a temporary total rating for convalescence for the three month period following the surgery. Aside from the convalescence period, the Veteran has not demonstrated unfavorable ankylosis of the entire spine at anytime during appeals period. (See VA examination reports from March 2006, June 2007, May 2009, and February 2013; Private medical records dated in March 2006, July 2006, May 2007, and February 2008). The Veteran occasionally presented to clinicians wearing a cervical collar, which would be tantamount to favorable cervical ankylosis. Nevertheless, there are absolutely no clinical findings remotely suggestive that the Veteran ever had unfavorable ankylosis of his entire spine. See id. The Veteran does not otherwise assert that his entire spine is fixed in position. The evidence is against a finding that the disability approximates the criteria for an increased rating under the General Formula for Diseases and Injuries of the Spine. 38 C.F.R. §§ 4.7, 4.21. A rating under incapacitating episodes, for IVDS, would not provide a higher disability rating, as there is no evidence in the record that he has had incapacitating episodes. (See VA examination reports from June 2007, May 2009, and February 2013). The Veteran is already in receipt of separate ratings for each extremity for his associated neurological symptoms. The Board has considered whether a separate rating is warranted for incontinence due to cervical myelopathy. 38 C.F.R. § 4.71a, DC 5235, Note 1. In March 2006, the Veteran reported having three episodes of incontinence. Private medical records from July 2006 reference that the Veteran had incontinence following the March 2006 fall. He also reported such episodic symptoms at the June 2007 hearing. At the June 2007 VA neck examination, he reported having bowel constipation and urinary urgency and hesitancy. Constipation was listed as a side effect of his medication. The May 2009 VA examination report reflects that while the Veteran had urinary urgency, he did not have urinary incontinence. In the December 2010 VA diabetes examination, the Veteran was noted to have urinary symptoms. Urinanalysis was normal. The examiner diagnosed erectile dysfunction. At the April 2011 hearing, the Veteran continued to regularly use the bathroom with his wife's assistance and use of a walker. VA treatment records from January 2012 reflect that the Veteran was not on a bowel/bladder program. However, he took extra precaution in quickly accessing a bathroom upon urinary/bowel urgency to prevent an accident. Most recently, the February 2013 VA examiner determined that the Veteran did not have any bowel or bladder problems related to cervical myelopathy. See February 2013 VA examination report. In short, the Veteran has provided subjective reports about bowel and bladder problems and such reports have been noted by treating clinicians. He has not had ongoing medical treatment for uncontrollable incontinence due to cervical myelopathy. At the April 2011 hearing, his testimony suggested that his impairment was caused by ambulatory limitations as opposed to cervical myelopathy. The Board is most persuaded by the negative determination at the February 2013 VA examination since the clinician evaluated the Veteran's neck disability and commented directly on the issue. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). For these reasons, the Board declines to assign a separate rating for bowel or bladder impairment as associated with his cervical spine disability. 38 C.F.R. § 4.71a, DC 5235, Note 1. For the above stated reasons, the preponderance of the evidence is against the claim. The benefit-of-the-doubt doctrine, even under VA's heightened obligations, is therefore not helpful to the Veteran, and the claim for an increased rating for a cervical spine disability or separate rating for associated disability must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57; O'Hare, 1 Vet. App. at 367. (iii) Additional rating considerations Extraschedular considerations The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board finds that the severity of the Veteran's service-connected cervical spine disability and associated neurological impairment of the upper extremities is fully contemplated by the rating criteria whether considered alone or jointly with additional service connected disabilities. Mittleider v. West, 11 Vet. App. 181 (1998). The symptoms are productive of pain, restricted motion, sensory disturbance of the median nerve, and slight (generally 4/5) decreased motor strength. There is no indication that either disability requires frequent inpatient care. The occupational impairment is contemplated by the high schedular ratings assigned for the disabilities and the overall total rating when considered with the additional service connected disabilities. It does not result marked interference with employment beyond the assigned ratings. The degree of disability exhibited for service connected neck disability and associated neurological impairment of the upper extremities is contemplated by the rating schedule whether consider separately or together. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration for the Veteran's increased rating claims. 38 C.F.R. § 4.16(b); Thun v. Peake, 22 Vet. App. 111 (2008). Total disability based upon individual unemployability (TDIU) A request for a TDIU whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. In this instance, the record shows that the Veteran has been in receipt of TDIU or a total rating throughout the entire claims period. TDIU is not for further consideration. IV. Eligibility for adaptive automobile or other adaptive equipment and specially adapted housing and/or a special home adaptation grant. The Veteran contends that his service connected upper and lower extremity disabilities meet the loss of use eligibility criteria for these benefits. Resolving reasonable doubt in his favor, the Board finds that such disabilities meet the "preclude locomotion" loss of use standard and will grant these claims. Under 38 U.S.C.A. § 3902, VA may provide, or assist in providing, an "eligible person" with an automobile or other conveyance, and necessary adaptive equipment. A Veteran is considered an "eligible person" if he is entitled to compensation for any of the disabilities described below, and if such disability is the result of an injury incurred or disease contracted in or aggravated by active military, naval, or air service: (i) The loss or permanent loss of use of one or both feet; or (ii) The loss or permanent loss of use of one or both hands; or (iii) The permanent impairment of vision of both eyes: central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than twenty degrees in the better eye. See 38 U.S.C.A. § 3901(1)(A) (West 2002 & Supp. 2012); see also 38 C.F.R. § 3.808(b) (2013). The term adaptive equipment means generally, that equipment which must be part of or added to a conveyance manufactured for sale to the general public to make it safe for use by the claimant and to assist him or her in meeting the applicable standards of licensure of the proper licensing authority. See 38 C.F.R. § 3.808(e). The regulation further provides that, with regard to automobiles and similar vehicles the term includes a basic automatic transmission as to a claimant who has lost or lost the use of a limb. See 38 C.F.R. § 3.808(e)(1). For a certificate of eligibility for assistance in acquiring specially adapted housing, the evidence must establish permanent and total service-connected disability due to: 1) the loss, or loss of use, of both lower extremities such as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair; or 2) blindness in both eyes, having only light perception, plus the loss of use of one lower extremity; or 3) the loss, or loss of use, of one lower extremity together with the residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair; or 4) the loss, or loss of use, of one lower extremity together with the loss, or loss of use, one upper extremity which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair. 38 U.S.C.A. § 2101(a) (West 2002); 38 C.F.R. § 3.809(b) (2013). The term "preclude locomotion" is defined as the necessity for regular and constant use of a wheelchair, braces, crutches or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809(d) (2013). Where entitlement to specially adapted housing is not established, an applicant may nevertheless qualify for a special home adaptation grant. This benefit requires that the evidence show permanent and total service-connected disability that either results in blindness in both eyes with 5/200 visual acuity or less, or involves the anatomical loss or loss of use of both hands. 38 U.S.C.A. § 2101(b) (West 2002); 38 C.F.R. § 3.809a(b) (2013). The Board notes initially that the regulations pertinent to SMC, discussed below, include terminology regarding loss of use of both feet (38 C.F.R. § 3.350) that is facially similar to the regulations pertinent to this issue, regarding loss of use of both lower extremities (38 C.F.R. § 3.809); however, the provisions used to define loss of use differ significantly between the two sections. As noted above, 38 C.F.R. § 3.350 defines loss of use as when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. In contrast, 38 C.F.R. § 3.809 defines loss of use as the requirement of braces, crutches, canes, or a wheelchair to aid in locomotion. The Veteran is currently service connected for the following disabilities: cerebral concussion with headaches, rated 70 percent; adjustment disorder, rated 50 percent; neck disability, rated 50 percent; right upper extremity neuropathy, rated as 30 percent; left upper extremity neuropathy, rated as 20 percent; lumbar back disability, rated 20 percent; myelopathy of lower extremities, rated 20 percent each; cataracts, rated 20 percent; neck scar, rated 10 percent; functional asplenia, rated 10 percent; glaucoma, rated 10 percent; renal insufficiency, anemia, adrenal insufficiency, hypertension, erectile dysfunction, and diabetes mellitus, Type II all rated noncompensable. He has a total combined rating. Thus, he has service connected upper and lower extremity disabilities for consideration of adaptive automobile certificate criteria, and the total rating for consideration of the specially adapted housing criteria. 38 C.F.R. § 3.809(b). Here, the three 20 percent ratings and one 30 percent rating for the extremity disabilities are not clearly suggestive of loss of use for any extremity. Multiple clinical assessments over the course of the appeal show findings primarily indicative of slight decrease in motor strength/ general diffuse weakness, abnormal reflexes, and sensory disturbances. (See VA examination reports from March 2006, June 2007, May 2009, and February 2013; Private medical records dated in March 2006, July 2006, May 2007, and February 2008). They are not indicative of paralysis, or muscle atrophy. Id. The February 2013 VA examiner specifically opined that the Veteran's remaining function in his upper extremities was not equivalent to functional loss of use. (See February 2013 VA examination report). Nonetheless, numerous clinical records reflect that he regularly used ambulatory devices due to service connected disabilities and had near total ambulatory impairment without their use. See June 2007 VA examination (Veteran uses wheelchair and walker; limited to walking 10 yards; September 2008 VA Aid and Attendance report (Veteran necessitates wheelchair, limited to walking one block); May 2009 VA cervical spine examination report (Veteran uses wheelchair, limited to walking 100 feet); February 2013 VA examination report (Veteran used wheelchair and walker as regular modes of locomotion, although he could ambulate unaided for short distances at his residence)). The Veteran has additional ratable service connected disabilities of cerebral concussion residuals and cervical and lumbar spine, among others, that may be productive of ambulatory impairment or affect his extremities beyond the clinical findings made above when considering each extremity in isolation. He adamantly asserts that his multiple service connected disabilities have substantially precluded ambulation. (See June 2007 and April 2011 hearings). As noted above, the "preclude locomotion" loss of use standard under 38 C.F.R. § 3.809(d) is more expansive than the SMC loss of use standard of 38 C.F.R. § 3.350(a)(2). Compare 38 C.F.R. § 3.809(b)(3) and (c) to 38 C.F.R. § 3.350(a)(2). The language of 38 C.F.R. § 3.809 is clear that the more expansive loss of motion standard is applicable to the home adaptation criteria as it was explicitly stated in the regulatory language. Viewing the legal criteria in the light most favorable to the Veteran, the Board extends the more expansive view of loss of use under 38 C.F.R. § 3.809 for automobile adaptation eligibility consideration. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. By resolving reasonable doubt in favor of the Veteran, the Board finds the evidence at least in equipoise as to whether his service connected upper and lower extremity disabilities met the regulatory definition of "preclude locomotion" to find loss of use of an extremity under 38 C.F.R. §§ 3.808(b) and 3.809(b)(1). (See June 2007 and April 2011 hearings; June 2007, May 2009, and February 2013 VA examination reports; September 2008 VA Aid and Attendance report). In summary, resolving reasonable doubt in the Veteran's favor, all statutory and regulatory criteria for certificates of eligibility for an automobile and/or specially adapted equipment and specially adapted housing have been met. The full benefits sought on appeal are granted for these claims. In light of the grant of entitlement to a certificate of eligibility for specially adapted housing, the claim for a special home adaptation grant under 38 U.S.C.A. § 2101(b) is rendered moot, as this benefit is available only if a Veteran is not entitled to the more substantial benefit of specially adapted housing under 38 U.S.C.A. § 2101(a). V. Entitlement to special monthly compensation (SMC) prior based upon the need for regular aid and attendance and/or homebound status prior to October 23, 2008. The Veteran has been awarded SMC based upon the need for regular aid and attendance beginning October 23, 2008. He asserts that the effective date should be May 19, 2003. On that date, he reportedly lost his job and was essentially on bed rest. See November 2009 Notice of Disagreement. After consideration of all pertinent evidence and legal criteria, the Board finds that the Veteran filed an informal claim on July 20, 2005 showing the need for aid and attendance. He did not demonstrate a factually ascertainable increase in service connected disability prior to the informal claim. Thus, a July 20, 2005 effective date for SMC based upon aid and attendance is granted. SMC for aid and attendance is payable when a Veteran, due to service-connected disability, 1) has the anatomical loss or loss of use of both feet, 2) has the anatomical loss or loss of use of one hand and one foot, 3) is blind in both eyes, or 4) is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C.A § 1114(l); 38 C.F.R. § 3.350(b). Determinations regarding the need for aid and attendance must be based on actual requirements of personal assistance from others. 38 C.F.R. § 3.352(a). Consideration is given to such conditions as: 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 aid; inability of the Veteran to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers inherent in his daily environment. Bedridden is that condition which, through its essential character, actually requires that the Veteran remain in bed. It is not required that all of the disabling conditions enumerated above exist and the particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. However, the Veteran must be unable to perform at least one of the enumerated disabling conditions. Turco v. Brown, 9 Vet. App. 222 (1996). The evidence need only establish that the Veteran is so helpless as to need regular, rather than constant, aid and attendance. 38 C.F.R. § 3.352(a). The effective date of an increase in disability compensation is the earliest date as of which it is factually ascertainable that an increase in disability has occurred if a claim is received within one year of such date. Otherwise, the effective date is the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2) (2013). The Court has held that 38 U.S.C.A. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2) are applicable only where an increase in disability precedes a claim for an increased disability rating; otherwise the general rule of 38 C.F.R. § 3.400(o)(1) applies. See Harper v. Brown, 10 Vet. App. 125, 126 (1997). Thus, three possible dates may be assigned depending on the facts of a case: (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o)(1)); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400(o)(2)); or (3) if an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o)(2)). Harper, 10 Vet. App. at 126. Thus, determining an appropriate effective date for an increased rating under the effective date regulations involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible, (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o)(2) (2013). The Board notes that a specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a) (West 2002); 38 C.F.R. § 3.151 (2013). Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. Such an informal claim must identify the benefit sought. Upon receipt of an informal claim, if the formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of the receipt of the informal claim. When a claim has been filed which meets the requirements of 38 C.F.R. § 3.151, an informal request for increase or reopening will be accepted as a claim. 38 C.F.R. § 3.155 (2013). A report of examination or hospitalization that meets the requirements of 38 C.F.R. § 3.157 (2013) will be accepted as an informal claim for benefits, if the report relates to a disability that may establish entitlement. Once a formal claim for compensation has been allowed, receipt of one of the following will be accepted as an informal claim for increased benefits: (1) Report of examination or hospitalization by VA or uniformed services. The date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim, only when such reports relate to examination or treatment of a disability for which service-connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. (2) Evidence from a private physician or layman. The date of receipt of such evidence will be accepted when the evidence furnished by or in behalf of the claimant is within the competence of the physician or layperson and shows the reasonable probability of entitlement to benefits. 38 C.F.R. § 3.157 (2013). The Veteran initially filed his claim for SMC based upon aid and attendance on September 2, 2005. During the prior calendar year, VA treatment records show that the Veteran had inpatient care from October 31, 2004 through November 4, 2004. It appears he was under observation for sepsis due to his symptoms of fever and hypotension. The discharge assessment included findings of leukocytosis and acute renal failure. He also had additional inpatient treatment later in November 2004 for diabetes, pneumonia, hypertension, and adrenal insufficiency. He was again hospitalized for acute renal failure and adrenal insufficiency on June 12, 2005 through June 23, 2005. Throughout the entire claims period he has been service connected for the following disabilities: cerebral concussion with headache, rated 10 percent prior to October 23, 2008 and 70 percent thereafter; adjustment disorder rated at 50 percent; neck disability, rated at 50 percent; neck scar, rated 10 percent. Prior to June 30, 2005, his overall disability rating was 80 percent. He received TDIU beginning May 30, 2003. The TDIU award is inclusive of the psychiatric and neck disabilities sharing the in-service MVA etiology. (See May 1994 RO decision). Beginning June 30, 2005, he was additionally service connected for the following disabilities: lumbar back, rated 20 percent; paralysis of both lower extremities, rated 20 percent each; paralysis of both upper extremities, rated 20 and 30 percent each; functional asplenia, rated 10 percent; renal and adrenal insufficiencies and anemia, rated as noncompensable. He had a total overall rating. On March 18, 2006, he was additionally service connected for the following disabilities: cataracts, rated 20 percent; glaucoma, rated 10 percent; hypertension, erectile dysfunction, and diabetes mellitus, Type II, all noncompensable. He had a total overall rating. The Veteran was not service connected for the disabilities that necessitated the 2004 and 2005 hospitalizations at the time of hospitalizations. He is service connected for anemia and renal insufficiency beginning June 30, 2005. He was service connected for diabetes and hypertension beginning March 18, 2006. Thus, he was not recognized by VA as having related service connected disabilities at the time of the above hospitalizations. Accordingly, these hospitalization reports do not meet the requirements of report of examination or hospitalization of 38 C.F.R. § 3.157 (2013). However, on July 20, 2005, a VA physician completed VA Form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance. He transcribed his clinical findings and concluded that the Veteran required daily personal health care services on account of his service connected neck and related neurological disabilities. The July 20, 2005 report meets the requirements of report of examination or hospitalization of 38 C.F.R. § 3.157 (2013). It was filed within a year of the formal claim. Thus, an informal claim was filed on July 20, 2005, and the Board finds it to be the date of claim. The July 20, 2005 report by the VA physician is prima facie evidence that the Veteran met the SMC aid and attendance criteria on that date. 38 C.F.R. §§ 3.350, 3.352(a). He continued to have treatment primarily for neck pain and associated neurological problems through October 23, 2008. The clinical evidence from the intervening period is not entirely clear that the Veteran had any significant improvement in his overall daily functioning. While the March 2006 VA examiner conducting a neck examination concluded he could perform activities of daily living; she does not appear to consider his additional non-musculoskeletal disabilities. Notably, the June 2007 neck surgery benefited the Veteran, but he continued to report problems with fine motor skills in his hands and unsteadiness when ambulating. Another aid and attendance examination was completed on September 3, 2008. It is unclear whether it was the same physician completing the prior report. In any event, the physician conducted a clinical examination and expressed another favorable opinion. For these reasons, the Board finds the aid and attendance criteria are met beginning July 20, 2005 or the date of the informal claim. 38 C.F.R. §§ 3.157, 3.352(a), 3.400(o). The Veteran seeks an effective date prior to July 20, 2005. As explained above, an effective date prior to July 20, 2005 can only be established if the evidence shows a factually ascertainable increase in service related disability within a year prior to July 20, 2005. See id. Prior to June 30, 2005, the Veteran was service connected for cerebral concussion, adjustment disorder with anxiety and depression, neck disability, and neck scar. On June 30, 2005, the additional disabilities of lumbar spine, upper and lower extremity neuropathy, asplenia, renal insufficiency, anemia, and adrenal insufficiency were recognized as service connected. As explained above, the prior hospitalizations in 2004 and June 2005 were for then not yet service connected disabilities. The evidence does not otherwise suggest that a factually ascertainable increase in then recognized service connected disabilities occurred prior to July 20, 2005. (See generally VA treatment records from June 2004 to July 2005). For the above stated reasons, the Board grants an effective date of July 20, 2005, but no earlier, for entitlement to SMC prior based upon the need for regular aid and attendance and/or homebound status. ORDER Service connection for a liver disorder is denied. Service connection for residuals of a groin muscle injury is denied. An increased initial rating for right median nerve (major hand) of 30 percent, but no higher, is granted, subject to governing criteria applicable to the payment of monetary benefits. An increased initial rating for left median nerve (minor hand) of 20 percent, but no higher, is granted, subject to governing criteria applicable to the payment of monetary benefits. An increased rating for cervical spine disability, currently rated as 50 percent disabling is denied. Entitlement to a certificate of eligibility for purchase of an automobile allowance and adaptive equipment or adaptive equipment only is granted, subject to governing criteria applicable to the payment of monetary benefits. Entitlement to a certificate of eligibility for specially adapted housing or a certificate of eligibility for a special home adaptation grant is granted, subject to governing criteria applicable to the payment of monetary benefits. Entitlement to special monthly compensation beginning July 20, 2005, but no earlier, based upon the need for regular aid and attendance and/or homebound status is granted, subject to governing criteria applicable to the payment of monetary benefits. HARVEY P. ROBERTS MATTHEW TENNER Veterans Law Judge Acting Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals ______________________________________________ J. A. MARKEY Veterans Law Judge Board of Veterans' Appeals Department of Veterans Affairs