Citation Nr: 1610018 Decision Date: 03/14/16 Archive Date: 03/22/16 DOCKET NO. 10-29 766 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Whether new and material evidence has been received sufficient to reopen the claim of service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a psychiatric disorder, to include PTSD and depression. 3. Whether the reduction in the disability rating from 60 percent to 30 percent, effective July 12, 2007, for the service-connected eczema of hands/dermatitis was proper. 4. Entitlement to special monthly compensation based on the need for the regular aid and attendance of another person or at the housebound rate. 5. Entitlement to specially adapted housing. 6. Entitlement to a special home adaptation grant. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran had active service from March 1975 to January 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which, in pertinent part, denied entitlement to specially adapted housing, entitlement to special home adaptation, and entitlement to SMC based on aid and attendance/housebound status. He timely appealed that decision. This matter also comes before the Board on appeal from the October 2007 rating decision by the VA RO in Chicago, Illinois, which, in pertinent part, denied the petition to reopen the claim of service connection for PTSD, and decreased the disability rating for service-connected eczema of hands/dermatitis from 60 percent disabling to 30 percent, effective July 12, 2007. In an October 2009 statement, the Veteran requested a Travel Board hearing at the Chicago RO, indicating his continued desire to appeal the claims for whether new and material evidence had been received to reopen the claims of service connection for PTSD, and whether the reduction of the disability rating from 60 percent to 30 percent for service-connected eczema of the hands/dermatitis was proper, to the Board. The Veteran testified at a personal hearing before the undersigned Veterans Law Judge (VLJ), which was held in Washington, D.C., in October 2015. A copy of the hearing transcript is of record. To establish jurisdiction over the psychiatric disorder claim, the Board must first consider whether new and material evidence has been received to reopen the claim. See 38 U.S.C.A. §§ 5108, 7105 (West 2014). The Board must proceed in this fashion regardless of the RO's actions. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) and VAOPGCPREC 05-92. As discussed fully under the analysis section, the Board finds that new and material evidence has been submitted sufficient to reopen the claim of entitlement to service connection for an acquired psychiatric disorder. Thus, the Board is granting this aspect of the Veteran's appeal. This appeal was processed using the Veteran's Benefits Management System (VBMS) . Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In addition to the VBMS file, there is a Virtual VA paperless claims file associated with the claim. Lastly, the Veteran submitted additional medical evidence, and specifically a letter issued by his VA psychiatrist, and dated in October 2009, which pertained to his petition to reopen his claim seeking service connection for PTSD. The submission of this evidence was accompanied by a waiver of RO consideration. 38 C.F.R. § 20.1304(c) (2014). At the beginning of the appeal, the Veteran was represented by the North Carolina Division of Veterans Affairs. In the June 2015 VA Form 21-22, the Veteran appointed the Disabled American Veterans as his representative, thereby revoking the earlier power of attorney. See 38 C.F.R. § 14.631(f)(1). The issues of entitlement to erectile dysfunction, to include as secondary to a service-connected disability, has been raised by the record in a an Application for Disability Compensation and Related Compensation Benefits, date-stamped as received, and scanned in VBMS, in December 2015, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The claims seeking entitlement to SMC based on the need for aid and attendance of another person, or on account of being housebound, as well as the claims seeking entitlement to specially adapted housing and a special home adaptation are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. By an October 2002 rating decision, the RO denied the Veteran's claim of service connection for PTSD on the basis that the evidence failed to confirm or corroborate the Veteran's reported in-service stressors. 2. The evidence received since the October 2002 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for PTSD, and raises a reasonable possibility of substantiating that claim. 3. The record evidence is at least in relative equipoise as to whether the Veteran has a diagnosis of PTSD. 4. The record evidence is at least in relative equipoise as to whether there is a causal relationship between the Veteran's acquired psychiatric disorder, variously diagnosed as PTSD, and his period of active military service. 5. By a March 2005 decision, the RO awarded an increased rating to 60 percent, effective from April 15, 2004 (date of claim) for the service-connected eczema of hands/dermatitis. 6. By the October 2007 rating decision, the RO reduced the disability rating for the Veteran's service-connected eczema of hands/dermatitis from 60 percent to 30 percent, effective July 12, 2007. 7. The entirety of the medical evidence relevant to this claim and associated during the appeal period does not demonstrate actual, sustained improvement of the Veteran's eczema under the ordinary conditions of life. CONCLUSIONS OF LAW 1. The October 2002 rating decision which denied service connection for PTSD, is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.302 , 20.1103 (2015). 2. The evidence received subsequent to the October 2002 rating decision is new and material, and the previously denied claim for service connection for PTSD is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2015). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for an acquired psychiatric disorder, variously diagnosed as PTSD and depressive disorder, are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 , 3.307, 3.309 (2015). 4. Resolving all reasonable doubt in the Veteran's favor, the reduction of the assigned rating from 60 percent to 30 percent for the eczema of hands/dermatitis was not proper; and the 60 percent rating for this disability is restored, effective from April 15, 2004. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2015); 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.25 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The Board concludes that these duties do not preclude the Board from adjudicating this portion of the Veteran's claim. This is so because the Board is taking action favorable to the Veteran by reopening his service connection claim. See Bernard v. Brown, 4 Vet. App. 384 (1993). Also, the Board acknowledges that, in the present case, VCAA notice did not directly address the issue of a rating reduction. However, as the instant decision restores the previously assigned rating, any notice deficiency as to this issue is moot. Accordingly, discussion of VA's compliance with the notice and assistance requirements would serve no useful purpose. II. Claim to Reopen In the current appeal, the Veteran contends that he developed PTSD after encountering several traumatic events while serving in the military. In this regard, the Board observes that the Veteran's claim seeking service connection for PTSD was last considered and denied in the October 2002 rating decision. In that decision, the RO denied this claim on the basis that the evidence of record failed to corroborate the Veteran's reported in-service stressors. The RO determined that the evidence of record did not establish that a stressful military experience occurred. The Veteran was notified of this decision and of his appellate rights; however, he did not submit a notice of disagreement with regard to this decision. In general, rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105 ; 38 C.F.R. § 20.1103. Where service connection for a disability has been denied in a final decision, a subsequent claim for service connection for that disability may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. As noted above, the Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. See Barnett, supra. Further analysis, beyond consideration of whether the evidence received is new and material is neither required nor permitted. Id. at 1384; see also Butler v. Brown, 9 Vet. App. 167, 171 (1996). New evidence means evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a) (2015). The evidence associated with the claims file prior to the October 2002 rating decision includes, but is not limited to, the Veteran's service treatment and service personnel records; an October 2001 VA treatment report; VA psychiatric records dated from December 2001 to January 2002; the March 2002 VA examination report; an April 2002 VA Depression screening examination; VA treatment records dated from April 2002 to August 2002; VA outpatient records issued from VA Chicago Health Care, and dated from January 2000 to May 2002; and the Veteran's lay assertions. The evidence associated with the claims file subsequent to the October 2002 rating decision includes, but is not limited to, VA outpatient records issued from the Salisbury VA Medical Center (VAMC), and dated from February 2002 to June 2005; VA outpatient records issued from the Fayetteville VAMC, and dated from September 2003 to June 2015; VA outpatient records generated through Crownpoint Cliff, Indiana, and dated from April 2002 to May 2006; a March 2007 letter issued by the Veteran's Social Worker, E.N., MSW, at the Veterans Resource Center; the July 2008 VA medical opinion issued by the VA staff psychiatrist at the Jesse Brown VAMC, C.S., M.D.;VA treatment records issued at the Jesse Brown VAMC, and dated from January 2008 to July 2009; an October 2009 medical opinion issued by Dr. S.; VA treatment records issued at the Milwaukee VAMC and dated from May 2011 to July 2011; the June 2013 VA psychiatric examination report; an April 2015 Mental Health consultation form; the October 2015 Hearing Transcript; and the Veteran's own lay assertions. The Veteran contends that he was exposed to several traumatic events while serving in the military, and relates his current psychiatric problems, including his PTSD, to these in-service stressors. According to the Veteran, the first incident occurred while he was assigned to a field artillery unit. He (the Veteran) recalled how during one of the unit's training sessions, he watched as one of his fellow serviceman's parachutes failed to open, causing him to plummet to the ground. The Veteran recalled a similar incident that occurred several years later, while he was on a field exercise at Fort Bragg. According to the Veteran, he performed a jump with several of his fellow soldiers, and when he landed, he saw the body of a soldier on the ground. It appeared that neither his primary chute nor reserve chute had deployed. The Veteran also recalled witnessing one of his fellow soldiers commit suicide by jumping out in front of a truck. According to the Veteran, he had been in charge of this soldier. See October 2002 and August 2010 Statements of Veteran. In the March 2007 letter issued by the Veterans Resource Center, the Veteran's social worker, E.N., M.S.W., noted that the Veteran had been involved with the Veterans Resource Center since January 2004, and that he had been undergoing individual and group therapy for treatment of his psychological disorder. E.N. wrote that the Veteran's involvement with the Veterans Resource Center program had been ongoing for the past few years with therapy focusing on his anxiety, depression, panic attacks and acute stressors. E.N. further noted that the Veteran continued exhibiting PTSD symptoms, to include recurrent and intrusive recollections of his military experiences while serving in the Army, and difficulty falling and staying asleep. According to E.N., the Veteran exhibited severe PTSD symptomatology and there was a corresponding increase in his level of depression. Based on his evaluation of the Veteran, E.N. diagnosed the Veteran with having PTSD and assigned him a Global Assessment of Function (GAF) score of 38. In a letter dated in July 2008, the staff psychiatrist at the Jesse Brown VAMC, C.S., M.D., wrote that the Veteran had been undergoing treatment at various VA clinics for many years and had been his patient at the VA Mental Health Clinic since September 2007. Dr. S. noted that the Veteran served as a paratrooper and wire team chief, and took into account his reported traumatic experiences in service. Specifically, Dr. S. noted that the Veteran witnessed his superior fall to the ground and die after his parachute did not open, and the Veteran himself had to utilize his reserve chute on two occasions to prevent falling to his death due to the fact that his primary chute did not open. According to Dr. S., the Veteran's intrusive thoughts and nightmares are closely related to these experiences, and it is likely that his current symptoms of PTSD are directly caused by these traumatic experiences. In a letter dated in October 2009, Dr. S. reiterated the same assertions made in the July 2008 statement, and related the Veteran's PTSD symptoms to his traumatic military experiences. According to Dr. S., the Veteran's symptoms, especially his nightmares, insomnia, irritability and avoidant behavior, "remain severe and persistent enough to continue to severely limit his functioning and make him unable to maintain gainful employment." During the pendency of the Veteran's appeal, VA regulations relating to stressor verification and service connection for PTSD changed. Specifically, 38 C.F.R. § 3.304(f)(3) went into effect on July 13, 2010. Under this amended regulation, if an in-service stressor involves fear of hostile military or terrorist activity, service connection for PTSD may be established if: a VA psychiatrist or psychologist, or contract equivalent, confirms that the claimed stressor is adequate to support a diagnosis of PTSD; the claimed stressor is consistent with the places and circumstances of the Veteran's service; and the Veteran's symptoms are related to the claimed stressor. See 38 C.F.R. § 3.304 (2015). In light of the October 2002 rating decision which denied the claim of service connection for PTSD because the evidence of record did not establish that a stressful military experience occurred, the new regulatory provisions, and the July 2008 and October 2009 opinions issued by Dr. S. concluding that the Veteran's in-service experiences were sufficient to support a diagnosis of PTSD, and specifically, that the Veteran's PTSD symptoms were closely related to his in-service experiences, the Board finds that the evidence associated with the claims file subsequent to the October 2002 decision is relevant in establishing that the Veteran's claimed stressors are adequate to support a diagnosis of PTSD. In determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. See Shade v. Shinseki, 24 Vet.App. 110, 118 (2010). Therefore, in light of the above and upon consideration of the Veteran's stressor statements during the course of the appeal, as well as the July 2008 and October 2009 medical opinions, the claim is reopened. Thus, the Board finds that new and material evidence has been presented to reopen the previously denied claim for service connection for PTSD. This aspect of his appeal is, therefore, granted. III. Service Connection The Veteran contends that his current psychiatric problems originated in, and are the result of, several traumatic experiences he encountered while serving in the military. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110 (West 2015); 38 C.F.R. §§ 3.303 , 3.304 (2015). In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; in-service occurrence or aggravation of a disease or injury; and a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including psychoses, may also be established based upon a legal "presumption" by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112 , 1137 (West 2015); 38 C.F.R. §§ 3.307, 3.309 (2015). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2015). Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, in accordance with 38 C.F.R. § 4.125(a) ; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304(f) ; Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The Board notes that the DSM-IV has been recently updated with a Fifth Edition (DSM-V). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule only apply, however, to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. During the pendency of the Veteran's appeal, VA regulations relating to stressor verification and service connection for PTSD changed. Specifically, 38 C.F.R. § 3.304(f)(3) went into effect on July 13, 2010. Under this amended regulation, if a stressor claimed by a veteran is related to the veteran's fear of hostile, military, or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The provisions of this amendment apply to applications for service connection for PTSD that are: received by VA on or after July 12, 2010; were received by VA before July 12, 2010 but have not been decided by a VA regional office as of July 12, 2010; are appealed to the Board on or after July 12, 2010; were appealed to the Board before July 12, 2010 but have not been decided by the Board as of July 12, 2010; or are pending before VA on or after July 12, 2010 because the Court vacated the Board decision on an application and remanded it for readjudication. See 75 Fed. Reg. 39843 -39852 (July 13, 2010). Where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the Veteran applies, absent congressional or Secretarial intent to the contrary. See Dudnick v. Brown, 10 Vet. App. 79 (1997). The amended versions may only be applied as of their effective date and, before that time, only the former version of the regulation should be applied. VAOPGCPREC 3-2000 (Apr. 10, 2000). As such, the Veteran's claim will be viewed in light of the amended language of the regulation. Review of the service treatment records reflect that the clinical evaluation of the Veteran's psychiatric system was shown to be normal at the January 1975 enlistment examination, and he denied a history of depression, excessive worry, or nervous trouble of any sort in his medical history report. At the August 1975 examination, the clinical evaluation of the Veteran's psychiatric system was once again shown to be normal, and he denied a history of mental health problems in his medical history report. The remainder of the Veteran's service treatment records and examination reports were negative for any psychiatric problems. However, an October 1991 health report reflects that a routine drug screening examination was positive for cocaine use, and the Veteran was referred for his separation physical examination. At the October 1991 physical examination, the clinical evaluation of the Veteran's psychiatric system was shown to be normal, and the Veteran denied a history of depression or excessive worry, nervous trouble of any sort, and frequent trouble sleeping. The Veteran underwent a mental status evaluation in December 1991, the results of which were unremarkable and within normal limits. The Veteran's DD-214 associated with his first period of service indicates that he served as a field crewman and that he received a Parachute Badge. The DD-214 associated with his second period of service reflects that the Veteran served as an administrative specialist for twelve years and ten months, and a cannon crewmember for thirteen years and five months. Review of the post-service treatment records reflect that the Veteran was afforded a VA psychiatric examination in March 2002, at which time he relayed his military stressors, and recounted having witnessed and experienced extremely traumatic events in-service that included actual or threatened death or serious injury to himself and to others. According to the Veteran, in the past month, he had re-experienced these events in distressing ways, including nightmares and intrusive thoughts. The Veteran recalled several occasions wherein one of his superiors, and several of his fellow servicemen, were unable to open their parachutes during their jumps. He also recalled two separate incidents wherein he himself had to use one of his reserve chutes due to the fact that his primary chute would not open up. The Veteran further recounted one additional incident wherein he was jumping while on a training exercise with the Infantry, and he witnessed one of his fellow soldiers struggling and unable to open his parachute, and thus falling to his death. The Veteran witnessed his fellow servicemen falling past him, and recalled witnessing him "throwing his arms trying to throw his reserve cute out to deploy, [but] it did not." Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner determined that the Veteran met the DSM-IV criteria for PTSD. Subsequent VA treatment records reflect that the Veteran underwent a depression screening evaluation in April 2002, the results of which were shown to be negative. During a May 2002 VA psychotherapy treatment visit, the staff psychologist, E.V., Ph.D., assessed the Veteran with having PTSD from military trauma and childhood trauma. At the July 2002 and March 2003 VA psychiatric treatment visits, the Veteran reported ongoing anxiety and was diagnosed with having dysthymia. A September 2003 VA Emergency Room note reflects that the Veteran presented with complaints of difficulty sleeping of one month duration. He was assessed with a medical history of PTSD of three years duration from military trauma. The Veteran was also assessed with having dysthymia. VA treatment records dated in May 2004 also reflected an assessment of PTSD of three years duration from military trauma, and dysthymia. The Veteran underwent a PTSD screening evaluation in May 2005, the findings of which were shown to be positive. Subsequent VA treatment records dated in 2005 and 2006 reflect diagnoses of depression and PTSD. Although the issue on appeal was originally framed as entitlement to service connection for PTSD, a review of the record indicates that the Veteran was also diagnosed as having depressive disorder and dysthymia throughout the pendency of the appeal. During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (Court) addressed the scope of claims generally in regard to what is claimed versus what should be addressed by VA. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons the Court held that, in determining the scope of a claim, the Board must consider the Veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. Id. at 5. In light of the Court's decision in Clemons and the varying diagnoses recounted above, the Board has recharacterized the issue as entitlement to service connection for an acquired psychiatric disorder, as stated on the title page of this decision. In a March 2007 letter issued from the Veterans Resource Center, E.N. (the Veteran's social worker), noted that the Veteran had been seeking treatment for his PTSD symptoms - namely his anxiety, depression, panic attacks and acute stressors, at their facility, for the past few years, and he continued exhibiting these symptoms. The Veteran reported difficulty falling and staying asleep, and recurrent and intrusive recollections of his military experiences while serving in the U.S. Army. The mental status evaluation revealed the Veteran to be friendly, cooperative, an open communicator, and concerned about the welfare of his fellow group members. The Veteran exhibited severe PTSD symptomatology, and there was a corresponding increase in his level of depression. E.N. observed no evidence of a thought disorder, and determined his intelligence to be average and his insight to be good. Based on his evaluation of the Veteran, E.N. diagnosed him with having PTSD pursuant to the DSM-IV criteria, and assigned him a GAF score of 38. In a letter dated in July 2008, the Veteran's VA staff psychiatrist, Dr. S., noted that the Veteran had been his patient at the Adam Benjamin VA Mental Health Clinic since September 25, 2007. According to Dr. S., the Veteran presented with symptoms of intrusive thoughts of his in-service trauma, impaired sleep, a depressed mood, irritability, hypervigilance, nightmares, and avoidant/isolative behavior, and had been diagnosed with having PTSD. Dr. S. noted that the Veteran served as a paratrooper and wire team chief, and during a training jump, he witnessed his superior fall to the ground and die when his parachute failed to open. Dr. S. further noted that during a training jump, the Veteran himself had to utilize his reserve chute on two occasions to prevent falling to his death. According to Dr. S., the Veteran's intrusive thoughts and nightmares are closely related to his in-service experiences, and it is likely that his current PTSD symptoms are directly caused by these traumatic experiences. In a letter dated in October 2009, Dr. S. reiterated the same assertions made in the July 2008 statement, and related the Veteran's PTSD symptoms to his traumatic military experiences. According to Dr. S., the Veteran's symptoms - especially his nightmares, insomnia, irritability and avoidant behavior, "remain severe and persistent enough to continue to severely limit his functioning and make him unable to maintain gainful employment." The Veteran was afforded a VA psychiatric examination in June 2013, during which time, he described symptoms of depression, anxiety, and insomnia. During the evaluation, the Veteran denied any psychiatric treatment during his childhood, and reported symptoms of depression, anxiety and sleep problems since 1999. Based on his evaluation of the Veteran, the VA examiner determined that the Veteran's symptoms did not meet the diagnostic criteria for PTSD pursuant to the DSM-IV criteria. The VA examiner did, however, diagnose the Veteran with having depressive disorder not otherwise specified (NOS), that resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The VA examiner acknowledged the earlier treatment reports written by Dr. S., but determined that said reports did not emphasize the fact that the Veteran was able to successfully perform over forty parachute jumps following his claimed stressors. Although the examiner determined that the Veteran's in-service stressors were adequate to support the diagnosis of PTSD, he concluded that they were not related to his fear of hostile military or terrorist activity. According to the examiner, the Veteran does not persistently re-experience the traumatic event, nor does he exhibit persistent avoidance of stimuli associated with the trauma. The examiner acknowledged the Veteran's symptoms of difficulty falling or staying asleep, irritability or outbursts of anger, and hypervigilance, but concluded that the Veteran did not meet the full criteria for PTSD. In reaching this assessment, the examiner noted that the Veteran was able to open his reserve parachute during the one frightful jump he still has recurring thoughts about, and he went on to complete over 40 additional parachute jumps following these incidents. With regard to his diagnosed depressive disorder, the examiner related this disorder to the Veteran's personal and marital issues and not to his military service. At the April 2015 VA Mental Health Consultation, the Veteran provided his military history, and reported that he had been suffering from PTSD symptoms, to include nightmares, fragmented sleep, heightened anxiety, depression, and hypervigilance, since he left service. He reported undergoing mental health treatment at a number of VAMCs over the past twenty years, and he listed the various medications he has taken to address his depression and nerves. The Veteran also admitted to a long history of self-medicating his anxiety, depression, and irritability. Upon conducting a mental status examination of the Veteran, the VA psychiatrist noted that the Veteran exhibited an angry mood, and his thought processes appeared linear without looseness of associations or flight of ideas. Based on his discussion with, and evaluation of the Veteran, the VA psychiatrist diagnosed the Veteran with having PTSD and depression, unspecified. Although the June 2013 VA examiner determined that the Veteran did not meet the requisite criteria for PTSD, the Veteran was shown to meet the DSM-IV criteria for PTSD at the March 2002 VA psychiatric examination. Also, the March 2007 treatment report, along with the July 2008 and October 2009 letters issued by the Veteran's psychiatrist reflect that he met the criteria for PTSD during the pendency of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). When comparing the June 2013 examiner's opinion with the diagnosis of PTSD made by the March 2002 VA examiner, the Veteran's treating psychiatrist (Dr. S.), as reflected in the July 2008 and October 2009 letters, which is presumed to be in accordance with the DSM-IV, and the April 2015 VA psychiatrist, the Board finds that there is an approximate balance of positive and negative evidence as to whether the Veteran's symptoms meet the requisite criteria for a diagnosis of PTSD. Resolving reasonable doubt in the Veteran's favor, the Board finds that the requirement of a current medical diagnosis of PTSD has been met. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In a June 2006 statement, the Veteran stated that he received his Parachute Based, and his Jump Wing in 1975/1976. He also stated that he jumped in jump school five times, and had a total of 34 jumps throughout his military career. The Veteran's DD-214 reflects that he received his Parachute Badge in service, which serves to corroborate his assertions that he participated in parachute jumps in service. Finally, the Board finds that the July 2008 and October 2009 letters issued by the Veteran's psychiatrist, which describe the Veteran's psychiatric symptoms (to include his nightmares, intrusive thoughts, impaired sleep, depressed mood, irritability, hypervigilance, and avoidant behavior), relates his psychiatric disorder to his period of service, and concludes that the reported in-service stressors (witnessing one of his superiors fall to the ground when his reserve chute did not open, having to utilize his reserve chute on two occasions to prevent a fall during his own parachute jumps, and witnessing a fellow serviceman commit suicide) are adequate to support the diagnosis of PTSD, is sufficient medical evidence of a link between the Veteran's current symptomatology and the claimed in-service stressor. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the competent medical evidence supports a finding that the Veteran's psychiatric disorder, variously diagnosed as PTSD and depressive disorder, is related to the traumatic events he witnessed in service. Although the July 2008 and October 2009 opinions issued by Dr. S. related the Veteran's PTSD to his military service, the Board notes that the evidence of record reflects that the Veteran has been diagnosed with PTSD and depressive disorder throughout the pendency of his claim. In light of the fact that the Veteran's symptoms have remained consistent throughout his claim, and his healthcare providers have based their diagnoses on his reported symptoms, to include symptoms of depression, anxiety, irritability, difficulty sleeping, and avoidant behavior, the Board finds that there is a factual basis to sufficiently support a presently existing psychiatric disorder, variously diagnosed as depressive disorder and PTSD, which is related to the traumatic events he experienced in service. Therefore, the Veteran has provided evidence of all three elements required for a grant of service connection for an acquired psychiatric disorder, variously diagnosed as PTSD and depressive disorder, and the claim for service connection for a psychiatric disorder is granted. IV. Reduced Rating A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C.A. § 1155, Greyzck v. West, 12 Vet. App. 288, 292 (1999). Where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons, and the RO must notify the veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. The veteran is also to be informed that he may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60 day period and no hearing is requested, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the veteran expires. 38 C.F.R. § 3.105(e) . VA's General Counsel has held that the provisions of 38 C.F.R. § 3.105(e) do not apply where there is no reduction in the amount of compensation payable. VAOPGCPREC 71-91 (Nov. 1991); VAOPGCPREC 29- 97 (Aug. 1997). It reasoned that this regulation is only applicable where there is both a reduction in evaluation and a reduction or discontinuance of compensation payable. In the present case, the reduction was initiated and finalized in a rating decision issued in October 2007, and was effective July 12, 2007. It reduced the Veteran's combined disability rating from 60 percent to 30 percent. However, notice of the October 2007 rating decision, dated in November 2007, reflected no reduction in the Veteran's monthly compensation amount. Indeed, it appears that the Veteran's compensation amount increased in December 2007 following the October 2007 rating decision. Thus, the Board finds that the provisions of 38 C.F.R. § 3.105(e) are not applicable. The Board must, however, still consider whether the reduction was factually appropriate based upon the evidence of record. Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. VA benefits recipients may be afforded greater protections under 38 C.F.R. § 3.344(a) & (b), which sets forth the criteria for reduction of ratings in effect for five years or more, which stipulate that only evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, can justify a reduction and prohibit a reduction on the basis of a single examination. Brown v. Brown, 5 Vet. App. 413, 417-18 (1995). However, with respect to other disabilities that are likely to improve (i.e., those in effect for less than five years), re-examinations disclosing improvement in disabilities will warrant a rating reduction. 38 C.F.R. § 3.344(c). Specifically, it is necessary to ascertain, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in disability and whether examination reports reflecting change are based upon thorough examinations. In addition, it must be determined that an improvement in a disability has actually occurred and that such improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 420-421; 38 C.F.R. 3.344(c) . In this case, the Veteran's service connected eczema of hands/dermatitis has been assigned multiple disability ratings throughout the duration of the appeal, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7806. A brief historical overview reflects that the Veteran was originally assigned a noncompensable disability rating for his service-connected skin disorder, effective from October 13, 2001. This rating was increased to 30 percent disabling effective November 10, 2003. In April 2004, the Veteran claimed that his service-connected dermatitis had worsened, and sought a higher disability rating for this disorder. He was afforded a VA dermatological examination in February 2005, during which time, he reported constant problems with his skin since he started in the military. According to the Veteran, he had been diagnosed with atopic dermatitis, and he had experienced ongoing flare-ups pertaining to his dermatological condition throughout the last twenty to thirty years. The Veteran reportedly underwent numerous treatments for his symptoms, the most recent of which was the medication Atarax, which he used for itching. According to the Veteran, he experiences a significant level of itching, but he does not have any systemic symptoms. He also claimed that his dermatitis had significantly impaired his function, his activities of daily living, and his occupation. On physical examination, the examiner noted that the Veteran's dermatitis affected approximately 30 percent of the visible area in his neck and hands, and 40 to 50 percent of his total body surface area. The examiner described the dermatitis as "lichenified plaques and hyperpigmented areas extending over his back, his lower extremities, his feet, his bilateral hands, and posterior neck." The examiner further observed numerous excoriated areas, with diffuse scaling in these areas. Based on his discussion with, as well as his evaluation of, the Veteran, the examiner diagnosed the Veteran with having severe atopic dermatitis and tinea pedis, pursuant to Diagnostic Code 7806. In light of these objective findings, by way of the March 2005 rating decision, the RO increased the disability rating for the service-connected eczema of hands/dermatitis to 60 percent disabling, effective April 15, 2004. In reaching this determination, the RO predominantly relied on the February 2005 VA examination report, which reflected the Veteran's complaints that his activities of daily living and occupation were significantly impaired as a result of his eczema, as well as the physical examination findings, which showed that his dermatological condition affected 30 percent of the visible area surrounding the Veteran's neck and hands, and 40 to 50 percent of the total body surface area. In the October 2005 report, the Veteran's dermatologist, J.J., M.D., wrote that visible skin diseases, such as psoriasis and eczema, can pose severe limitations on a person's ability to function in society. According to Dr. J., the extensive itching and scratching the Veteran reports could limit his ability to interact with the public. Dr. J. described the Veteran's skin disorder as severe, and found it unsurprising that he had a difficult time obtaining employment with his current skin condition. In a March 2006 statement, the Veteran described the difficulties he faced trying to obtain and maintain employment as a result of his service-connected eczema and dermatitis. He also commented that his skin disorders cause him to itch constantly and break out in an awful rash. At the July 2007 VA dermatological examination, the VA examiner reviewed the Veteran's medical history, and took into account his reported claims of chronic skin problems since his military service. Upon reviewing his last dermatological examination in February 2005, the examiner noted that the Veteran complained of constant generalized itching, but no specific locations were noted. According to the examiner, the Veteran offered no further complaints, and his physical examination revealed "lichenified plaques diffusely over [his] body, with scaling and hyperpigmented areas, specifically over the back, lower extremities, feet, hands, and posterior neck." Since his last VA examination, the Veteran was seen by his primary care provider at the Chicago VA in August 2006, with complaints of a pruritic rash on his legs and around his eyes. Physical examination of the Veteran revealed "periorbital xerosis with few hyperpigmented lesions with nummular eczema over the thighs." The Veteran was given prescription cream to apply twice daily for ten to fourteen days, as well as a specific ointment to apply to his face. He was also advised to use over-the-counter Keri lotion as needed. According to the examiner, there was no evidence of any further follow-up treatment since then. The Veteran's VA records reflect that he is currently on Fluocinonide (0.05 percent), which he applies twice daily to his feet; Nystatin cream that he applies between the toes twice daily for fungus; DermaCerin cream that he applies four times a day; and Triamcinolone (0.025 percent), which he applies twice daily, on an as needed basis for skin and inflammation. At the current examination, the Veteran complained of "constant generalized pruritis 'all over [his] body, whenever [he gets] upset or [has] exposure to extreme heat and cold weather." The Veteran also reported constant itching whenever dirt or dust was blown on him, and he denied any pustules, vesicles, ulcerations, exfoliation, crusting, weeping, scarring or disfigurement. According to the examiner, the Veteran had been on the four medications referenced above since January 2007, and he reported to use this medication on a daily basis. He denied the use of any oral medications for his generalized pruritis, and he denied any other aggravating factors. According to the Veteran, the medication provides some level of relief from the itching, but he continues to experience dry scaly patches, specifically surrounding his elbows, hands and knees. On physical examination, the examiner observed a 14 centimeter (cm) well-healed surgical scar extending from the epigastric area to the umbilicus, without tenderness, adherence, hypersensitivity, breakdown, depression, inflammation or edema. The examiner further observed lichenified dry scaly patches over the elbows and knees, with evidence of pruritis, as well as dry scaly areas involving the web spaces of the fingers and palmar surface. The remainder of the Veteran's skin was normal, specifically the posterior neck, back, legs and feet. According to the examiner, the Veteran's tinea pedis was under good control with the current use of medicine listed above, and there were no pustules, vesicles, ulcerations, exfoliation, crusting, weeping, scarring or disfigurement. According to the examiner, the current lesions accounted for approximately 10 percent of exposed areas affected and 20 percent of the entire body affected. With regard to the Veteran's work history, the examiner noted that the Veteran had been unemployed since 1997, and had reported multiple orthopedic problems, which appeared to be the largest contributing factor affecting his ability to gain and maintain employment. The examiner determined that the Veteran's ability to work was not affected as a result of his skin or stomach condition, but commented that employers would not hire the Veteran as a result of his service-connected conditions. Based on her discussion with, and evaluation of, the Veteran, the VA examiner diagnosed the Veteran with chronic eczema involving the elbows, hands and knees. According to the examiner, there was no flare of tinea pedis on examination due to good control with medication. In light of these objective medical findings, and by way of the October 2007 rating decision, the RO decreased the disability rating for the Veteran's service-connected eczema of the hands/dermatitis from 60 percent disabling to 30 percent disabling. The Veteran disagreed with this determination. Although the July 2007 VA dermatological examination did reflect some level of improvement in the Veteran's eczema, the more recent VA examination report and treatment records reflect the Veteran's ongoing complaints of eczema, as well as evidence of potential worsening of his service-connected disorder. At the May 2009 VA examination, the Veteran reported a history of 'break outs' surrounding his body secondary to his eczema, and described his condition as constant in nature. He also reported intermittent flares that are severe in intensity. The Veteran reported to shower in warm water, and use dial soap and hydrophilic ointment to help stay moisturized, as the humidity serves to worsen his skin disorder. He added that he applies Diprosone ointment to only the pruritis patches, with occasional improvement, and has been using this ointment for over twelve months. The Veteran also takes 25 milligrams of hydroxyzine on a daily basis for his pruritis, with some improvement. On physical examination, the examiner observed mild xerosis and scattered excoriations on the Veteran's arms and legs, a scar on the right dorsal forearm, and hyperkeratosis and lichenified patches on the bilateral knees. The examiner also observed xerotis and scattered deep-seated ruptured vesicles over the palms and sides of digits bilaterally with excoriations. With respect to the feet, the examiner observed interdigital macerations in the 3-4th webspaces bilaterally. He (the examiner) also noted a few deep seated dark brown vesicles over the medial soles bilaterally. The Veteran denied the use of any corticosteroid, immunosuppressive drugs, UVB, PUVA or electron beam therapy. Based on his evaluation of the Veteran, the VA examiner diagnosed the Veteran with having atopic dermatitis. Subsequent VA and private treatment records reflect that the Veteran continues to experience ongoing eczema on his body that flares-up and subsides on an intermittent basis, and requires the application of cream several times a day to help alleviate and control his symptoms. At a February 2012 VA treatment visit, the VA treatment provider observed an eczematous lesion on the Veteran's extremities. During a private treatment visit at his podiatrist's office in March 2015, the Veteran stated that he had run out of medicated cream for his dermatitis, and it appeared as though his dermatitis had returned. According to the Veteran, he had been using astringent powder and Betadine to soak his feet, which had helped. His list of medication included an antifungal cream, Katoconazole, Gabapentin (oral tablet), "[p]etrolatum 0.41 MG/MG Topical Ointment," cetirizine hydrochloride 10 MG oral tablet, and "Capasaicin 0.7 MG/ML Topical Cream." At a February 2015 VA treatment session, the Veteran requested a refill of his eczema medication, which possibly included Naprosyn, potassium chloride tablets, and spironolactone. The record is unclear as to which medication he uses for his eczema, whether any of these drugs qualified as corticosteroids or other immunosuppressive drugs, and how long he had been taking this medication. During a March 2015 VA treatment session, the Veteran reported that he needed to see an orthopedist for a specialized brace for the knee, wrist and ankle that prevents him from sweating, and consequently worsening his eczema. Based on the totality of the evidence, the Board finds that relying solely on the July 2007 VA examination findings as the basis for the reduction of the disability rating for service-connected eczema from 60 percent to 30 percent disabling, was not proper. The record reflects that the Veteran's eczema and dermatitis continues to fluctuate with periods of improvement intermingled with periods of deterioration. Indeed, a majority of the periods of improvement appear to be attributed to his diligent use of his medication, and the periods of decline appear to be related to the changes in the weather and factors within his environment. Furthermore, the record evidence is equivocal as to whether the improvement shown at the July 2007 VA examination has been consistently maintained under the ordinary conditions of life. In this regard, the Veteran's eczema has not exhibited a sustained level of improvement throughout the pendency of the appeal. Moreover, the more recent evidence of record appears to reflect that the Veteran could also be taking oral medication, and possibly undergoing systemic therapy, for his skin disorder. In reviewing the entirety of the evidence, the Board finds there to be an approximate balance of evidence both for and against a finding of actual, sustained improvement in the Veteran's service-connected eczema of hands/dermatitis that has remained throughout the years, and resolves all reasonable doubt in favor of the Veteran. Thus, the Board finds that the reduction from 60 percent to 30 percent for the Veteran's eczema was improper. Accordingly, the 60 percent disability rating for eczema of hands/dermatitis is restored. ORDER New and material evidence having been received sufficient to reopen the previously denied claim for service connection for PTSD, this portion of the Veteran's appeal is granted. Entitlement to service connection for an acquired psychiatric disorder, diagnosed as PTSD and depressive disorder, is granted. The reduction of the 60 percent disability rating for the eczema of hands/dermatitis was improper, and the 60 percent disability rating is restored, effective April 15, 2005. The appeal is granted. REMAND The Veteran seeks entitlement to special monthly compensation based on the need for regular aid and attendance of another person or at the housebound rate. Special monthly compensation is payable if, as the result of service-connected disabilities, the Veteran is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b) . Under 38 C.F.R. § 3.352(a), the following factors will be accorded consideration in determining whether a veteran is in need of regular aid and attendance of another person: (1) the inability of the veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; (3) inability of the veteran to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; and (4) 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 incident to his daily environment. Housebound benefits are warranted if, in addition to having a single permanent disability rated 100 percent disabling under the VA Schedule for Rating Disabilities, the Veteran: (1) has additional disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability rated as 100 percent disabling and involving different anatomical segments or bodily systems, or, (2) is "permanently housebound" by reason of disability or disabilities. This requirement is met when the Veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, 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. § 1502(c) (West 2014); 38 C.F.R. § 3.351(d). The Veteran is currently service-connected for bilateral hallux valgus, which is evaluated as 50 percent disabling; radiculopathy of the right upper extremity, evaluated as 40 percent disabling; radiculopathy of the left upper extremity, evaluated as 30 percent disabling; eczema, which as determined above, is now evaluated as 60 percent disabling; duodenal ulcer with surgical scar, evaluated as 20 percent disabling; degenerative arthritis of the left talonavicular joint, evaluated as 20 percent disabling; degenerative arthritis of the right talonavicular joint, evaluated as 20 percent disabling; degenerative arthritis with degenerative disc disease of the cervical spine, evaluated as 20 percent disabling; degenerative joint disease (DJD) of the lumbar spine, evaluated as 20 percent disabling; right knee medial meniscal injury with medial joint degenerative joint disease, evaluated as 10 percent disabling; status post right wrist distal radius fracture with arthritis, evaluated as 10 percent disabling; and arthritis of the left knee with patellofemoral syndrome and bipartite patella, evaluated as 10 percent disabling. The combined rating of the service-connected disabilities is 100 percent, effective June 23, 2010. See 38 C.F.R. § 4.16. The Veteran was granted entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), effective from March 30, 2006 to June 23, 2010. At the May 2009 examination in connection to the Veteran's claim for housebound status or permanent need for regular aid and attendance, the VA examiner diagnosed the Veteran with having osteoarthritis, DJD of the spine, and fibromyalgia syndrome, commenting that while the Veteran is able to feed himself, he does need assistance when it comes to bathing and tending to other hygiene needs. When asked whether the Veteran was legally blind, required nursing home care, or medication management, the examiner indicated that he did not. According to the examiner, the Veteran could not stand fully erect, required assistance with right shoulder use and range of motion, and was wheelchair bound. With respect to the Veteran's restrictions, the examiner noted that the Veteran had minimal upper extremity problems, but commented that he had "FMS which causes shoulder discomfort but no limitation." The examiner further noted that the Veteran's severe osteoarthritis in his knee and DJD of the spine limits his ability to stand for prolonged periods of time. According to the examiner, the Veteran uses a wheelchair to ambulate, and has a difficult time walking more than three to five feet. The examiner also noted that the Veteran's PTSD affects his ability to leave his home. When asked how often a day or week, and under what circumstances, the Veteran is able to leave him home or immediate premises, the examiner noted that the Veteran can leave home for a few days to a week for water therapy, as long as he is transported with a wheelchair. When asked whether assistive devices such as canes, braces, crutches or the assistance of another person is required for locomotion, the examiner responded yes, and added that assistive devices are required for a distance of less than one block. At the June 2012 VA examination, the VA examiner noted that the Veteran is able to feed himself and prepare his own meals. She also noted that the Veteran requires assistance with certain activities, to include bathing and tending to other hygiene needs, and added that the Veteran uses homecare for bathing, cooking and cleaning. She (the examiner) observed that the Veteran was not legally blind, did not require nursing home care, and did not require medication management. With respect to his posture and general appearance, it was noted that the Veteran ambulated with the help of two canes and a motor scooter. The examiner observed no restrictions associated with the upper extremities due to the Veteran's disabilities, and when asked about any restrictions associated with the lower extremities, she simply wrote "non-weight bearing." With respect to any restrictions associated with the spine, trunk and neck, the examiner noted that the Veteran experienced stiffness due to his fibromyalgia. As for any pathology affecting the Veteran's ability to perform self-care, ambulate, or travel beyond the premises of the home due to his disabilities, the examiner wrote that the Veteran had poor balance. According to the examiner, the Veteran is able to leave the home or immediate premises on an as needed basis. When asked whether any assistive devices are required for locomotion, the examiner marked yes and indicated that the Veteran required assistance when travelling any distance greater than one block. At a June 2014 VA examination in connection with this claim, the examiner noted that the Veteran was not permanently bedridden, and could travel beyond his current domicile. The Veteran used a specially equipped van to travel to his examination, and was accompanied by one of his family members at the examination. When asked about his typical daily activities, the Veteran stated that he rarely goes outside, he watches television most of the day, and he tries to perform stretching exercises in his upper and lower extremities every day. It was noted that the Veteran required assistance when putting on and taking off his bilateral knee brace, and when putting on, and taking off, his back brace. It was further noted that the Veteran wore special boots, and needed help when putting them on and taking them off. With respect to the Veteran's ability to protect himself from daily hazards/dangers, the examiner noted that the Veteran did not experience any dizziness or memory loss, and any imbalance attributed to his disabilities did not affect his ability to ambulate. When asked whether there were any other body parts or system impairments that affect the Veteran's ability to protect himself from the daily environment, the examiner indicated that the Veteran's right shoulder ability prevents him from pushing, pulling or lifting, and his bilateral knee disability occasionally give out and cause him to fall. According to the examiner, the Veteran is unable to dress/ undress himself, bathe, groom and perform his own toileting. On physical examination, the examiner noted that the Veteran presented in a wheelchair, and described the Veteran as overweight and with an average posture. The examiner also noted that the Veteran can walk without the assistance of another person when he is at home, and even then he requires a walker to help him ambulate. In addition, the examiner noted that the Veteran needs to be transported around in his wheelchair, and he does not go out by himself, as he is usually accompanied by a family member. The examiner determined that the Veteran's functional impairments were permanent, and noted that the Veteran's spine did exhibit limitation of motion, as he had difficulty bending forward to pick up objects. According to the examiner, the Veteran's functional capacity of the upper extremities was abnormal, and while he had normal strength in his upper extremity, he exhibited mild or moderate impairment in the right upper extremity. The examiner determined that the Veteran had some difficulty self-feeding, and marked difficulty dressing/undressing himself, bathing, grooming performing his toileting abilities. According to the examiner, the Veteran's functional capacity in his lower extremities was also abnormal. Specifically, the Veteran exhibited limitation of joint motion, muscle weakness, and lack of coordination in both lower extremities. The examiner also described the Veteran's weight bearing and propulsion as abnormal, and attributed the abnormal propulsion to his DJD. The examiner did not observe any abnormalities in the Veteran's mental competency, and found that the Veteran was capable of managing his financial affairs. Based on his discussion with, and evaluation of the Veteran, the VA examiner diagnosed him with having bilateral upper extremity radiculopathy, DJD lumbar spine, DDD in the cervical spine, DJD in the bilateral knees, bilateral ankle DJD, and shoulder DJD. At a July 2014 VA examination in connection with this claim, the instructions noted that the Veteran was claiming loss of all effective function in his right lower extremity/foot due to his service-connected hallux valgus, degenerative changes in the right talonavicular joint, DJD of the lumbar spine, and right knee meniscal injury with medial DJD. It was also noted that the Veteran was claiming loss of all effective function in the left lower extremity/foot due to service-connected hallux valgus, degenerative changes in the left talonavicular, and DJD of the lumbar spine. The examiner was asked to provide a complete description of the remaining function in the right lower extremity/foot and left lower extremity/foot with respect to both balance and propulsion, and to give an assessment as to whether the remaining foot function was no better than would be provided by an amputation and a suitable prosthesis. In his assessment, the examiner wrote that the Veteran "reported in motorized chair with bilateral full leg ankle back arthrosis in place [that] he paid a trained attendant to apply that AM." According to the examiner, the Veteran can stand but he is unsteady with cane crutch support, and his weight imbalance makes an attempt to examine him impossible without risk to the safety of myself and the patient. The examiner determined that this examination could only be performed in a "therapy" environment with adequate staff and equipment to accomplish the goal in a safe and valuable manner. The Veteran's claims file was referred to another examiner for a clarifying opinion in August 2014. The examiner was asked whether it was at least as likely as not that the limitations described in the June 2014 and July 2014 VA examinations were due solely to the Veteran's service-connected hallux valgus, degenerative changes in the right and left talonavicular, degenerative joint disease of the lumbar spine, and right knee meniscal injury with medial degenerative joint disease. In response to this question, the examiner wrote "due to the conditions stated in the previous template dated [July 2014], the individual was not and could not be examined therefore any medical opinion regarding causes for such conditions would be purely speculative and without substantive foundation...." The Board notes that additional evidence in the form of VA examination reports dated in December 2014 and March 2015, along with numerous VA treatment records issued from the Fayetteville VA Medical Center, and dated from 2011 to June 2015, have been scanned into the VBMS and Virtual VA Claims processing system after the issuance of the most recent Supplemental Statement of the Case (SSOC) in connection to this disorder (in October 2014). These examinations were in connection with the Veteran's request for SMC based on the need for regular aid and attendance or at the housebound rate. VA treatment records dated from August 2011 to June 2015 reflect outpatient treatment for the Veteran's various service-connected disabilities, to include his lower extremities. The Veteran has not specifically stated that he was waiving consideration of the additional evidence by the AOJ. Pursuant to 38 C.F.R. § 20.1304(c), any pertinent evidence submitted by the Veteran must be referred to the AOJ for initial review, unless this procedural right is waived by the Veteran or his representative, or unless the Board determines the benefit sought can be allowed on appeal without such a referral. Therefore, the Board may not properly consider this evidence or issue a decision at this time, and must remand the case to allow the AOJ opportunity to review this evidence and readjudicate the Veteran's claim. See 38 C.F.R. § 19.31 Finally, the claims of entitlement to specially adapted housing, and special home adaptation must be remanded because they are inextricably intertwined with the claim for SMC based on the need for aid and attendance of another person, or on account of being housebound. In this regard, the Veteran has indicated that he is no longer mobile, and requires the use of a wheelchair and the assistance of a caretaker to help him function on a day-to-day basis. In essence, the Veteran has asserted that he is unable to use his lower extremities, and this loss of use precludes locomotion without the aid of braces, crutches, canes, or a wheelchair. The Veteran has also asserted that the loss of use of one lower extremity together with residuals of organic disease or injury affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. These are specific criterion associated with the claim for specially adapted housing. As such, the claim of entitlement to SMC based on the need for aid and attendance of another person, or on account of being housebound should be determined before the claims for entitlement to specially adapted house and entitlement to a special home adaptation grant can be decided. In addition, effective October 25, 2010, VA amended its regulations regarding eligibility for specially adapted housing grants, and it is unclear whether the AOJ has provided the Veteran with the revised regulations. On remand, any ongoing private and VA treatment records should also be obtained. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b) ; see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the issues of entitlement to SMC based on the need for aid and attendance of another person, or on account of being housebound, as well as the issues of entitlement to specially adapted housing and a special home adaptation grant are REMANDED for the following action: 1. The AOJ should take appropriate steps to contact the Veteran and request that he identify all VA and non-VA health care providers, other than those already associated with the Veteran's claims file, that have treated or evaluated him since service for her service-connected disorders. This shall specifically include updated treatment records from VA. The aid of the Veteran in securing these records, to include providing necessary authorization(s), should be enlisted as needed. If any requested records are not available, or if the search for any such records otherwise yields negative results, that fact should clearly be documented in the claims file, and the Veteran informed in writing. The Veteran may submit medical records directly to VA. 2. Then, the Veteran should be scheduled for another VA examination in a "therapy environment" (as instructed by the July 2014 VA examiner) with an examiner qualified to determine whether it is at least as likely as not, i.e., a 50 percent probability or greater, that the Veteran's service-connected disabilities (bilateral hallux valgus; radiculopathy of the right and left upper extremities; eczema; duodenal ulcer; degenerative arthritis of the right and left talonavicular joints; DDD cervical spine; DJD of the lumbar spine; right knee medial meniscal injury with medial joint DJD; status post right wrist distal radius fracture with arthritis; arthritis of the left knee) individually or collectively cause him to be in need of regular A&A of another person. The paperless claims file must be made available to a VA examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the electronic records that were reviewed. In reaching these conclusions, the examiner must address the following: Whether as a result of the Veteran's service-connected disabilities, he had (1) an inability to dress or undress himself or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability could not be done without aid; (3) an inability to feed himself through loss of coordination of his upper extremities or through extreme weakness; (4) an inability to attend to the wants of nature; or (5) presence of incapacity, either physical or mental, which required care or assistance on a regular basis to protect the Veteran from hazards or dangers incident to his daily environment. The examiner must provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. Finally, after undertaking any other development deemed appropriate, the AOJ must readjudicate the issues on appeal. If any benefits sought are not granted, the AOJ must furnish the Veteran and his representative with a supplemental statement of the case which must include the revised regulations for entitlement to specially adapted housing. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs