Citation Nr: 1752575 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 13-02 978 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for neuropathy of the left upper extremity as secondary to service-connected cervical disc disease and / or service-connected loss of use of the right upper extremity. 2. Entitlement to an increased disability rating greater than 10 percent for a service-connected left shoulder disability. 3. Entitlement to special monthly compensation (SMC) on account of the need for regular aid and attendance under 38 U.S.C.A. § 1114(l). 4. Entitlement to a higher rate of SMC under 38 U.S.C.A. § 1114(o) and (r)(1). REPRESENTATION Veteran represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD P.S. Rubin, Counsel INTRODUCTION The Veteran had active duty service in the United States Army from April 1968 to April 1970 and from August 1985 to June 1999. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July 2012 and January 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In April 2015, the Veteran and his spouse presented testimony at a Travel Board hearing at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is included in the claims file. The Veteran also perfected an appeal of the RO's denial of an increased rating greater than 70 percent for loss of use of the right upper extremity. However, the Veteran clearly and unambiguously withdrew that appeal in writing in a May 2014 statement. See 38 C.F.R. § 20.204(b) (2017); DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). Therefore, that issue is not on appeal before the Board. Finally, after the RO last considered the appeal in the June 2014 Supplemental Statement of the Case (SSOC), the Veteran has submitted private medical evidence and argument. In any event, there is now an automatic waiver of initial RO review of evidence submitted to the RO or to the Board at the time of or subsequent to the submission of a Substantive Appeal filed on or after February 2, 2013, unless the claimant or claimant's representative requests in writing that the RO initially review such evidence. See 38 U.S.C.A. § 7105(e)(1) (West 2014). In the present case, the Veteran's Substantive Appeal was received in October 2013, which is after the February 2, 2013 effective date of the new statute. Also, the Veteran did not request initial RO review of this evidence. Thus, no waiver of RO consideration for this evidence is necessary for the Board to consider it. FINDINGS OF FACT 1. There is an approximate balance of favorable and unfavorable evidence as to whether the Veteran has neuropathy of the left upper extremity due to or the result of service-connected cervical disc disease and service-connected loss of use of the right upper extremity. 2. The Veteran's service-connected non-dominant left shoulder disability is productive of pain, fatigue, weakness, tenderness, some limitation of motion with less movement than usual, and other functional loss factors, but is not productive of limitation of motion to 25 degrees from the side, ankylosis, impairment of the humerus, or impairment of the clavicle or scapula causing dislocation, nonunion, or malunion. 3. The collective impact of the Veteran's service-connected disabilities (loss of use of the right upper extremity, low back degenerative disc disease, cervical disc disease, asthma, tinnitus, a right thumb disability, a right shoulder disability, a left shoulder disability, a psychiatric adjustment disorder, and others) - excluding his service-connected lower extremity disabilities, demonstrates the necessity for the regular aid and attendance of another person. 4. The Veteran's need for aid and attendance and his loss of use of both feet are based on separate service-connected disabilities. As such, the Veteran has suffered disability under conditions which would entitle him to two SMC awards at the L-rate, without consideration of any condition twice. Therefore, the Veteran meets the criteria for additional SMC under 38 U.S.C.A. § 1114 (o) and (r)(1). CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in his favor, the Veteran's neuropathy of the left upper extremity is secondary to his service-connected cervical disc disease and loss of use of the right upper extremity. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.310(a) (2017). 2. The criteria are met for a higher 20 percent rating, but no greater, for the Veteran's service-connected left shoulder disability. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.27, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Code 5024-5201 (2017). 3. The criteria are met for entitlement to SMC benefits by reason of being in need of aid and attendance of another person. 38 U.S.C.A. §§ 1114(l), 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.350(b), 3.352(a) (2017). 4. The criteria are met for a higher rate of SMC at the 38 U.S.C.A. § 1114(o) and (r)(1) levels. 38 U.S.C.A. §§ 1114(o), (r)(1), 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.102, 3.159, 3.350, 3.352 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or the duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Secondary Service Connection for Left Upper Extremity Neuropathy The Veteran contends that he has neuropathy of the left upper extremity secondary to his service-connected cervical disc disease, or in the alternative, secondary to his service-connected loss of use of the right upper extremity. He says he experiences pain, numbness, tingling, weakness, reduced grip, and tremors in his left upper extremity beginning around 2006 or 2007. He asserts these symptoms are similar to the symptoms he experiences from his already service-connected cervical radiculopathy in the right upper extremity. He contends that his cervical disc disease has progressed from previously being only present at C5-C6 (right-sided), to also compressing the C6-C7 (left-sided) nerve root by way of moderate foraminal stenosis. According to the Veteran, this correlates to a radicular pain pattern with intermittent numbness and weakness in the left upper extremity due to cervical disc disease, as opposed to mere ulnar nerve entrapment in the left arm. See April 2012 Veteran statement; July 2012 Veteran statement; October 2012 claim; January 2013 NOD; October 2013 VA Form 9; April 2014 private medical opinion of Dr. A.L.R., DO. In the alternative, the Veteran also believes that his neuropathy of the left upper extremity could be due to overuse. He explains that after he lost the use of his service-connected right upper extremity, he has had to adjust by using his left extremity more and more to accomplish daily tasks like eating, dressing, going to the bathroom, attending social activities, home maintenance, home cleaning, shopping, and rising from a seated position. He adds that at one time he was able to use both his right and left arms and hands to rise from a sitting position such as from his wheelchair, his sofa, his bed, his car, and his toilet seat. However, after he lost the use of his service-connected right hand and right arm, he has compensated by putting more pressure onto his left hand and left arm, in order to stand up. In other words, he overuses his left upper extremity in order to compensate for the service-connected loss of use of the right upper extremity. See April 2012 Veteran statement; July 2012 Veteran statement; October 2012 claim; January 2013 NOD; October 2013 VA Form 9; April 2015 Travel Board hearing testimony at page 4. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). When determining service connection, all theories of entitlement, direct and secondary, must be considered if raised by the evidence of record, applying all relevant laws and regulations. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). With regard to secondary service connection, a disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Moreover, secondary service connection may be established, as well, by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b), effective October 10, 2006. See 71 Fed. Reg. 52,744-52,747 (September 7, 2006). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. In short, in order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) probative evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). A VA medical opinion regarding both the causation and aggravation facets of a secondary service connection claim must be provided in a secondary service connection claim. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) VA is to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. 38 U.S.C.A. § 1154(a). The Federal Circuit has held that medical evidence is not always or categorically required in every instance to establish a medical diagnosis or the required nexus between the claimed disability and the Veteran's military service or a service-connected disability. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). That is, lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson, 581 F.3d at 1316. See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In short, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent on the issues of diagnosis and medical causation. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). "The question of whether a particular medical issue is beyond the competence of a layperson-including both claimants and [VA adjudicators] must be determined on a case-by-case basis. Id. For instance, a layperson is competent to identify such disorders as varicose veins, tinnitus, and flat feet. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8°Vet. App. 398, 405 (1995). In contrast, a layperson is not competent to identify medical conditions that require scientific, technical, or other specialized knowledge, such as in identifying rheumatic fever. 38 C.F.R. § 3.159(a)(1); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Therefore, the Board must assess the competence and credibility of lay statements. Barr, 21 Vet. App. at 308. In determining whether secondary service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Upon review of the evidence of record, the Board finds that service connection for neuropathy of the left upper extremity as secondary to service-connected cervical disc disease and service-connected loss of use of the right upper extremity, is warranted. At the outset, as noted, the Veteran is already service-connected for cervical disc disease and loss of use of the right upper extremity. In addition, the existence of a current disability for the left upper extremity is undisputed - the Veteran has some sort of neuropathy of the left upper extremity. See e.g., December 2012 VA peripheral nerves examination; December 2012 VA EMG report; January 2013 private magnetic resonance imaging (MRI) of the cervical spine; April 2014 private medical opinion of Dr. A.L.R., DO. Service treatment records (STRs) are negative for any complaint, treatment, or diagnosis of left hand neuropathy or left arm neuropathy. Post-service, the first reported instance of left arm or left hand neurological symptoms is from VA treatment records dated in 2006 and 2007, approximately six to seven years after separation from active duty. In fact, there is neither evidence nor allegation of in-service incurrence for the Veteran's current left upper extremity neurological symptoms. With regard to secondary service connection for neuropathy of the left upper extremity, the evidence in the claims folder contains a mix of favorable and unfavorable medical opinions, lay evidence, and medical treatise evidence. In analyzing the evidence, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). With regard to favorable evidence, there is some probative medical and lay evidence of record that demonstrates that the Veteran's current neuropathy of the left upper extremity is proximately due to or the result of his service-connected cervical disc disease and service-connected loss of use of the right upper extremity. 38 C.F.R. § 3.310(a); Velez v. West, 11 Vet. App. 148, 158 (1998). Specifically, as explained in detail above, the Veteran has submitted lay statements and hearing testimony from himself and his wife and his representative credibly setting forth his contentions in support of secondary service connection. In addition, a June 2009 VA primary care outpatient note indicated that his left hand pain was due to "overuse" in daily activities like showering and bathing because the Veteran was compensating for his service-connected right arm impairment. Further, a December 2012 VA peripheral nerves examiner diagnosed left upper extremity ulnar mononeuropathy, "consistent with overuse" by way of a December 2012 electromyography (EMG) report. Also, a January 2013 MRI of the cervical spine revealed moderate left-sided C6-C7 foraminal stenosis and end plate osteophyte compressing the left C7 root across the spinal canal. Based on these MRI findings, a January 2013 private medical opinion of Dr. A.L.R., DO, concluded that "[i]t is my medical opinion that these findings correlate with presenting symptoms of left upper extremity and indicate progression of previously documented cervical degeneration as a result of service related injuries." Medical treatise evidence was included in support of this conclusion. With regard to favorable evidence, in April 2014 Dr. A.L.R., DO, proffered an additional medical opinion. Dr. A.L.R. opined that after reviewing the Veteran's EMG and MRI reports, the Veteran's pain pattern and numbness pattern demonstrate involvement of not only the ulnar nerve but also median nerve distribution, which is a derivative of cervical nerve roots C5, C6, C7, C8 and T1. In short, it was Dr. A.L.R.'s impression that some of the pain pattern the Veteran is experiencing in the left arm is derived from "cervical nerve roots." Dr. A.L.R. added that on the Veteran's MRI there was spondylosis and mild canal stenosis at C5-C6 and C6-C7 and moderate foraminal stenosis at C6-C7. It was his opinion that the Veteran's moderate foraminal stenosis could cause nerve root compressive symptoms resulting in a radicular pain pattern and intermittent numbness and weakness in the left arm. In addition to the pain, weakness, tremors, and numbness in the left hand, the Veteran also has pain in the left upper arm. He describes pain at the base of his neck on the left. With rotation, the Veteran has pain in his upper arm on the left. All of this symptomology is consistent with a "cervical" radicular pain pattern. Dr. A.L.R. surmised that his impression was based on his practice experience of 10 years, 3 years of medical residency in family medicine, and 4 years of education in an osteopathic medical school. It was his practice experience that patients do experience radicular pain patterns and have chronic ongoing cervical radicular pain despite having EMG findings which fail to indicate EMG abnormality at the cervical level, like the present Veteran. Given that the Veteran's symptoms complex does not entirely correlate with an ulnar nerve entrapment, despite what the VA examiner says, Dr. A.L.R.'s impression is that the Veteran has radicular symptoms in the left upper extremity from service-connected degenerative cervical disc disease. However, with regard to the unfavorable, negative evidence of record, there is some probative medical evidence and medical treatise evidence of record that is against secondary service connection. 38 C.F.R. § 3.310(a). A December 2012 VA peripheral nerves examiner, based on abnormal EMG testing at the examination, diagnosed the Veteran with left upper extremity ulnar mononeuropathy. But the VA examiner found no evidence of a left upper extremity cervical radiculopathy. The VA examiner explained that the Veteran's left upper extremity symptoms of numbness, tingling, and tremors are "less likely as not" due to or the result of the service-connected mechanical cervical muscle strain or cervical disk disease C5-C6 with osteophyte complex. The reasoning was that the EMG was negative for any cervical radiculopathy findings. Instead the EMG showed a left upper extremity ulnar neuropathy. With regard to unfavorable evidence, a December 2012 VA EMG report assessed mild non-localizable left ulnar mononeuropathy, but "no electrophysiological evidence of left cervical radiculopathy." With regard to unfavorable evidence, in an April 2013 VA medical opinion, a VA examiner reviewed recent MRI findings revealing stenosis at C7 with left-sided findings. Nonetheless, the VA examiner concluded that in stark contrast, the recent EMG of the left upper extremity clearly showed no evidence of a cervical radiculopathy. Instead, it showed evidence of a mononeuropathy at the ulnar nerve, which is a localized finding. The VA examiner surmised that if the Veteran's service-connected cervical disease was truly causing his left upper extremity complaints, then EMG testing would surely show this, especially with the moderate level of findings noted on MRI testing. However, the EMG did not show this. The VA examiner added that this could easily change in the future, should the Veteran's cervical disease progress, but at this time, more weight needs to be placed on specific EMG testing, rather than the MRI alone. The VA examiner further cited medical treatise evidence for the argument that EMG testing was much more specific than an MRI alone, based on delineating neuropathies. The EMG carries more weight than the MRI, according to the VA examiner. With regard to unfavorable evidence, in a June 2013 VA medical opinion, a VA examiner opined that it was his medical opinion that the Veteran's left upper extremity condition is less likely than not as a result of or aggravated by his service-connected loss of use of his right upper extremity. The VA examiner added that the intention tremors the Veteran experiences in the left upper extremity are also not related to the service-connected cervical spine, as tremors are related to the cerebellum instead. Neither the EMG nor the MRI of record would establish a cervical cause of his left-sided tremor, as an intention tremor is usually "cerebellar" in nature. (It is noted by the Board that in contrast, the Veteran submitted medical treatise evidence along with his October 2013 VA Form 9 espousing the theory that an MRI is better than an EMG for purposes of establishing any nerve root pinching caused by a herniated cervical disc). Although the Court has held that, in general, information contained within medical articles and treatise evidence is too abstract to prove the nexus element of a service-connection claim, the Court has also held that treatises "can provide important support when combined with an opinion of a medical professional." Sacks v. West, 11 Vet. App. 314, 316-17 (1998). Furthermore, a medical article or treatise, standing alone, may provide sufficient evidence of a causal connection when it "discusses generic relationships with a degree of certainty" so that the causal connection is "based upon objective facts rather than on an unsubstantiated lay medical opinion." Id. at 317. Both the VA and private examiners have submitted contrasting, yet probative medical treatise texts in the present case. As currently codified, VA law defines the "benefit of the doubt" doctrine as: When, after consideration of all evidence and material of record in this case before the Department with respect to benefits under laws administered by the Secretary, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination in the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). See also 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Here, there is an approximate balance of the positive and negative evidence as to secondary service connection for neuropathy of the left upper extremity. Certain elements of both the positive and negative opinions in this case, as well as the medical treatise evidence, are probative. All of the medical opinions, both VA and private, have their respective flaws as well. But there is no apparent basis for wholly rejecting the favorable medical opinions of record. In light of the contrasting, yet equally probative medical opinions in the present case, in such situations, the benefit of the doubt is resolved in the Veteran's favor. Accordingly, secondary service connection for neuropathy of the left upper extremity is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board emphasizes that it is granting secondary service connection for neuropathy of the left upper extremity on the basis that it is the direct result of the Veteran's service-connected cervical disc disease and service-connected loss of use of the right upper extremity, as opposed to aggravation. III. Increased Rating for Left Shoulder at 10 Percent Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Veteran filed an increased rating claim for his service-connected left shoulder disability in May 2012. The Veteran's entire history is reviewed when assigning a disability evaluation. 38 C.F.R. § 4.1. However, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board must consider whether there have been times when his left shoulder disability has been more severe than at others, and rate it accordingly. "The relevant temporal 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." Hart, 21 Vet. App. at 509. The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and duration of his service-connected left shoulder disability. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). The Veteran's left shoulder disability is currently assigned a 10 percent rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5024-5203 (tenosynovitis and impairment of the clavicle or scapula). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. Under Diagnostic Code 5024, tenosynovitis is rated on limitation of motion of the affected part, or as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. Traumatic arthritis under Diagnostic Code 5010 is rated analogous to degenerative arthritis under Diagnostic Code 5003. Degenerative arthritis, when established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For purposes of rating disability from arthritis, the shoulder is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic code that focuses on limitation of motion of the shoulder is Diagnostic Code 5201. The provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 must be considered in assigning an evaluation for degenerative or traumatic arthritis under Diagnostic Code 5003 or 5010. Rating personnel must consider functional loss and clearly explain the impact of pain on the disability. VAOPGCPREC 9-98. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I. At the outset, VA examiners have noted that the Veteran is right-hand dominant. Therefore, his service-connected left shoulder is clearly on the minor, i.e., non-dominant side. See 38 C.F.R. § 4.69. Under Diagnostic Code 5201, limitation of motion of the minor arm at the shoulder level (i.e., motion limited to 90 degrees) provides a 20 percent rating. Limitation of motion midway between the side and the shoulder level (i.e., motion limited from 45 to 90 degrees), is assigned a 20 percent evaluation. A maximum 30 percent evaluation is warranted for the minor arm when limitation of motion is limited to 25 degrees from the side. 38 C.F.R. § 4.71 (2017). A Veteran is only entitled to a single disability rating under Diagnostic Code 5201 as that diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013). Under Diagnostic Code 5203, impairment of the clavicle or scapula, for a minor (non-dominant) shoulder, malunion of the clavicle or scapula is rated as 10 percent disabling. Nonunion of the clavicle or scapula, without loose movement is rated as 10 percent disabling. Nonunion of the clavicle or scapula, with loose movement is rated as 20 percent disabling. Dislocation of the clavicle or scapula is rated as 20 percent for the minor shoulder. Diagnostic Code 5203 also provides an alternative rating based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71 (2017). When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). With any form of arthritis, painful motion is an important factor of disability. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Moreover, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. When § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, VA should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). Upon review of the evidence, a higher 20 percent rating, but no greater, is warranted for the service-connected left shoulder under Diagnostic Code 5201. 38 C.F.R. § 4.7. In this regard, VA treatment records dated from 2007 to 2014, as well as a VA shoulder examination dated in May 2012 reveal observable left shoulder pain, fatigue, weakness, tenderness, some limitation of motion with less movement than usual, and other functional loss factors. The Veteran has weekly flare-ups for his left shoulder. His strength was reduced at 4/5 for the left shoulder. In addition, at the April 2015 Travel Board hearing (at page 5), the Veteran credibly demonstrated limited range of left shoulder motion below the mid-level (below 90 degrees). In this regard, the Court has held that painful motion may be "objectively confirmed" by either a clinician or a layperson who witnessed the veteran experience painful motion. Petitti v. McDonald, 27 Vet. App. 415, 429-30 (2015) (emphasis added). But most importantly, as pertinent to the assignment of a 20 percent rating for the left shoulder, VA regulation provides that joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint, even if arthritis is not present. 38 C.F.R. § 4.59; Burton, 25 Vet. App. at 3-5. A veteran experiencing an actually painful joint is entitled to at least the minimum compensable rating for the joint under the appropriate diagnostic code to the joint involved. In other words, section 4.59 does not require "objective" evidence of painful motion. In this case, there is credible medical and lay evidence of left shoulder pain, limitation of motion, and other functional loss factors throughout the appeal period. The minimum compensable rating under the limitation of motion code pertaining to the affected left shoulder joint is 20 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Therefore, a 20 percent rating is warranted for the Veteran's left shoulder throughout the entire appeal period under Diagnostic Code 5201. 38 C.F.R. § 4.59, Burton, 25 Vet. App. at 3-5, Petitti, 27 Vet. App. at 424-30. In this regard, where the joint at issue is the shoulder, it is not to the Veteran's benefit to apply the Lichtenfels case and assign a 10 percent rating under DC 5003 for painful motion. That is, in cases where there is painful shoulder motion, it is more beneficial to apply Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), and where there is functional loss, to apply DeLuca v. Brown, 8 Vet. App. 202, 205-06 (1995) and Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011), because these cases provide for the assignment of the minimum compensable rating under the limitation of motion code pertaining to the affected joint, or 20 percent, in the case of the shoulder. See 38 C.F.R. § 4.71a, DC 5201. Thus, a minimum 20 percent rating is assigned for the left shoulder in the present case. However, throughout the entire appeal period, the Veteran is not entitled to an increased evaluation in excess of 20 percent for the left shoulder. See 38 C.F.R. § 4.7. Specifically, even with consideration of functional loss, the evidence does not show that there is functional loss more nearly approximating 25 degrees from the side for flexion or abduction for the minor left shoulder joint. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Range of motion findings for the left shoulder, although limited, do not demonstrate motion limited to 25 degrees from the side. See Plate I; 38 C.F.R. §§ 4.40, 4.45, 4.59; Mitchell, 25 Vet. App. 32; DeLuca, 8 Vet. App. 202. At the May 2012 VA shoulder examination, the Veteran exhibited left shoulder forward flexion to 130 degrees and abduction to 120 degrees, with consideration of pain and three repetitions of range of motion. There was also no evidence of limitation of external or internal rotation for the left shoulder. At the April 2015 Travel Board hearing (at page 5), range of motion demonstration also did not reveal functional loss more nearly approximating 25 degrees from the side for the left arm. In making this determination, the Board has consistently considered the impact of functional loss upon the Veteran's range of motion of the left shoulder. In addition, the medical and lay evidence of record from 2011 onwards reveals no evidence of malunion or nonunion of the clavicle or scapula, no evidence of impairment of the humerus, and no evidence of ankylosis of the scapulohumeral articulation. There was no evidence of flail shoulder, false flail joint, dislocation, guarding, rotator cuff tear, an AC joint condition, malunion, or nonunion. Thus, consideration of ratings under Diagnostic Codes 5200, 5202, or 5203 is not warranted. In particular, the March 2012 VA shoulder examiner, after objective testing, found no evidence of these potential conditions. Consequently, the Board concludes that Diagnostic Code 5201 most appropriately reflects the Veteran's service-connected left shoulder disability, as opposed to Diagnostic Code 5203. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if supported by explanation and evidence). The Board acknowledges that the Veteran was previously assigned a 10 percent rating by the RO under Diagnostic Code 5203 for impairment of the clavicle or scapula with malunion or nonunion. At present, no current evidence of record reveals this impairment. In any event, Diagnostic Code 5203 also specifically provides for an alternative rating based on "impairment of function of the contiguous joint." See 38 C.F.R. § 4.71. In this respect, the Veteran has already been assigned a higher 20 percent rating for limitation of motion of the left arm under Diagnostic Code 5201. Therefore, to assign a separate, additional 10 percent rating under Diagnostic Code 5203 would constitute pyramiding. That is, the impairment of function to the left shoulder under Diagnostic Codes 5201 and 5203 are overlapping. The manifestations of left shoulder disability are not shown to be separate and distinct in this case. Evaluation of the same disability or the same manifestations of disability under multiple diagnoses (i.e., pyramiding) is to be avoided. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. Thus, a separate, additional 10 percent evaluation for the left shoulder is not warranted under Diagnostic Code 5203. The Board emphasizes it is permissible to switch diagnostic codes to more accurately reflect a claimant's current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the situs of the disability, or the diagnostic code associated with it, is corrected to more accurately determine the benefit to which a veteran may be entitled for a service-connected disability). Consequently, the Board concludes that a 20 percent rating under Diagnostic Code 5201 most appropriately reflects the Veteran's service-connected left shoulder disability. See again Butts, 5 Vet. App. at 538 (noting that the choice of diagnostic code should be upheld if supported by explanation and evidence). With regard to the increased rating issue for the left shoulder, the Board acknowledges the Court recently held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Thus, the Court's holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. A review of the claims file reveals that neither the May 2012 VA shoulder examination of record, nor VA or private treatment records dated from 2007 to 2014, demonstrate range of motion testing for the left shoulder in passive motion or weight-bearing situations. However basic common sense would lend itself to the view that the shoulders, unlike the knees, are generally not a weight-bearing joint. In addition, there is no logical indication why passive range of motion of the left shoulder would change the outcome here. Furthermore, the shoulder issue on appeal has been pending since 2012, so for close to six years. An immediate Board adjudication is to the Veteran's benefit. Moreover, neither the Veteran nor his representative has requested a new VA shoulder examination based on the holding of Correia. So even though the VA shoulder examinations of record may not strictly satisfy the requirements of the Correia case, here this is inconsequential and, therefore, at most harmless error. See 38 C.F.R. § 20.1102. Accordingly, the Board finds that the evidence supports an increased disability rating of 20 percent, but no higher, for a left shoulder disabilty. 38 C.F.R. § 4.3. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record)." IV. SMC - Aid and Attendance at "L" Level SMC is available when, as the result of service-connected disability, a veteran suffers additional hardships above and beyond those contemplated by VA's schedule for rating disabilities. See 38 U.S.C.A. § 1114; 38 C.F.R. §§ 3.350, 3.352; see also VA Gen. Coun. Prec. 5-89 (Mar. 23, 1989) (explaining that SMC is a supplementary statutory benefit based on noneconomic factors such as personal inconvenience, social inadaptability, or the profound nature of a disability). The rate of SMC varies according to the nature of the Veteran's service-connected disabilities. Basic levels of SMC are listed at 38 U.S.C.A. § 1114(k). Higher levels of SMC are provided at 38 U.S.C.A. § 1114(l), (m), (n), and (o). SMC is payable in addition to the basic rate of compensation otherwise payable for the degree of disability. The RO has already awarded the Veteran SMC at the following levels: K-1 - Under 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350(a) on account of loss of use of a creative organ, effective from March 7, 2007; K-1 - Under 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350(a) on account of loss of use of the right hand, effective from July 7, 2009; L-1 - Under 38 U.S.C.A. § 1114(l) and 38 C.F.R. § 3.350(b) on account of loss of use of both feet, effective from January 16, 2007; P-1 - Under 38 U.S.C.A. § 1114(p) and 38 C.F.R. § 3.350(f)(3) at an intermediate rate between subsections (l) and (m) on account of loss of use of both lower extremities due to the combined effects of the Veteran's lower extremity bilateral radiculopathy, bilateral knee disorder, and low back disorders, effective from January 16, 2007; and P-3 - Under 38 U.S.C.A. § 1114(p) and 38 C.F.R. § 3.350(f)(5) at the next higher rate or intermediate rate of subsection (p), on account of loss of use of three extremities from July 7, 2009. However, the Veteran seeks an even higher award of SMC based on the loss of use of both hands under 38 U.S.C.A. § 1114(m); or based on the need for regular aid and attendance under 38 U.S.C.A. § 1114(l), due to service-connected disabilities independent of the service-connected lower extremity disabilities. Initially, it is noted that the Veteran has been in receipt of a 100 percent total rating for his service-connected disabilities, effective from January 16, 2017. In any event, there is no statutory or regulatory threshold requirement for a total 100 percent rating, in order to be eligible for entitlement to SMC based either on the loss of both hands, OR on the need for regular aid and attendance. See 38 U.S.C.A. § 1114(l), (m); 38 C.F.R. §§ 3.350(b), (c), 3.351(b), 3.352(a). "Loss of use of a hand or foot" is defined as no effective function remaining other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. §§ 3.350(a)(2)(i), 4.63. An example under 38 C.F.R. § 3.350(a)(2) and 38 C.F.R. 4.63 which constitutes loss of use of a hand includes complete ankylosis of two major joints of an extremity. In Tucker v. West, 11 Vet. App. 369, 373 (1999), the Court stated that the relevant inquiry concerning loss of use is not whether amputation is warranted, but whether the claimant has had effective function remaining other than that which would be equally well served by an amputation with use of a suitable prosthetic appliance. The Court also stated that in accordance with 38 C.F.R. § 4.40, the Board is required to consider the impact of pain in making its decision and to articulate how pain on use was factored into its decision. Id. The responsibility for determining whether there is loss of use rests with the adjudicator; the Board may not ask a clinician to determine whether there is "loss of use." See VBA Live Manual M21-1, IV.ii.2.H.1.b. In this case, the veteran has the following service-connected disabilities: loss of use of both lower extremities, rated as 100 percent disabling; loss of use of the right upper extremity, rated as 70 percent disabling; low back degenerative disc disease, rated as 60 percent disabling; asthma, rated as 60 percent disabling; a left shoulder disability, rated as 20 percent disabling; a right shoulder disability, rated as 10 percent disabling; bilateral knee degenerative joint disease, rated as 10 percent disabling; a right thumb disability, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; a psychiatric adjustment disorder, rated as 10 percent disabling; cervical disc disease with strain, rated as 10 percent disabling; and hiatal hernia, tinea pedis, and erectile dysfunction, each rated as 0 percent disabling. The combined service-connected disability rating is 100 percent from January 16, 2007, with consideration of the bilateral factor. See 38 C.F.R. §§ 4.25 (combined ratings table); 4.26. The Veteran has also been awarded a permanent and total (P&T) rating due to his service-connected disabilities, effective from August 31, 2005. Finally, the Veteran has also been awarded ancillary benefits such as SMC, automobile and adaptive equipment, and specially adapted housing. At the outset, the probative medical and lay evidence of record does NOT establish SMC on account of loss of use both hands under 38 U.S.C.A. § 1114(m) and 38 C.F.R. § 3.350(c). The Board acknowledges the Veteran has already been granted SMC under 38 U.S.C.A. § 1114(k) for loss of use of the right hand. However, the left upper extremity is not as severe as the right upper extremity. In particular, the Veteran's service-connected left arm disability has not caused a level of impairment such that no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow with use of a suitable prosthetic appliance. 38 C.F.R. §§ 3.350(a)(2)(i), 4.63. The Board notes there is also no medical evidence of record showing complete ankylosis of two major joints of the left upper extremity. See 38 C.F.R. § 4.63. Specifically, a June 2009 VA primary care outpatient note indicated the Veteran was unable to comb his hair due to his service-connected right arm, but he can use his left arm and left hand to eat food, shower, and cleanse his body. In an April 2012 statement, the Veteran reported that due to loss use of his right upper extremity, he has to use his left upper extremity more and more to accomplish daily tasks like eating, dressing, going to the bathroom, attending social activities, home maintenance, home cleaning, shopping, and rising from a seated position. So the Veteran admitted to being able to use his left upper extremity, albeit with difficulty. A May 2012 VA aid and attendance examination found that the Veteran had only "mild or moderate" impairment in left upper extremity strength and coordination for self-feeding, dressing, bathing, grooming, and toileting. A September 2012 VA addendum opinion for A&A stated that the Veteran can self-feed, but with difficulty. A December 2012 VA peripheral nerves examiner concluded the Veteran does not have loss of use of his left upper extremity. He has good grip, good sensation and functionality, and is able to roll his wheelchair wheels with both arms. He has full range of motion of his left upper extremity, with normal reflexes and no trophic changes. The VA examiner added that functioning is not so diminished in the left upper extremity that amputation with prosthesis would equally serve the Veteran when considering grasping and manipulation. A January 2013 private report of Dr. A.L.R., DO noted worsened ability to grip and pain and numbness in the left arm. In the October 2013 VA Form 9, the Veteran reported he can use his left arm and left hand to stand himself up. A December 2013 VA aid and attendance examination indicated the Veteran's left hand was worsening. At the April 2015 Travel Board hearing (at pages 6-9), the Veteran demonstrated an inability to pick up a penny with his left hand, but was able to use his left arm to lift a drink, albeit simultaneously shaking. The Board finds the evidence of record discussed above, as well as the Veteran's hearing testimony, does not rise to the level of loss of use of the left hand. As such, the Veteran does not meet the SMC criteria at the "M" level for loss of use both hands under 38 U.S.C.A. § 1114(m) and 38 C.F.R. § 3.350(c). His right hand demonstrates loss of use, but his left hand does not. However, SMC on a higher level under 38 U.S.C.A. § 1114(l) and 38 C.F.R. § 3.350(b) is also payable as the result of service-connected disability if a veteran has an anatomical loss or loss of use of both feet, or of one hand and one foot; has blindness in both eyes with visual acuity of 5/200 or less (or concentric contraction of the field of vision beyond 5 degrees in both eyes); is permanently bedridden; or is so helpless as to be in need of regular aid and attendance of another person. The RO has already established that the Veteran is entitled to SMC at the L-rate based on the loss of use of both feet, due solely to his service-connected lower extremity disabilities. However, the Veteran also requests a separate award of SMC at the L-rate based on the need for regular aid and attendance due to his other service-connected disabilities, independent and without consideration of his service-connected lower extremity disabilities. This would entail consideration for aid and attendance purposes of his service-connected loss of use of the right upper extremity, low back degenerative disc disease, cervical disc disease, asthma, tinnitus, a right thumb disability, a right shoulder disability, a left shoulder disability, a psychiatric adjustment disorder, and several other disabilities. In turn, based on the award of these two separate L-rates of SMC (both loss of use of the feet and aid and attendance), the Veteran believes he is entitled to a higher level of SMC, namely at the R-1 rate. See April 2012 informal claim; January 2013 and April 2014 representative statements; October 2016 appellant brief. In determining the need for regular aid and attendance of another person, the following will be accorded consideration: Inability of a claimant to dress or undress him or herself, or to keep him or herself 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 (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of a claimant to feed him or herself through loss of coordination of the 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 a claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). Bedridden, i.e., the Veteran is actually required to remain in bed, will be a proper basis for the determination. The fact that a Veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated be found to exist before a favorable rating may be made. See Turco v. Brown, 9 Vet. App. 222, 224 (1996) (providing that eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met, but not all). The particular personal functions that the Veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the Veteran is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the Veteran's condition is such as would require him or her to be in bed. They must be based on the actual requirements of personal assistance from others. 38 C.F.R. § 3.352(a). The performance of the necessary aid and attendance service by a relative of the beneficiary or other member of his or her household will not prevent the granting of the additional allowance. 38 C.F.R. § 3.352(c). Upon review of the evidence, SMC on account of the need for regular aid and attendance is warranted. See 38 U.S.C.A. § 1114(l), 38 C.F.R. §§ 3.350(b), 3.352(a). This award is based on the collective impact of the Veteran's remaining service-connected disabilities, in particular his loss of use of the right upper extremity, low back degenerative disc disease, cervical disc disease, asthma, tinnitus, a right thumb disability, a right shoulder disability, a left shoulder disability, and a psychiatric adjustment disorder - without any consideration of the effect of his service-connected lower extremity disabilities. At the outset, the medical and lay evidence of record does not reveal blindness in both eyes with visual acuity of 5/200 or less (or concentric contraction of the field of vision beyond 5 degrees in both eyes), or permanent bedridden status. See 38 U.S.C.A. § 1114(l), 38 C.F.R. § 3.350(b). Moreover, the Veteran does not allege he meets these particular criteria. In any event, with regard to the factors of aid and attendance, the Veteran meets the criteria for the need of the aid and attendance of another person, due to his remaining service-connected disabilities. 38 C.F.R. § 3.352(a). The Veteran is currently 69 years old. He lives with his wife. He uses a wheelchair when he leaves the home. VA treatment records and VA examinations and private treatment records and lay evidence / testimony show that his medical condition has slowly deteriorated since 2012. The following evidence is supportive of the A&A claim: With regard to lay evidence, in an April 2012 spouse statement, the Veteran's spouse reported that the loss of strength in the Veteran's upper extremities has caused many problems with dressing, showering, going to the bathroom, social activities, rising up from a seated position, shopping, home repairs, meal preparation, and home cleaning. Because of pain and tremors in the Veteran's upper extremities, she has to assist him with daily activities of life like pulling over his shirt, cutting his toe nails, combing and curling his hair, buttoning his dress shirt, zipping and unzipping his pants, and putting and taking off his belt. When the Veteran showers she washes his hair, back, legs, feet, and puts soap on his scrubber since he cannot use a wash cloth. Also, the loss of strength from his upper extremities has caused problems with him rising up from a seated position. His spouse has to pull up on both of his arms to help him stand up. When they attend church, if he has to go to the bathroom she helps him zip and unzip his pants, putting and taking off his belt, and helps him from a seated position. He cannot push up from a seated position without help because of the pain and tremors in his upper extremities. When his spouse is not present in the house, she ensures she prepares his dressing, showering, meal preparation, and going to the bathroom in advance. If he has any problems when she is not present, the Veteran contacts his neighbor for aid and assistance. Therefore, the Veteran's spouse credibly indicates the Veteran needs A&A due to his service-connected upper extremities, cervical spine, asthma, and low back disabilities. With regard to lay evidence, in an April 2012 Veteran statement, the Veteran credibly reports that his wife assists him with dressing, including putting on his socks. His wife zips and unzips his pants for him to go to the bathroom, as well as puts on and takes off his belt. His wife buttons his shirts. His wife washes his hair, back, legs, feet, and neck. His wife has to towel dry him because of the upper extremity tremors and pain, as well as his asthma. His asthma causes great fatigue. His wife assists him in rising up due to his upper extremity fatigue. Since he has pain and tremors in both arms he needs help lifting himself out of the bed and chairs. The Veteran hires companies to cut his grass, snow removal, clean windows, and do home repairs, since he cannot complete the tasks mentioned above because of functional loss and weakness in his upper extremities. With regard to lay evidence, in an August 2012 Notice of Disagreement (NOD), the Veteran credibly states that the tremors of the upper extremity neuropathy of both arms interfere with his ability to dress, undress, and feed himself. With regard to lay evidence, in a July 2012 statement, the Veteran credibly states that his upper extremity disabilities and asthma and cervical spine and anxiety cause problems such as protecting himself from the hazards of his daily environment, the need for help bathing, dressing, undressing, adjusting prosthetic devices, household chores, and cooking. With regard to lay evidence, at the April 2015 Travel Board hearing (at pages 8-9), the Veteran's spouse credibly testified that the Veteran's upper extremity disabilities alone prevent the Veteran from putting a shirt on himself, feeding himself, and cleaning up. A September 2012 VA addendum opinion for A&A noted that his wife helps him with eating by cutting food for him, washing his hair, bathing, and shaving. However, the VA examiner did assess this was due to a combination of both upper and lower extremity disabilities. A January 2013 private report of Dr. A.L.R., DO, indicated the Veteran cannot shave by himself, due to his bilateral arm tremors. He also cannot grip objects properly. A June 2013 VA caregiver certificate note on Virtual VA recorded the Veteran's statement that his wife helps him with most tasks around the house. A December 2013 VA aid and attendance examination by a private doctor Dr. A.L.R., DO, considered the Veteran's service-connected upper extremity tremors, his cervical disc disease, his upper extremity numbness, and his low back pain. His lower extremities were not considered. The Veteran was not bedridden. However, he can only eat with assistance. He cannot use a spoon or knife, unless his wife helps. He cannot prepare his own meals. He needs assistance dressing, shaving, bathing, brushing his teeth, and combing his hair. He also requires the assistance of his wife for medication preparation and management because he forgets. He exhibited upper extremity restrictions on grip, fine movements, feeding, buttoning clothing, shaving, attending to the needs of nature, with deceased grip strength and severe tremor bilaterally. In summary, in light of the above evidence, the Veteran meets nearly all of the factors of aid and attendance. See Turco, 9 Vet. App. 224 (eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met, but not all). The above evidence reflects the necessity of the regular aid and attendance of another family member or person, due to his remaining service-connected disabilities, apart from his lower extremities. 38 C.F.R. § 3.352(a). Simply stated, it does not appear the Veteran would be able to take care of himself without the regular assistance of another person. VA and private treatment records and VA examinations and lay evidence corroborate that the severity of the Veteran's service-connected loss of use of the right upper extremity, low back degenerative disc disease, cervical disc disease, asthma, tinnitus, a right thumb disability, a right shoulder disability, a left shoulder disability, and a psychiatric adjustment disorder, standing alone, would necessitate the regular aid and attendance of another person for many activities of daily living. Consequently, it is apparent from the medical and lay evidence above that the basic requirements for SMC on account of regular aid and attendance have been met - without considering his service-connected lower extremity disabilities. 38 U.S.C.A. § 1114(l); 38 C.F.R. §§ 3.350, 3.352. Therefore, resolving any doubt in the Veteran's favor, the Board finds the evidence supports SMC for regular aid and attendance at the L-level. 38 U.S.C.A. § 5107(b). V. SMC - Higher Rate at "O" and "R-1" Level In addition to seeking entitlement to SMC at the L-rate based on the loss of use of his lower extremities and aid and attendance pursuant to 38 U.S.C.A. § 1114(1), the Veteran also contends that he is entitled to an even higher level of SMC, namely SMC at the R-1 rate, at the level designated under 38 U.S.C.A. § 1114(r)(1). The Veteran asserts this is supported by both the law and the evidence of record. See April 2012 informal claim; January 2013 and April 2014 representative statements; October 2016 appellant brief. The Board is required "to maximize benefits," which includes a requirement to consider whether a claimant is entitled to SMC. Cf. Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2011) ("VA's duty to maximize benefits requires VA to assess all of the claimant's disabilities without regard to the order in which they were service connected to determine whether any combination of the disabilities establishes entitlement to special monthly compensation under section 1114(s)"). See also AB v. Brown, 6 Vet. App. 35, 38 (1993) ("the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded"). The Board has determined that in the present case, SMC at the R-1 rate is reasonably inferred from the evidence of record. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991) (holding that VA was obliged to infer a claim for SMC where it "may be applicable and the veteran does not place his eligibility at issue"). The Veteran's representative has requested that the Board consider an SMC claim at the R-1 rate. In fact, recently, VA expressly adopted the Akles rule for all complete claims, stating "VA will adjudicate as part of [a] claim entitlement to any ancillary benefits that arise as a result of the adjudication decision (e.g., . . . entitlement to [SMC] under 38 C.F.R. § 3.350 . . . )." 38 C.F.R. § 3.155(d)(2) (2017) (applicable to claims filed on and after March 24, 2015). 38 U.S.C.A. § 1114(r) provides for a higher level of benefit called "special aid and attendance" in certain circumstances. That is, a veteran receiving the maximum rate under 38 U.S.C.A. § 1114(o), who is also in need of regular aid and attendance or a higher level of care, is entitled to an additional allowance during periods he or she is not hospitalized at United States Government expense. 38 U.S.C.A. § 1114(r)(1)-(2) (West 2014). A still higher level aid and attendance allowance is authorized by 38 U.S.C.A. § 1114(r)(2), and is payable in lieu of the regular aid and attendance allowance authorized by 38 U.S.C.A. § 1114(r)(1). But the Veteran has not asserted, and the evidence of record does not demonstrate, entitlement to SMC at the R-2 rate, such that the Board will only consider the R-1 rate here. In this regard, a May 2012 VA aid and attendance examiner opined the Veteran had no need for "skilled services." In addition, a June 2013 VA caregiver certificate note on Virtual VA commented the Veteran does not need a professional bath aid. In short, the Veteran does not require skilled care, and is therefore not eligible for SMC at the R-2 level. SMC at the threshold O-rate is necessary before considering whether the Veteran is entitled to SMC at the R-1 rate. SMC at the O-rate is warranted, if the veteran as the result of service-connected disability has suffered disability under conditions which would entitle such veteran to two or more of the rates provided in one or more subsections (l) through (n), with no condition being considered twice in the determination. 38 U.S.C.A. § 1114(o); 38 C.F.R. § 3.350(e)(1)(ii). The amount payable is $4,667. In other words, determinations for entitlement to the O-rate of SMC must be based upon separate and distinct disabilities. 38 C.F.R. § 3.350(e)(1)(ii). The Court has further held that a veteran who is in receipt of SMC at a rate under 38 U.S.C.A. § 1114 (l) through (n) cannot establish entitlement to a second rate under subsection (l) based on the need for aid and attendance, which would result in a higher payment of SMC at the rate under 38 U.S.C. § 1114(o), unless the need for aid and attendance arises from a disability other than that for which the veteran is already in receipt of SMC. The Court explained that such payment is prohibited because section 1114(o) prohibits a "condition from being considered twice" in subsections (l) through (n) when determining whether a veteran is entitled to a higher rate of SMC under subsection (o). Breniser v. Shinseki, 25 Vet. App. 64, 65 (2011). See also 38 C.F.R. § 3.350(e)(1)(ii). Simply stated, a higher payment of SMC at the rate under 38 U.S.C.A. § 1114(o) is assigned when a veteran to entitled to two SMC rates under 38 U.S.C.A. § 1114 (l), (m), or (n). However, each SMC entitlement under (l), (m), or (n), must be totally separate from the other. Applied to the facts of the present case, the same service-connected disability(ies) cannot support both SMC entitlements under 38 U.S.C.A. § 1114(l) for loss of use of the feet and aid and attendance. Fortunately, here, as explained above, the Veteran is entitled to SMC at the L-rate due to the loss of use of his lower extremities as a result of his lower extremity disabilities alone. Additionally, he is entitled to SMC at the L-rate for the separate and distinct need for regular A&A due to his other service-connected disabilities, including his loss of use of the right upper extremity, low back degenerative disc disease, cervical disc disease, asthma, tinnitus, a right thumb disability, a right shoulder disability, a left shoulder disability, and a psychiatric adjustment disorder. Again, determinations for entitlement to the O-rate of SMC must be based upon separate and distinct disabilities. Thus, SMC at the O-rate is warranted here, because the Veteran has separate and distinct service-connected disabilities which would entitle him to two or more of the SMC rates listed in subsections (l) through (n). See 38 C.F.R. § 3.350(e)(1)(ii). That is, the Veteran has been awarded two separate SMC awards at the L-rate, without consideration of the same disability twice. 38 U.S.C.A. § 1114(r)(1) provides that if a veteran is entitled to SMC at the O-rate and is also need in aid and attendance, he shall be paid an additional amount of SMC in the amount of $2,002.00. Because the Veteran here is entitled to SMC at the level designated under 38 U.S.C.A. § 1114(o), he qualifies for SMC at the R-1 rate-at the level designated under 38 U.S.C.A. § 1114(r)(1)-if the evidence establishes the need for regular aid and attendance. As discussed in detail above, the Veteran is in need of regular aid and attendance due to his service-connected disabilities. See 38 C.F.R. § 3.350(e)(1)(ii), (h); 38 C.F.R. § 3.352(a). In fact, SMC at the R-1 rate is virtually automatic for those veterans who are already rated under 38 U.S.C.A. § 1114(o), such as the Veteran in the present case. Therefore, resolving any doubt in the Veteran's favor, the Board finds the evidence supports an increased level of SMC at the R-1 rate - at the level designated under 38 U.S.C.A. § 1114(r)(1). See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection neuropathy of the left upper extremity as secondary to service-connected cervical disc disease and service-connected loss of use of the right upper extremity, is granted. A higher 20 percent disability rating for a service-connected left shoulder disability is granted. SMC under 38 U.S.C.A. § 1114(l) by reason of being in need of aid and attendance of another person, due to service-connected disabilities independent of the service-connected lower extremity disabilities, is granted. A higher rate of SMC under 38 U.S.C.A. § 1114(o) and (r)(1) is granted. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs