Citation Nr: 1801558 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 13-22 133A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for bilateral shoulder disability. 4. Entitlement to a rating in excess of 20 percent for thoracic spine disability. 5. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity. 6. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. 7. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance. 8. Entitlement to a total disability rating based on individual unemployability as the result of service-connected disabilities (TDIU). WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J.A. Flynn, Counsel INTRODUCTION The Veteran served on active duty from May 1980 to May 1983, and from November 1983 to November 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from three rating decisions of the VA RO. A March 2011 rating decision denied the claims for service connection for tinnitus and a bilateral shoulder disability, and it denied the claim for SMC. A December 2012 rating decision denied the claim for service connection for a bilateral hearing loss disability. An April 2016 rating decision denied the Veteran's claims for increased ratings for a thoracic spine disability and peripheral neuropathy of the lower extremities. The issues of service connection for bilateral hearing loss and tinnitus, and for entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's right and left shoulder disorders were not caused or aggravated by a service-connected disability. 2. The Veteran's thoracic spine disability is not manifested by forward flexion functionally limited by pain to 30 degrees or fewer, ankylosis, or incapacitating episodes of intervertebral disc syndrome (IVDS). 3. The peripheral neuropathy of the Veteran's lower extremities is not manifested by symptoms approximating moderate incomplete paralysis of the sciatic nerve or worse for either leg. 4. The Veteran's service-connected disabilities do not result in anatomical loss or loss of use of both feet or of one hand and one foot, or blindness in both eyes with visual acuity of 5/200 or less; the Veteran is not permanently bedridden, nor is he so helpless as to be in need of regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral shoulder disability have not been met. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.102, 3.303, 3.310 (2017). 2. The criteria for a rating in excess of 20 percent for thoracic spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.71a, Diagnostic Code 5242 (2017). 3. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 4. The criteria for ratings in excess of 10 percent for peripheral neuropathy of the left lower extremities have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 5. The criteria for entitlement to SMC based on the need for regular aid and attendance or by reason of being housebound have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.350, 3.352(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has certain notice and assistance obligations to claimants. 38 U.S.C. § 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). In this case, the Veteran was provided with all appropriate notification in September 2010 and March 2016. The Veteran has not alleged or demonstrated any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009). Thus, adjudication of the Veteran's claims at this time is warranted. With respect to the duty to assist, VA has done everything reasonably possible to assist the Veteran with respect to this claim for benefits. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records, post-service treatment records, and records from the Social Security Administration (SSA) have been obtained, to the extent available. The Veteran has been provided with examinations addressing his service-connected back disability and peripheral neuropathy. The Board finds that the examiners reviewed the Veteran's claims file and past medical history, noted his current complaints, and rendered appropriate opinions consistent with the remainder of the evidence of record. With that said, the Board further notes that a claimant's cooperation is essential to the development of any claim. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that "[t]he duty to assist is not always a one-way street"). Claimants who fail to cooperate during VA examinations "subject them[selves] to the risk of an adverse adjudication based on an incomplete and underdeveloped record." Kowalski v. Nicholson, 19 Vet. App. 171, 181 (2005). In this case, the Veteran, despite retaining muscle mass in the lower extremities and self-reporting an ability to stand at times, refused to leave his power scooter to participate in testing during his March 2017 examination. The Board will therefore rate the Veteran's disabilities using the information available in the March 2017 examination report, despite the Veteran's refusal to fully cooperate. In sum, the Board finds that the medical evidence of record is adequate for the purpose of rendering a decision. 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran was not afforded a VA examination addressing his bilateral shoulder disability. When determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159(c)(4) (2017). In this case, as discussed in greater detail below, the Veteran has alleged that his bilateral shoulder disability is related to his past use of a manual wheelchair, which, the Veteran argues, he was required to use as a result of his service-connected disabilities. The weight of the evidence fails to show that the Veteran used a manual wheelchair as a result of his service-connected disabilities; instead, the Veteran, at the time he used a manual wheelchair, attributed such need to fibromyalgia. The Veteran has been denied service connection for fibromyalgia. With the Board finding the Veteran not to be a credible reporter of his symptom history, and without a clinical association of the Veteran's bilateral shoulder disability to service-connected disabilities, the Board finds that a medical opinion would not elicit information pertinent to the Veteran's claim. Accordingly, the Board finds that referral for a VA medical opinion is unwarranted. The Veteran testified before the undersigned at a May 2017 videoconference hearing, and a transcript of this hearing has been associated with the record. The Board finds that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection for Shoulder Disability The Veteran contends that he has a bilateral shoulder disability not as a direct result of his service, but instead as the result of his need to use a manual wheelchair due to symptoms associated with his service-connected disabilities. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017); Harder v. Brown, 5 Vet. App. 183 (1993). Additional disability resulting from the aggravation of a non-service-connected disability by a service-connected disability is also service connected. 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995). To establish service connection for a claimed disability on a secondary basis, there must be evidence of a current disability, a service-connected disability, and medical evidence of a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). Turning to the facts in this case, in April 2004, a VA examiner noted that the Veteran had used a wheelchair for one year. In June 2004, the Veteran stated that he had experienced a three-month history of shoulder pain such that he could not push himself in his wheelchair. In a May 2005 evaluation for the use of a power scooter rather than manual wheelchair, the Veteran asked a clinician, "don't you know that I have fibromyalgia and my joints are shot. My rotator cuffs are shot too and I can't even propel the [wheel]chair". In March 2006, the Veteran stated that he had a torn rotator cuff of the right shoulder; the examiner noted that the Veteran sustained an injury to both shoulders as a result of pushing a wheelchair. The examiner noted that x-rays of both shoulders revealed stable, mild degenerative changes. The Veteran filed his claim for service connection for a shoulder disability in September 2010, at which time he stated that he had such disability as the result of "pushing [him]self in a manual wheelchair due to peripheral neuropathy of the lower extremities." In May 2011, an x-ray of the Veteran's right shoulder showed degenerative changes of the acromioclavicular joint. In a September 2016 treatment record, the Veteran reported experiencing shoulder pain, greater on the right side than on the left. The Veteran indicated that he began having shoulder pain in 2005 after he had been propelling a heavy manual wheelchair for several years. In May 2017, the Veteran stated that his bilateral shoulder disability was not directly related to service. Instead, the Veteran argued that he "ripped [his] rotator cuffs out" while using a manual wheelchair, which the Veteran stated that he had to use as a result of his back disability. Turning to an analysis of these facts, the Board finds that the Veteran indeed has a bilateral shoulder disability. At issue in this case, however, is whether such disability is related to the Veteran's service-connected disabilities, which include only a back disability and peripheral neuropathy of the bilateral lower extremities. VA has previously denied the Veteran's claims for other disabilities, including fibromyalgia, a neck disability, and a left knee disability. While the evidence indicates that the Veteran indeed used a manual wheelchair in the past, the weight of the evidence does not support a finding that the Veteran used a manual wheelchair as a result of his service-connected back and peripheral neuropathy symptoms. Instead, the evidence indicates Veteran used such a wheelchair as the result of the generalized body aches that were associated with the Veteran's fibromyalgia. Indeed, the Veteran himself, in a May 2005 record regarding his wheelchair use, attributed his need to use a wheelchair to his fibromyalgia, not to his service-connected disabilities. Furthermore, no clinician has associated the Veteran's use of a manual wheelchair solely with his service connected disabilities, nor has a clinician otherwise associated the Veteran's shoulder disability with service-connected disability. To the extent that the Veteran has argued that his shoulder disability is related to his use of a manual wheelchair for the treatment of service-connected disabilities, the Board, for reasons that it will more fully express in its below discussion of the Veteran's claims for increased ratings, finds that the Veteran is not a credible reporter of his symptoms. For example, the Veteran's May 2017 contention that he "ripped his rotator cuffs out" while using a manual wheelchair is not supported by the contemporaneous medical evidence. The Board thus places relatively little probative weight in the Veteran's own contentions regarding the etiology of his bilateral shoulder disability. In sum, the Board concludes that the preponderance of the evidence is against granting service connection for a bilateral shoulder disability. As the weight of the evidence is against the claim, the claim is denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In general, when 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). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, staged ratings have been assigned, and as discussed below, the evidence does not support the assignment of any additional staged rating periods other than those discussed herein. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2017); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same manifestation of a disability under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2017). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2017). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2017). The intent of the rating schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2017). Spine disabilities are evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R § 4.71a, Diagnostic Code 5242 (2017). The General Rating Formula for Diseases and Injuries of the Spine rates lumbar spine disabilities as follows, in pertinent part: 20 percent: Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 40 percent: Forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. 50 percent: Unfavorable ankylosis of the entire thoracolumbar spine. 100 percent: Unfavorable ankylosis of the entire spine. 38 C.F.R § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2017). "Ankylosis" is immobility and consolidation of a joint due to a disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Formula for Rating IVDS Based on Incapacitating Episodes rates lumbar spine disabilities as follows, in pertinent part: 20 percent: Incapacitating episodes having a total duration of at least two weeks but fewer than four weeks during the past 12 months. 40 percent: Incapacitating episodes having a total duration of at least four weeks but fewer than six weeks during the past 12 months. 60 percent: Incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R § 4.71a, Diagnostic Code 5243 (2017). An "incapacitating episode" is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. 38 C.F.R § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2017). Turning to the facts in this case, in January 2015, the Veteran complained of a constant, deep, throbbing pain in his back that worsened with bending. In April 2015, a clinician noted that the Veteran used a walker and a power chair for ambulation. In June 2015, the Veteran's back had a full range of motion with no tenderness. In July 2015, the Veteran denied experiencing back pain. In a December 2015 record, the Veteran refused to stand to be assessed due to pain in his knees. In a December 2015 x-ray examination, the Veteran was noted to have mild multilevel degenerative changes of the spine. The Veteran filed his claim for an increased rating for a spine disability in January 2016. In January 2016, the Veteran sought emergency treatment for "extreme chronic spine pain". The Veteran became "very threatening and intimidating" towards clinicians after they advised him that they would not treat him for because he already received Morphine to treat such symptoms. In February 2016 and May 2016, the Veteran complained of pain in his back. The Veteran underwent a VA contract examination in March 2017, at which time the examiner diagnosed the Veteran with degenerative joint disease of the thoracic spine. The Veteran complained of severe pain in his mid to low back, but he denied experiencing flare-ups of his disability. The Veteran reported that while he could stand at times, he refused to get out of his wheelchair for examination, and he had to use a power scooter because he could not walk. The Veteran's range of motion could not be tested, though the examiner noted that the Veteran could slightly bend forward with pain. The examiner noted evidence of pain with weight-bearing. No ankylosis of the spine was noted, and there was no muscle spasm or guarding. The Veteran did not have IVDS of the thoracolumbar spine. Turning to an evaluation of these facts, the Board first finds that the Veteran's spine has not been ankylosed, or immobile, at any time. Indeed, in March 2017, the Veteran was able to bend forward with pain while seated in his power scooter. The Board thus finds that neither a 50 percent rating (requiring unfavorable ankylosis of the entire thoracolumbar spine) nor a 100 percent rating (requiring unfavorable ankylosis of the entire spine) is warranted at any time. A 40 percent rating requires either favorable ankylosis of the entire thoracolumbar spine or forward flexion limited to 30 degrees or fewer. As noted above, the Veteran's back has never been ankylosed, and a 40 percent rating is unavailable to the Veteran on this basis. The Board further finds that the evidence does not support a finding that Veteran's forward flexion has been limited to 30 degrees or less, even when taking pain into consideration. The Veteran declined to participate in range of motion testing at the time of his March 2017 examination, despite, as the Board will discuss in further detail below, retaining the ability to participate more meaningfully in the examination if he wished to. No other clinician has indicated that the Veteran's forward flexion was limited to 30 degrees or fewer. The Board thus finds that the weight of the evidence is against a finding that the Veteran's forward flexion has been limited to 30 degrees or fewer at any time. In reaching this conclusion, the Board considered functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board has considered the effects of weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2017). Although the Board accepts the Veteran's assertions that his spine disability causes him to experience significant pain, the Board has taken this into account in its above discussion of range of motion. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Furthermore, even when the Veteran's complaints of pain are considered, the Board concludes that the overall manifestations of his spine disability generally do not demonstrate a degree of functional loss so as to warrant higher ratings for the period on appeal. A rating in excess of 20 percent is similarly unavailable under the formula for rating IVDS. A rating in excess of 20 percent based on IVDS requires incapacitating episodes with a total duration of at least 4 weeks during a 12-month period. In this case, there has been no showing that bed rest has actually been prescribed during the course of the appeal. Accordingly, a rating in excess of the currently-assigned 20 percent rating is unavailable to the Veteran as a result of IVDS, which would require incapacitating episodes having a total duration of at least 4 weeks during any 12-month period. In sum, the criteria for a rating in excess of 20 percent for a back disability have not been met. Turning now to an evaluation of the neurological manifestations of the Veteran's back disability, under Diagnostic Code 8520, applicable to impairment of the sciatic nerve, in pertinent part, a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy, and; an 80 percent rating is warranted for complete paralysis; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakness or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Turning to the facts in this case, in July 2015, the Veteran denied experiencing numbness or weakness. In September 2015, the Veteran reported experiencing right-sided paralysis and buckling in his legs. In December 2015, the Veteran's deep tendon reflexes were 2+ and symmetric, and the Veteran moved his lower extremities appropriately and of his own volition. In January 2016, the Veteran complained of bilateral leg weakness and numbness, bowel incontinence, and bladder incontinence, but the Veteran was unable to be assessed because he was uncooperative and left before he could be treated. The Veteran stated that he had a complete loss of all sensation and strength in his right leg and a partial loss of sensation and strength in the left leg. In response to these symptoms, VA clinicians arranged for the Veteran to undergo an MRI examination at another facility. The Veteran refused to be transported to such facility and left the emergency room. In April 2016, the Veteran stated that he was considered a fall hazard and that he was essentially paralyzed below the waist. The Veteran stated that he had "definite incontinent issues" with little or no bowel or bladder control. In August 2016, a clinician noted that the Veteran spent most of his day in a motorized chair but occasionally used a walker to ambulate in his home. The Veteran's sensation to light touch was absent to the level of the tibia bilaterally. Muscle strength testing was 2/5. In July 2016, a clinician noted that the Veteran was continent of both bowel and bladder. The Veteran underwent a VA contract examination in March 2017, at which time the examiner diagnosed the Veteran with radiculopathy of the bilateral lower extremities. The Veteran had 4/5 muscle strength at the bilateral hips, knees, ankles, and toes, and no muscle atrophy was noted (though the examiner noted that the Veteran was obese, so his muscle tone was not defined). The Veteran's deep tendon reflexes were hypoactive at the bilateral knees and ankles. Light touch sense was decreased at the bilateral thighs, knees, lower legs, ankles, feet, and toes, but it was normal at the upper anterior thighs. The examiner found that the Veteran had moderate constant pain, paresthesias, dysesthesias, and numbness bilaterally. No other neurologic abnormalities were noted. The examiner found that the Veteran's bilateral radiculopathy was of a moderate severity. During his May 2017 hearing, the Veteran stated that he was paralyzed from the waist down, could not feel his legs at all, and he had little to no motor control over his legs. The Veteran stated that he could not use a walker because his legs "collapsed". Upon review of these facts, the Board initially notes that the severity of the symptoms that the Veteran has subjectively endorsed far exceed the severity of the symptoms that clinicians have observed. The Veteran has alleged, for example during his May 2017 hearing, that he is completely paralyzed from the waist down. No clinician has found the Veteran to be paralyzed. Indeed, during the Veteran's March 2017 examination, the Veteran had 4/5 muscle strength in his lower extremities, deep tendon reflexes, and no muscle atrophy. These findings are inconsistent with a finding that the Veteran was completely paralyzed. Furthermore, when the Veteran complained of symptoms of paralysis to clinicians, for example in January 2016, the Veteran refused to undergo further diagnostic testing to treat such symptoms. The Veteran has otherwise frequently been uncooperative with clinicians attempting to assess his symptoms and provide him with care. The Board finds it to be unlikely that the Veteran would refuse medical care had he indeed been suffering from paralysis at any time during the appeal. Thus, while the Board acknowledges the Veteran's subjective contentions regarding the severity of his symptoms, the Board finds him not to be a credible reporter of the severity of his symptoms. The Board instead turns to the medical evidence to assess the symptom picture associated with the Veteran's peripheral neuropathy. Upon review of such evidence, the Board notes that the Veteran maintained deep tendon reflexes throughout the appeal. While the Veteran had no muscle atrophy of the lower extremities, clinicians noted at least some diminishment of muscle strength. Upon review of these symptoms, the Board finds that the objective manifestations of the Veteran's neurological symptoms do not approximate moderate incomplete paralysis or worse, as would be required for ratings in excess of 10 percent. While the Board acknowledges that the March 2017 examiner found the Veteran's peripheral neuropathy to be of a moderate severity, such conclusion was based in part on the Veteran's report of subjective symptoms that the Board has found not to be credible. Upon a review of the entirety of the evidence, the Board finds that ratings in excess of the currently-assigned 10 percent ratings for peripheral neuropathy of the bilateral lower extremities are unwarranted. SMC SMC is payable if, as the result of service-connected disability, the Veteran has 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; is permanently bedridden or is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114(l) (2012); 38 C.F.R. § 3.350(b) (2017). VA considers the following factors in order to determine whether a veteran is in need of regular aid and attendance of another person: the inability of the veteran to dress herself or to keep herself ordinarily clean and presentable; the frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; the inability to feed herself because of the loss of coordination of upper extremities or because of extreme weakness; the inability to attend to the wants of nature; or incapacity, physical or mental, that requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to her daily environment. 38 C.F.R. § 3.352(a). A veteran need not demonstrate all of these conditions in order to obtain SMC based on aid and attendance. Instead, VA considers the particular personal functions that the veteran is unable to perform in connection with her condition as a whole. Rather than meeting all of the above criteria, the veteran need only demonstrate that he is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352(a); Turco v. Brown, 9 Vet. App. 222, 224 (1996) (holding that the evidence of record must demonstrate at least one factor for a grant of SMC based on need for aid and attendance). In addition, a "bedridden" veteran also warrants the regular aid and attendance of another person. 38 C.F.R. § 3.352(a). The term "bedridden" means the condition that, through its essential character, actually requires that the veteran remain in bed. The fact that the 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 does not suffice. 38 C.F.R. § 3.352(a). SMC is also payable when the veteran has a single service-connected disability rated as 100 percent disabling, without resort to individual unemployability, and, in addition: (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the Veteran is substantially confined as a result of his service-connected disabilities to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). In this case, the Veteran is service-connected for a back disability with a 20 percent rating and peripheral neuropathy of the bilateral lower extremities, with a 10 percent rating for each leg. The Veteran's combined schedular evaluation is 40 percent. Turning to the facts in this case, the Veteran filed a claim of entitlement to SMC in October 2010, stating that he desired SMC because he was restricted to his power scooter. In September 2011, the Veteran was noted to have a normal range of motion and normal muscle strength of the upper and lower extremities. The Veteran's muscle tone was normal. In a March 2013 examination for housebound status or permanent need for regular aid and attendance, a clinician diagnosed the Veteran with low back pain, a compression fracture of the spine, fibromyalgia, shoulder pain, and knee pain. The examiner noted that the Veteran used a power scooter. The clinician found that the Veteran's fibromyalgia and arthralgia restricted his activities and functions. The Veteran was able to feed himself, but he was not able to prepare his own meals. The Veteran needed assistance in bathing and tending to other hygiene needs. The Veteran was not legally blind, he did not require nursing home care, and he did not require medication management. The Veteran had the ability to manage his own financial affairs. The Veteran had an "ok" range of motion in the shoulders and an "ok" grip, but he complained of pain. The Veteran's range of motion in his knees was "ok" but painful. The Veteran complained of difficulty bending and hip pain. The Veteran was able to leave his home with the use of his power scooter. In a June 2013 peripheral nerve examination, the Veteran stated that he could only walk a few steps. The examiner noted that a December 2012 nerve study showed that the Veteran's right lower extremity was normal. In August 2013, a clinician noted that the Veteran had degenerative arthritis in his spine, and he used a power scooter for mobility "partly due" to his problems with balance. The Veteran stated that he required his spouse's assistance to shower, dress, shop, do laundry, and cook. Also in August 2013, the Veteran stated that he needed his spouse to complete daily chores, bathe him, and dress him. In September 2015, the Veteran stated that his spouse quit her job in December 2014 to care for him at home. The Veteran stated that he had been falling at home, hurting himself, and having trouble attending to his personal needs. The Veteran stated that he almost never left his power scooter except to use the bathroom, bathe, and sleep. In a September 2015 social work consultation, the Veteran stated that his spouse assisted him with transferring, ambulating, bathing and grooming, housekeeping, cooking, and driving. The Veteran complained of right-sided paralysis. In December 2015, a clinician noted that the Veteran was able to move himself onto the toilet with his spouse's assistance and the use of hand rails. The Veteran stated that he could not move his legs, and a clinician noted that the Veteran would not attempt to move his legs. In January 2016, it was noted that the Veteran did not have a history of falling in the last three months. The Veteran's gait and transferring were noted to be weak. The clinician noted that the Veteran could not independently bathe, dress, toilet, transfer, and he was not continent. The Veteran could feed himself independently. In a separate January 2016 record, the Veteran stated that he had experienced both bowel and bladder incontinence over the past three days. During his May 2017 hearing, the Veteran stated that he was paralyzed from the waist down, and he did not have total function of his hands. The Veteran stated that his spouse had to lift him out of his power scooter, transfer him to a toilet, clean him after toileting, lift him out of bed, place him in his power scooter, and assist him with bathing. The Veteran stated that his spouse assisted him with ambulation by clearing gravel from the path in front of him. The Veteran reported that he could not drive. Turning to an analysis of this evidence, the Veteran does not, as the result of service-connected disability, have an anatomical loss of both feet or of one hand and one foot, have blindness in both eyes with visual acuity of 5/200, nor is the Veteran permanently bedridden, and the Veteran has not so argued. With regard to SMC based on loss of use of both feet or of one hand and one foot, the Veteran has alleged on a number of occasions that he is paralyzed from the waist down. During his May 2017 hearing, the Veteran argued that he no longer had full functionality of his hands. As the Board explained in its above discussion of the Veteran's claims for increased ratings, the Board finds that the Veteran's subjective description of his symptomatology is not credible, particularly given clinicians' findings that the Veteran retained muscle mass, strength, and reflexes in his extremities. Thus, for the reasons set forth above, the weight of the evidence does not support a finding that the Veteran has experienced the loss of use of both feet or of one hand and one foot. The Veteran has additionally alleged that he is so helpless as to be in need of regular aid and attendance of another person as a result of his service-connected disabilities. The Veteran has alleged that his spouse has to dress him, keep him ordinarily clean and presentable, help him with toileting, and protect him from the hazards or dangers incident to his daily environment. While the Board acknowledges that the Veteran has consistently made such statements to clinicians, the weight of the evidence is against a finding that the Veteran requires such aid as a result of his service-connected disabilities. As noted above, the Board has found that the Veteran does not credibly reports the severity of his symptoms; for example, the medical evidence of record, including the notations that the Veteran retained muscle mass, strength, and reflexes, does not support the Veteran's allegations that he is fully paralyzed from the waist down. Furthermore, while clinicians have observed the Veteran's impairment in engaging in self-care, they have not attributed such impairment solely to the Veteran's service-connected disabilities. For example, in March 2013, an examiner attributed the Veteran's impairment, at least in part, to the Veteran's fibromyalgia and arthralgia, neither of which is connected to service. Clinicians have otherwise found the Veteran to be able to manage his own financial affairs. Therefore, upon consideration of all of these factors, the Board finds that the weight of the evidence of record does not support a finding that the Veteran is so helpless as to need regular aid and attendance, despite the Veteran's arguments to the contrary. With regard to the Veteran's housebound status, the Veteran does not have a single service-connected disability rated as 100 percent disabling without resort to individual unemployability. Furthermore, the evidence does not suggest that the Veteran has at any time been permanently housebound by reason of any service-connected disability. Accordingly, the Board concludes that the Veteran is not entitled to SMC based on the need for aid and attendance or housebound status. In rendering this decision, it is important for the Veteran to recognize that, as the recipient of a 40 percent combined schedular evaluation, VA has already acknowledged the severity of the Veteran's disabilities. As stated above, however, the evidence of record simply does not meet the criteria for the additional award of SMC based on the need for regular aid and attendance or being housebound. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364-65 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for bilateral shoulder disability is denied. A rating in excess of 20 percent for thoracic spine disability is denied. A rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. A rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. SMC based on the need for regular aid and attendance is denied. REMAND With respect to the Veteran's claims of entitlement to service connection for bilateral hearing loss disability and tinnitus, the Veteran last underwent a VA audiological examination in May 2012, at which time the examiner found that the Veteran did not have a bilateral hearing loss disability for VA compensation purposes. Since that time, evidence has been added to the record, for example an October 2015 audiogram, suggesting that the Veteran has a bilateral hearing loss disability. Accordingly, the Veteran should be afforded with an additional examination addressing the nature and etiology of both his bilateral hearing loss disability and his tinnitus. Additionally, the Veteran is unemployed, and he has claimed that he is prevented from working as a result of his service-connected disabilities. As such, the question of TDIU is raised by the record. Accordingly, the case is REMANDED for the following actions: 1. Arrange for the Veteran to undergo an additional examination addressing the likely etiology of the Veteran's bilateral hearing loss disability and tinnitus. This examination must include audiometric testing. The examiner should opine as to whether it is at least as likely as not (that is, a 50 percent likelihood or greater) that the Veteran's bilateral hearing loss disability and tinnitus began during or was otherwise caused by the Veteran's military service. When rendering this opinion, the examiner should assume that the Veteran was exposed to loud noise in service. 2. Then, after ensuring any other necessary development has been completed, adjudicate the issue of entitlement to a TDIU, and readjudicate the claims for service connection for a bilateral hearing loss disability and tinnitus. If any action remains adverse to the Veteran, provide the Veteran with a supplemental statement of the case, allow an appropriate opportunity to respond, and thereafter return the case to the Board. The Veteran has the right to submit additional evidence and argument on the 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs