Citation Nr: 18146844 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 14-28 347A DATE: November 1, 2018 ORDER Entitlement to special monthly compensation (SMC) on account of loss of use of both feet under 38 U.S.C. § 1114(l) is granted. Entitlement to SMC based on the need for regular aid and attendance under 38 U.S.C. § 1114(l) is granted. Entitlement to a certificate of eligibility for an automobile and adaptive equipment, or for adaptive equipment only, is granted. REMANDED Entitlement to an increased disability rating greater than 20 percent for peripheral neuropathy of the LEFT upper extremity is remanded. Entitlement to an increased disability rating greater than 30 percent for peripheral neuropathy of the RIGHT upper extremity is remanded. Entitlement to an increased disability rating greater than 30 percent for peripheral neuropathy of the LEFT lower extremity is remanded. Entitlement to an increased disability rating greater than 30 percent for peripheral neuropathy of the RIGHT lower extremity is remanded. Entitlement to SMC on account of loss of use of both hands under 38 U.S.C. § 1114(m), is remanded. FINDINGS OF FACT 1. The Veteran’s service-connected type II diabetes mellitus and service-connected peripheral neuropathy in the lower extremities disabilities are productive of loss of use of both feet. That is, these service-connected disabilities cause 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 knee, with use of a suitable prosthetic appliance. 2. The collective impact of all the Veteran’s service-connected disabilities demonstrates the necessity for the regular aid and attendance of another person. 3. The Veteran meets the requirements for entitlement to a certificate of eligibility in the purchase of an automobile or other conveyance and adaptive equipment, or for adaptive equipment only. CONCLUSIONS OF LAW 1. The criteria are met for entitlement to SMC benefits at the L-rate on account of loss of use of both feet. 38 U.S.C. §§ 1114(l), 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.350(a)(2), (b), 4.63, 4.71a (2017). 2. The criteria are met for entitlement to SMC benefits at the L-rate by reason of being in need of aid and attendance of another person. 38 U.S.C. §§ 1114(l), 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.350(b), 3.352(a) (2017). 3. Resolving reasonable doubt in the Veteran’s favor, the criteria are met for a certificate of eligibility in the purchase of an automobile or other conveyance and adaptive equipment, or for adaptive equipment only. 38 U.S.C. §§ 3901, 3902, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.350, 3.808, 4.63, 17.156, 17.157 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the U.S. Army from May 1970 to November 1971. His awards and decorations include the Bronze Star Medal for valor in combat in the Republic of Vietnam during the Vietnam Era. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from September 2011 and August 2014 rating decisions issued by Department of Veterans Affairs (VA) Regional Offices (ROs) in Indianapolis, Indiana. In addition, the Board has recognized an inferred claim for SMC based on the need for regular aid and attendance under 38 U.S.C. § 1114(l). Despite the RO’s failure to adjudicate this particular theory of SMC, the Board finds it was reasonably inferred from the evidence of record. In fact, in a February 2015 representative statement, the Veteran requested that VA adjudicate entitlement to SMC based on the need for regular aid and attendance. Moreover, the Court has held that a claim for an increased rating may include the “inferred issue” of entitlement to SMC, even where the Veteran has not expressly placed entitlement to SMC at issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). As such, the Board has added this particular theory of SMC to the present appeal. 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) (2016) (applicable to claims filed on and after March 24, 2015). During the course of the appeal, the Veteran requested a Board videoconference hearing before a Veterans Law Judge (VLJ). However, he failed to report for the Board videoconference hearing scheduled for him in March 2018. But a review of the claims file reveals that in an earlier an October 2016 representative statement (VA Form 646), the Veteran advised that he would not appear at any Board hearing scheduled for him, due to the severity of his medical conditions. Therefore, the Board hearing request is considered withdrawn. See 38 C.F.R. § 20.704(d) (2017). Finally, after the RO last considered the appeal in the November 2016 Supplemental Statement of the Case (SSOC), the Veteran has submitted private medical evidence and argument. But the Veteran did not submit a waiver of initial RO review of this evidence. See 38 C.F.R. §§ 20.800, 20.1304(c) (2017). That notwithstanding, 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. § 7105(e)(1). In the present case, the Veteran’s Substantive Appeals were received in August 2014 and October 2016, 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. 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. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 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). The RO sent the Veteran compliant VCAA notice letters dated in June 2011, July 2011, and July 2014, addressing the criteria necessary to establish entitlement to SMC and automobile and adaptive equipment. In any event, in the decision below, the Board has granted the Veteran’s claims of entitlement to SMC and automobile and adaptive equipment. Therefore, the benefits sought on appeal have been granted in full for these particular issues. Accordingly, regardless of whether the notice and assistance requirements have been met with regard to these issues, no harm or prejudice to the Veteran has resulted. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. With regard to the four increased rating issues and the issue of entitlement to SMC on account of loss of use of both hands under 38 U.S.C. § 1114(m), the Board finds that further evidentiary development is needed and will be discussed in the remand below. Therefore, an analysis for these issues regarding whether there was compliance with the VCAA is not required at this time. 1. SMC – Loss of Use of Feet 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 generally 38 U.S.C. § 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. § 1114(k). Higher levels of SMC are provided at 38 U.S.C. § 1114(l), (m), (n), and (o). SMC is payable in addition to the basic rate of compensation otherwise payable for the degree of disability. SMC under 38 U.S.C. § 1114(l) and 38 C.F.R. § 3.350(b) is 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. Here, the Veteran seeks an award of SMC at the rate set forth under 38 U.S.C. § 1114(l), based on the loss of use of both feet or based on the need for regular aid and attendance. See January 2011 increased rating claim; January 2011 Auto / Adaptive Application (VA Form 21-4502); February 2012 and May 2018 Veteran’s statements; August 2014 Notice of Disagreement (NOD); February 2015 representative statement; October 2016 representative statement (VA Form 646); and October 2016 VA Form 9. Initially, it is noted that the Veteran has been in receipt of a 100 percent total schedular rating for his service-connected disabilities, effective from December 8, 2006. 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 on the loss and use of the feet, or on the need for regular aid and attendance. See 38 U.S.C. § 1114(l); 38 C.F.R. §§ 3.350(b), 3.351(b), 3.352(a). Under VA regulation, “loss of use of a 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 knee with use of a suitable prosthetic appliance. The determination for the foot will be made on the basis of the actual remaining function of balance, propulsion, etc., which could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. §§ 3.350(a)(2)(i), 4.63. Examples under 38 C.F.R. § 3.350(a)(2) which constitute loss of use of a foot include extremely unfavorable ankylosis of the knee, complete ankylosis of two major joints of an extremity, shortening of the lower extremity of 3 1/2 inches or more, and complete paralysis of the external popliteal (common peroneal) nerve and consequent foot-drop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of that nerve. See also 38 C.F.R. § 4.63. Under Diagnostic Code 8521, complete paralysis of the common peroneal nerve encompasses foot drop and slight droop of the first phalanges of all toes, an inability to dorsiflex the foot, loss of extension (dorsal flexion) of the proximal phalanges of the toes, loss of abduction of the foot, weakened adduction of the foot, and anesthesia covering the entire dorsum of the foot and toes. 38 C.F.R. § 4.124a. If loss of use of the foot is found to exist, a veteran is entitled to SMC in addition to the basic rate of compensation otherwise payable on the basis of degree of disability. See generally 38 C.F.R. § 3.350. 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. “Loss of use” may be organic or “functional” in origin. See VAOPGCPREC 60-90 (Jul. 18, 1990) (holding that SMC was warranted for functional (as opposed to organic) loss of the foot due to service-connected functional hysteria or conversion reaction, where such loss was permanent in nature). Moreover, in Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017), the Court clarified that the standard for “loss of use of the feet” under 38 C.F.R. §§ 3.350(a)(2)(i) and 4.63 is not the same as “loss of use of the lower extremities” for purposes of entitlement to specially adapted housing under 38 C.F.R. § 3.809(b). That is, “loss of use of the feet” is a more stringent standard for the Veteran to meet than “loss of use of the lower extremities.” Id. The Board emphasizes that the ultimate 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 is 68 years of age. The Veteran has the following service-connected disabilities: post-traumatic stress disorder (PTSD), rated as 50 percent disabling; type II diabetes mellitus, rated as 40 percent disabling; peripheral neuropathy of the LEFT upper extremity, rated as 20 percent disabling; peripheral neuropathy of the RIGHT upper extremity, rated as 30 percent disabling; peripheral neuropathy of the LEFT lower extremity, rated as 30 percent disabling; peripheral neuropathy of the RIGHT lower extremity, rated as 30 percent disabling; hypertension, rated as 10 percent disabling; and a left medial calf scar, rated as 0 percent disabling. The combined service-connected disability rating is 100 percent, with consideration of the bilateral factor. See 38 C.F.R. §§ 4.25 (combined ratings table); 4.26. Also, the Veteran has been awarded a permanent and total (P&T) rating and a TDIU rating due to his service-connected disabilities, effective from October 23, 2003. There is no question he is severely disabled. The critical issue in the present case is whether the Veteran’s service-connected disabilities cause “loss of use of both feet” for purposes of entitlement to SMC under 38 U.S.C. § 1114(l). See 38 C.F.R. §§ 3.350(a)(2)(i), (b), 4.63. Initially, with regard to loss of use of the feet, the Board acknowledges the following are not demonstrated by the evidence of record: extremely unfavorable ankylosis of the knee, complete ankylosis of two major joints of an extremity, shortening of the lower extremity of 3 1/2 inches or more, or complete paralysis of the external popliteal nerve and consequent foot drop. See 38 C.F.R. §§ 3.350(a)(2), 4.63. VA treatment records dated from 2007 to 2018, private treatment records, and VA examinations of record fail to reveal ankylosis of the knees or lower extremities, shortening of the lower extremities, complete paralysis, or foot drop. However, these criteria are mere examples of what could serve as loss of use of the feet. They are not absolute or limiting. Upon review of the evidence of record, SMC on account of loss of use of both feet under 38 U.S.C. § 1114(l) is warranted. In making this determination, the Board has considered both the lay and medical evidence of record. The evidence of record establishes that the Veteran’s service-connected type II diabetes mellitus and service-connected left and right lower extremity peripheral neuropathy cause 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 knees, with use of a suitable prosthetic appliance. See 38 C.F.R. §§ 3.350(a)(2)(i), 4.63. In particular, the following evidence of record supports the award of SMC under 38 U.S.C. § 1114(l) on account of loss of use of both feet: At a February 2007 VA heart examination, the Veteran was observed on a motorized scooter, which he uses almost all the time. He can barely walk up two small dilapidated steps into his home as the motorized wheelchair cannot go up into his home. He mentions that his right lower extremity injury has restricted his activity level and led to his weight gain. He has “uncontrolled” service-connected diabetes mellitus. At a February 2007 VA peripheral nerves examination, the Veteran was diagnosed with service-connected diabetic neuropathy in the lower extremities. He has had problems with falls. He fell the week before when his toe got caught underneath his foot and he fell forward onto the carpet. He has had problems with instability over the past couple of years. He was given a motor scooter through his VA primary care doctor and uses it to ambulate. The impression was peripheral polyneuropathy in the lower extremities, most likely due to service-connected type II diabetes mellitus. The VA examiner opined that his service-connected diabetic neuropathy is “severe” given his loss of proprioception in the lower extremities and numbness up to his knees. VA treatment records dated from 2010 to 2018 confirm that the Veteran uses a M94 power wheelchair to ambulate. A July 2010 private physician letter from Dr. J.L.P., MD., diagnosed the Veteran with severe nonservice-connected generalized osteoarthritis; morbid obesity with weight at approximately 480 pounds; service-connected type II diabetes mellitus, complicated by “severe” service-connected peripheral neuropathy in the lower extremities; nonservice-connected endstage osteoarthritis of the knees, with the unavailability of a corrective knee operation because of his obesity; and nonservice-connected chronic pain syndrome with degenerative arthritis of the back and lumbar spondylosis. Dr. J.L.P. added that the Veteran has exhausted all of his other conventional modalities, and now his current treatment is chronic oral pain medication. The Veteran requires the use of two canes most of the time or a motorized wheelchair to get around. Both his service-connected and nonservice-connected disabilities were factored into this determination. In a January 2011 VA occupational therapy consult, the reason for the consultation was noted to be a veteran with morbid obesity and service-connected peripheral neuropathy. The Veteran stated he would like the VA to reimburse him as much as possible for a new van with adaptive equipment such as hand controls for him to drive since he could not use his legs due to service-connected neuropathy in his feet. The Veteran explained he would like to be a driver in his van with hand controls only. At a January 2011 occupational therapy driving evaluation, vocational personnel observed the Veteran could use his service-connected hands to drive, but it was recommended he refrain from any driving involving his service-connected feet and lower extremities due to decreased sensation and limited range of motion. He can only walk a few feet and stand for only short periods of time. An April 2011 VA primary care note documented the Veteran has “bad” service-connected neuropathy in his feet that makes walking difficult, in addition to his weight of 500 pounds. On examination, the lower extremities reflexes were diminished 1+ with pitting edema bilaterally with hyper-pigmentary changes in a sock like distribution. Sensation was diminished to light touch and monofilament bilaterally. The impression was “uncontrolled” service-connected type II diabetes mellitus, morbid obesity of 500 pounds, service-connected hypertension, and nonservice-connected knee and back pain. In a June 2012 letter from a private physician - Dr. J.L.P., MD., the assessment was “severe” service-connected peripheral neuropathy in the Veteran’s feet. As a result, he has very little sensation in his feet and lower legs and is only able to walk several feet or to stand for a few seconds unassisted. He requires adaptive equipment on his motor vehicle which includes a hand acceleration pedal brake pedal and a low vehicle floor to allow him to enter his van in the wheelchair with floor locks in order to drive. He currently has a driver’s license indicating these adaptive measures are required. The Board emphasizes this private physician has treated the Veteran since the 1980s. In a February 2014 VA PMRS clinic note, the Veteran reported he weighs 500 pounds, and can only walk about 10 steps. In a June 2014 VA wheelchair clinic note, the Veteran underwent a Wheelchair Clinic HISA Grant Home Evaluation. In the problem list, the various service-connected disabilities were listed, as well as nonservice-connected knees, low back, morbid obesity, and fibromyalgia. The Veteran was in an electric scooter most of the time. He needs a ramp for his home. He uses an Invacare pronto M94 powered wheelchair to get around due to the combination of the service-connected and nonservice-connected disabilities above. In a December 2014 private housebound / aid and attendance examination (VA Form 21-2680), the Veteran was deemed unable to walk due to the combination of his various service-connected and nonservice-connected disabilities. He is confined to a motorized wheelchair. A February 2015 VA social work note reflected that the Veteran was confined to a wheelchair for the past 14 years. The Veteran reported the VA did not fulfill a promise to provide hand controls on his van since he cannot drive a vehicle with his service-connected feet. An August 2015 VA psychiatry medication management note observed the Veteran is able to walk from his wheelchair to his bed, using a cane at night to go to the bathroom. An October 2015 VA primary care note remarked the Veteran does not walk at all. He can only stand for a few minutes. He has utilized a motorized wheelchair for 14 years due to the effects of his service-connected diabetic neuropathy in the feet and nonservice-connected knee arthralgias and arthritis. In a December 2016 private housebound / aid and attendance examination (VA Form 21-2680), the Veteran was deemed unable to walk due to the combination of his various service-connected and nonservice-connected disabilities. He is confined to a motorized wheelchair. His relevant disabilities for aid and attendance purposes were morbid obesity, service-connected PTSD, nonservice-connected back pain, and service-connected lower extremity neuropathy. He can only use his feet for weight bearing when transferring from his wheelchair to his bed due to his service-connected lower extremity neuropathy. He has poor balance and is unable to ambulate without his wheelchair or the assistance of another person. With regard to lay evidence, the Board has reviewed the Veteran’s lay submissions throughout the entire appeal. He has repeatedly stated that his service-connected diabetic peripheral neuropathy in both lower extremities causes loss of use of his feet. He advises these disabilities are “severe” in nature. See January 2011 increased rating claim; January 2011 Auto / Adaptive Application (VA Form 21-4502); June 2011, November 2011, December 2011, February 2012, and May 2018 Veteran’s statements; August 2014 NOD; February 2015 representative statement; October 2016 representative statement (VA Form 646); and October 2016 VA Form 9. He maintains he often has no sensation or feeling in his feet. He cannot press on the gas petals in his car. Walking more than a few steps is impossible. He is in a wheelchair all the time or in his bed. He is wheelchair dependent. He takes oxycodone and gabapentin every 6 hours to manage the pain in his feet. His feet feel like they are “on fire” with needles in them. He feels helpless most of the time and requires his wife’s assistance in ambulating to use the bathroom and in completing activities of daily living. He says that he desires VA to grant SMC for loss of use in either the feet or hands, but not necessarily both. The Veteran is competent and credible in his description of the severe, disabling effects of his service-connected type II diabetes mellitus and associated peripheral neuropathy in the feet. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 307-09 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). In reaching this decision, the Board notes that the question involved in a loss of use analysis is whether there is any remaining function of the legs and feet that is more than would be provided by a suitable prosthetic device. See Tucker, 11 Vet. App. 369. When viewed from this perspective, the Board finds that the Veteran’s nearly constant use of a wheelchair and minimal ability to walk even short distances due to his service-connected type II diabetes mellitus and service-connected lower extremity peripheral neuropathy is no better than what would be experienced with suitable prosthetics. In so finding, the Board recognizes that no physician has specifically stated that no “effective function remains [in the feet] other than that which would be equally well served by an amputation stump at the site.” However, the regulation defining “loss of use” clearly leaves the question open to some interpretation to the extent that it includes an intentionally non-exhaustive list of “example” situations which may reflect loss of use. Thus, the Board exercises its authority to interpret the immediate facts as being sufficiently similar to those examples presented as demonstrative of the regulatory definition of loss of use of the feet. It is important to note the Court recently emphasized that loss of use under § 3.350(a)(2)(i) contemplates “balance and propulsion” equivalent to that provided by a prosthetic devise. The Court added that SMC due to loss of use of the feet is not limited to those veterans who have “no” remaining effective functioning of the feet. See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). So, the fact that the current Veteran can walk a few feet unaided does not mean a finding of loss of use of the feet is precluded here. In any event, the facts of this case demonstrate the Veteran has no effective function of both feet, as his ability to balance and propulse (push off his feet) is severely limited. In making this favorable determination, the Board is aware of the severe effects of the Veteran’s various nonservice-connected disabilities as well. In particular, his knees and his low back contribute to loss of use of the feet. In addition, he suffers from morbid obesity, at times weighing close to 500 pounds. In any event, when the signs and symptoms of a service-connected disability cannot be distinguished from those attributable to a non-service-connected condition, all signs and symptoms that cannot be distinguished must be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181, 192 (1998). Thus, the Board attributes the loss of use of his feet to his service-connected type II diabetes mellitus and service-connected peripheral neuropathy in the lower extremities disabilities. With regard to the Veteran’s morbid obesity (500 pounds at times), this is undoubtedly a strong factor contributing to loss of use of his feet. On this issue, in January 2017 VA’s Office of General Counsel (OGC) issued a precedential opinion concluding that obesity is not a “disease” or “disability” for VA purposes and, therefore, is not eligible for service connection on a direct or secondary basis. VAOPGCPREC 1-2017 (January 6, 2017). Precedent opinions issued by VA’s chief legal officer are binding on the Board. See 38 U.S.C. 7104(c). Also, the Court recently affirmed a Board decision finding that service connection is not warranted for obesity, holding it does not have jurisdiction to review VA’s determination that obesity is not considered a disability under the Rating Schedule. Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). Regardless, there is probative lay and clinical evidence in the record suggesting the Veteran’s obesity (as a sign or symptom) is at least associated in part with his service-connected type II diabetes mellitus, lower extremity neuropathy, and PTSD disabilities. Diabetes can cause obesity because the high amount of insulin the Veteran takes increases his appetite, compounded by no means of exercise due to his service-connected lower extremity peripheral neuropathy. His service-connected PTSD with depression also causes him to gain weight due to his lack of motivation to exercise. See January 2011 claim for an increased rating; April 2011 VA primary care note; May 2018 Veteran statements. Thus, his obesity (a factor contributing to the loss of use of his feet), is partially associated and intertwined with his service-connected disabilities. Accordingly, resolving doubt in the Veteran’s favor, the Board finds that the combined effects of the Veteran’s service-connected type II diabetes mellitus and service-connected peripheral neuropathy in the lower extremities disabilities have resulted in the equivalent of loss of use of both feet. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran is therefore entitled SMC on account of loss of use of the feet under 38 U.S.C. § 1114(l). 2. SMC – Aid and Attendance at “L” Level SMC under 38 U.S.C. § 1114(l) and 38 C.F.R. § 3.350(b) is also payable as the result of service-connected disability if a veteran so helpless as to be in need of regular aid and attendance of another person. 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. § 1114(l), 38 C.F.R. §§ 3.350(b), 3.352(a). This award is based on the collective impact of the Veteran’s service-connected PTSD, diabetes mellitus, and lower and upper extremity bilateral peripheral neuropathy. This SMC award is an alternate award at the “L” level to the SMC award above for loss of use of the feet. 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 the above service-connected disabilities. 38 C.F.R. § 3.352(a). 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. § 1114(l), 38 C.F.R. § 3.350(b). In this regard, the Veteran is currently 68 years old. He lives with his wife. He is wheelchair bound for most of the day as the result of his service-connected disabilities. Both medical and lay evidence of record is supportive of the A&A claim. He requires his wife’s assistance when he needs to go to the bathroom. Due to his service-connected upper extremity neuropathy, he needs help cooking and with food. See May 2018 Veteran’s statements. A July 2010 private physician letter from Dr. J.L.P. assessed that the Veteran has great difficulty dressing and undressing. Although he could obtain this treatment at a physical therapy clinic for a short period of time, it is difficult for him to go there without assistance. VA treatment records confirm the Veteran requires the assistance of his wife anytime he has to leave the home for medical appointments. VA treatment records dated in 2014 to 2015 document the Veteran has extreme difficulty with the following daily activities without the regular assistance of another person: preparing meals (planning, cooking, setting out food and utensils) – meals were prepared by others; performing housework; shopping (selecting items, managing money); and transportation (getting to places beyond walking distance by any mode). An August 2015 VA psychiatry medication management note stated the Veteran is dependent on his wife for most activities of daily living, including toileting, driving, and all chores and responsibilities around the home. Moreover, in a December 2016 private housebound / aid and attendance examination (VA Form 21-2680), the Veteran was deemed unable to walk due to the combination of his various service-connected and nonservice-connected disabilities. He is confined to a motorized wheelchair. His relevant disabilities were morbid obesity, service-connected PTSD, nonservice-connected back pain, and service-connected lower extremity neuropathy. These disabilities prevent him from preparing his own meals. He requires assistance bathing himself. He requires medication management due to memory loss from his service-connected PTSD. He can only use his feet for weight bearing when transferring from his wheelchair to his bed due to his service-connected lower extremity neuropathy. He has poor balance and is unable to ambulate without his wheelchair or assistance of another person. 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 the collective impact of all his service-connected disabilities. 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. 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, based on the collective impact of his service-connected disabilities — 38 U.S.C. § 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 (A&A) at the L-level. 38 U.S.C. § 5107(b). In making this determination, the Board emphasizes it 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 type II diabetes mellitus and service-connected lower extremity peripheral neuropathy disabilities. The Board is now also awarding an alternative award for SMC at the L-rate based on the need for A&A. But importantly, the Board is not awarding a separate award of SMC at the L-rate based on the need for regular aid and attendance due to other service-connected disabilities, independent and without consideration of his service-connected type II diabetes mellitus and lower extremity disabilities. On this issue, the evidence of record does not show that the Veteran’s service-connected PTSD and service-connected hypertension and service-connected upper extremity neuropathy, in conjunction with each other, would necessitate the regular aid and attendance of another person for many activities of daily living. (If for example the Veteran had been entitled to two separate L-rates of SMC (for both loss of use of the feet and aid and attendance), based on separate and distinct service-connected disabilities, then he would have been entitled to a higher level of SMC, namely at the O- and R-1 rate, at the levels designated under 38 U.S.C. § 1114(o) and 38 U.S.C. § 1114(r)(1). But as the Board has concluded - he is not entitled to separate awards). On another side note, SMC benefits at the “S” level by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling, and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) is “permanently housebound” by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i)(1). Housebound benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011). A total disability rating based on individual unemployability (TDIU) satisfies the total (100 percent) rating requirement if the TDIU evaluation was, or can be, predicated upon a single disability and there exists additional disability or disabilities independently ratable at 60 percent or more, for purposes of entitlement to special monthly compensation for a housebound rating. Bradley v. Peake, 22 Vet. App. 280, 293 (2008). In other words, a TDIU rating based on a single disability, but not multiple disabilities, is permitted to satisfy the statutory requirement of a total rating. Bradley, 22 Vet. App. at 293. Nonetheless, the TDIU rating based on a single disability that satisfies the total (100 percent) rating requirement must be separate and distinct from the additional disability or disabilities independently ratable at 60 percent or more for purposes of housebound benefits. Bradley, 22 Vet. App. at 293. In addition, the decision to treat multiple disabilities as one under 38 C.F.R. § 4.16(a) was specifically limited to TDIU ratings. That is, a TDIU rating based on multiple service-connected disabilities does not satisfy the criteria for one total disability in considering entitlement to housebound benefits under 38 U.S.C. § 1114(s). Bradley, 22 Vet. App. at 290-91. A “TDIU rating that is based on multiple disabilities cannot satisfy the section 1114(s) requirements of ‘a service-connected disability’ because that requirement must be met by a single disability.” Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010). However, VA’s duty to maximize benefits requires VA to assess all of a claimant’s disabilities, regardless of the order in which they were service-connected, to determine whether any combination of disabilities establishes housebound benefits under 38 U.S.C. § 1114(s). Buie, 24 Vet. App. at 249-250. A veteran is permanently housebound when he is substantially confined to his house (ward or clinical areas, if institutionalized) or immediate premises as a direct result of his service-connected permanent disability or disabilities, and it is reasonably certain that the disability of disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(2). As noted above, the Veteran has the following service-connected disabilities: PTSD, rated as 50 percent disabling; type II diabetes mellitus, rated as 40 percent disabling; peripheral neuropathy of the LEFT upper extremity, rated as 20 percent disabling; peripheral neuropathy of the RIGHT upper extremity, rated as 30 percent disabling; peripheral neuropathy of the LEFT lower extremity, rated as 30 percent disabling; peripheral neuropathy of the RIGHT lower extremity, rated as 30 percent disabling; hypertension, rated as 10 percent disabling; and a left medial calf scar, rated as 0 percent disabling. The combined service-connected disability rating is 100 percent, with consideration of the bilateral factor. See 38 C.F.R. §§ 4.25 (combined ratings table); 4.26. Also, the Veteran has been awarded a permanent and total (P&T) rating and a TDIU due to his service-connected disabilities, effective from October 23, 2003. With regard to housebound status, the threshold statutory requirement is that the Veteran must have a single permanent disability rated at a schedular 100 percent. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The Veteran does not have a single permanent disability rated at 100 percent. His highest rated disability is his PTSD, which is rated as 50 percent disabling. However, in a November 2005 rating decision, the Veteran was awarded a TDIU rating, effective from October 23, 2003. Nevertheless, when the RO awarded the TDIU rating, the RO predicated the TDIU award on the combination of the effects of his service-connected PTSD, type II diabetes mellitus, and upper and lower extremity bilateral peripheral neuropathy disabilities. See November 2005 rating decision. The RO did not determine that the effects of a single service-connected disability, standing alone, were sufficient to award the TDIU rating due to unemployability. Again, a TDIU rating based on a single disability, but not multiple disabilities, is only permitted to satisfy the statutory requirement of a total rating for housebound purposes. Bradley, 22 Vet. App. at 290-91. In short, the TDIU award was based on multiple disabilities. The Board agrees with the RO’s assessment. No clinical evidence of record demonstrates that any of the Veteran’s individual service-connected disabilities, standing alone, render him unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability. See 38 C.F.R. § 4.16(a). Consequently, for the multiple reasons cited above, the basic requirements for special monthly compensation by reason of being housebound at the “S” level are not met, to the extent that issue would not already be moot due to award of SMC at the “L” level for A&A in the present decision. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). 3. Automobile and Adaptive Equipment Financial assistance may be provided to an “eligible person” in acquiring an automobile or other conveyance and adaptive equipment, or adaptive equipment only. 38 U.S.C. § 3902(a), (b). Eligibility for assistance to purchase a vehicle and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis (ALS); or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 U.S.C. §§ 3901, 3902; 38 C.F.R. §§ 3.808, 17.156. The term, adaptive equipment, means equipment which must be part of or added to a conveyance manufactured for sale to the general public to make it safe for use by the claimant, and enable that person to meet the applicable standards of licensure. Adaptive equipment includes any term specified by the Under Secretary for Health or designee as ordinarily necessary for any of the classes of losses or combination of such losses specified in §17.156 of this part, or as deemed necessary in an individual case. Adaptive equipment includes, but is not limited to, a basic automatic transmission, power steering, power brakes, power window lifts, power seats, air-conditioning equipment when necessary for the health and safety of the veteran, and special equipment necessary to assist the eligible person into or out of the automobile or other conveyance, regardless of whether the automobile or other conveyance is to be operated by the eligible person or is to be operated for such person by another person; and any modification of the interior space of the automobile or other conveyance if needed because of the physical condition of such person in order for such person to enter or operate the vehicle. 38 C.F.R. § 17.157. Ankylosis is complete immobility of the knee joint in a fixed position, either favorable or unfavorable. See, e.g., Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992). The term “permanent loss of use” is not defined under 38 C.F.R. § 3.808. However, under other relevant VA regulations, what constitutes “loss of use of a hand or foot” is defined and discussed in detail above. See again 38 C.F.R. §§ 3.350(a)(2)(i), 4.63. In a January 2011 Application for Automobile or Other Conveyance and Adaptive Equipment (VA Form 21-4502) and in other evidence of record, the Veteran alleged his qualifying disability is permanent loss of use of both feet. After 10 hours of training in 2011 with Easter Seals Crossroads, the Veteran received an amended driver’s license for the van he purchased. Adaptive equipment was recommended for the van, some of which has already been purchased by the Veteran. He is requesting that VA pay the cost of the van and the necessary adaptive equipment. This adaptive equipment will assist with his entry and exit into the van, as well as his driving of the van. The main adaptive equipment is hand controls, negating the necessity for foot pedals. He cannot use foot pedals due to his service-connected loss of use of his feet. He is not permitted to drive with his amended license until he receives payment from VA to purchase the necessary adaptive equipment for his van. The critical issue in the present case is whether the Veteran’s service-connected disabilities cause “loss or permanent loss of use of one or both feet” for purposes of entitlement to automobile and / or specially adapted equipment. See 38 C.F.R. § 3.808. Upon review of the evidence, the Board concludes that the Veteran’s service-connected disabilities cause permanent loss of use of both feet, such that entitlement to automobile and / or specially adapted equipment is warranted. See 38 C.F.R. § 3.808. In making this determination, the Board has considered both the lay and medical evidence of record. The Board incorporates into the present analysis the extensive discussion above, which already described in detail why the Veteran meets the criteria for service-connected loss of use of both feet. There is no reason to repeat this analysis verbatim. But in short, the evidence of record discussed above establishes that the Veteran’s service-connected type II diabetes mellitus and service-connected peripheral neuropathy in the lower extremities disabilities cause 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 knee with use of a suitable prosthetic appliance. 38 C.F.R. §§ 3.350(a)(2)(i), 4.63. Accordingly, resolving doubt in the Veteran’s favor, the Veteran meets the criteria for a certificate of eligibility for an automobile and adaptive equipment, or for adaptive equipment only, on account of permanent loss of use of both feet due to service-connected disabilities. 38 U.S.C. §§ 3902, 5107(b); 38 C.F.R. §§ 3.102, 3.808. (On a side note, the Veteran is now awarded an automobile allowance with automotive adaptive equipment as appropriate for his situation, to be determined by the experts who administer these programs). REASONS FOR REMAND 1. Entitlement to an increased disability rating greater than 20 percent for peripheral neuropathy of the LEFT upper extremity is remanded. 2. Entitlement to an increased disability rating greater than 30 percent for peripheral neuropathy of the RIGHT upper extremity is remanded. 3. Entitlement to an increased disability rating greater than 30 percent for peripheral neuropathy of the LEFT lower extremity is remanded. 4. Entitlement to an increased disability rating greater than 30 percent for peripheral neuropathy of the RIGHT lower extremity is remanded. 5. Entitlement to SMC on account of loss of use of both hands under 38 U.S.C. § 1114(m), is remanded. First, a remand is required for a more current VA peripheral nerves examination to adequately rate the Veteran’s service-connected peripheral neuropathy of the bilateral upper extremities and bilateral lower extremities. The Veteran was last provided a VA peripheral nerves examination in connection with these service-connected disabilities in February 2007, so over 11 years ago. The Veteran has contended many times that these disabilities have continued to worsen. When a claimant asserts that the severity of a disability has increased since the most recent rating examination (or the evidence indicates it has), and the evidence of record is otherwise insufficient to evaluate the appeal, an additional VA examination is appropriate. 38 C.F.R. § 3.327(a) (2017). See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Therefore, the appropriate VA peripheral nerves examination is necessary for the purpose of ascertaining the current severity and manifestations of the Veteran’s service-connected peripheral neuropathy of the bilateral upper extremities and bilateral lower extremities. On the issue of scheduling a VA examination for the Veteran, the Board acknowledges that the Veteran cancelled and / or failed to appear to previous VA peripheral nerves examinations scheduled for him in July 2014 and October 2016, despite being sent notice letters of the time and place for both examinations. The action to be taken in instances where the Veteran fails to report for a VA examination depends on if the examination was scheduled in connection with a service connection / initial rating claim or a claim for an increase. A service connection claim or an initial rating claim is classified as an original compensation claim under 38 C.F.R. § 3.655(b) (2017), so where the Veteran fails to report for such an examination, the case shall be rated on the evidence of record. Fenderson v. West, 12 Vet. App. 119, 125 (1999); Turk v. Peake, 21 Vet. App. 565, 568-70 (2008). In contrast, where the Veteran fails to report for an examination scheduled in connection with a claim for an increase or any other original claim (such as the current increased rating issues on appeal), the claim shall be denied. 38 C.F.R. § 3.655(b). But as a threshold matter, when a Veteran misses a scheduled VA examination, the Board must consider (1) whether the examination was necessary to establish entitlement to the benefit sought, and (2) whether the Veteran lacked good cause to miss the scheduled examination. See 38 C.F.R. § 3.655(a) (2017) (emphasis added); Turk, 21 Vet. App. at 569. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a) (emphasis added). As to the necessity of a VA peripheral nerves examination in the instant case, the Board finds that, based on the present evidence of record, a more current VA peripheral nerves examination is necessary to provide a clearer picture of the Veteran’s degree of impairment from his service-connected upper extremity and lower extremity disabilities. The evidence of record is not adequate to clearly rate his upper extremity and lower extremity disabilities under their respective neurological diagnostic codes – Diagnostic Codes 8515 and 8521. See 38 C.F.R. § 4.124a. As to the issue of good cause for failure to appear to the previous July 2014 and October 2016 VA peripheral nerves examinations, the Board finds that good cause was warranted on both occasions, due to the illness of the Veteran. See 38 C.F.R. § 3.655(a). Specifically, he and his representative have credibly asserted that his morbid obesity (500 pounds), inability to use the smaller-sized restrooms in the VA facility (he also cannot use the toilet without his wife’s help), and necessity for a VA ambulance to transport him to any scheduled VA examination, all make it nearly impossible for him to report to the VA facility for a VA examination. See September 2016 and October 2016 representative statement (VA Form 646); October 2016 Veteran statement; October 2016 VA Form 9; and October 2016 VA addendum note. In this regard, the Veteran has asked that VA provide him with a bedside VA compensation examination at his home for his peripheral neuropathy disabilities. On this issue, the Board sees that an October 2016 VA addendum note advised the Veteran that VA offers a service that would allow his VA primary care provider to come to his home and provide medical services and prescription refills for his medications. The Veteran and his wife at that time expressed interest in the at-home service. Similarly, for incarcerated veterans who cannot leave their facility, the Court has held that VA must “tailor [its] assistance to the peculiar circumstances of confinement.” Such individuals are entitled to the same care and consideration given to their fellow Veterans. Bolton v. Brown, 8 Vet. App. 185, 191 (1995). While VA does not have authority under 38 U.S.C. § 5711 to require a correctional institution to release a Veteran so that VA can provide him the necessary examination at the closest VA medical facility, VA’s duty to assist an incarcerated Veteran extends, if necessary, to either having him examined by VBA contract examination providers, a fee-basis physician contracted by VHA, VHA personnel, or a prison medical provider at VA expense. Bolton, 8 Vet. App. 191. See also VBA Live Manual, M21-1, Part III, Subpart iv, Chapter 3, Section F, Topic 2, Block d (June 21, 2018). Accordingly, as part of its statutory duty to assist, VA must make reasonable efforts to accommodate the Veteran at his home and schedule him for a VA bedside examination for his peripheral nerves disabilities, or if not possible, at least explain why. Documentation of substantial efforts to schedule and conduct the VA examination at his home must be documented in the claims file by the AOJ. Second, since the increased rating issues are already being remanded for further development, the Board sees the Veteran’s VA treatment records on file from the VA Medical Center (VAMC) in Indianapolis, Indiana date to October 2016. If the Veteran has had any additional treatment at the VA, these records should be obtained by the AOJ. Third, the SMC claim on appeal for loss of use of both hands under 38 U.S.C. § 1114(m) is inextricably intertwined with the increased rating claims on appeal. If the increased rating claims for peripheral neuropathy of the upper extremities are granted by the AOJ, this will directly impact the adjudication of the SMC claim. See 38 C.F.R. § 3.350(c). For this reason, the increased rating claims being remanded in the present case must be resolved prior to resolution of the claim for SMC based on loss of use of the hands. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, a remand is required for the AOJ to adjudicate these inextricably intertwined increased rating and SMC claims. Therefore, these five issues are REMANDED for the following action: 1. The AOJ should obtain the Veteran’s VA treatment records from the VAMC in Indianapolis, Indiana dated from October 2016 to the present, and associate them with the claims file. 2. After completion of step 1, the AOJ should schedule the Veteran for the appropriate VA peripheral nerves examination to ascertain the current severity and manifestations of the Veteran’s service-connected peripheral neuropathy of the bilateral upper extremities and bilateral lower extremities. Access to the electronic claims file must be made available to the examiner for review. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examination should include a statement as the effect of the Veteran’s service-connected peripheral neuropathy of the bilateral upper extremities and bilateral lower extremities on the Veteran’s occupational functioning and daily activities. The VA examiner should provide a complete rationale for any opinions provided. The AOJ must make reasonable efforts to accommodate the Veteran with a bedside VA compensation examination at his home for his service-connected peripheral neuropathy disabilities. On this issue, the Board sees that an October 2016 VA addendum note advised the Veteran that VA offers a service that would allow his VA primary care provider to come to his home and provide medical services and prescription refills for his medications. The Veteran and his wife at that time expressed interest in this at home service. Similarly, for incarcerated veterans who cannot leave their facility, the Court has held that VA must “tailor [its] assistance to the peculiar circumstances of confinement.” Such individuals are entitled to the same care and consideration given to their fellow Veterans. Bolton v. Brown, 8 Vet. App. 185, 191 (1995). See also VBA Live Manual, M21-1, Part III, Subpart iv, Chapter 3, Section F, Topic 2, Block d (June 21, 2018). In this vein, VA must make reasonable efforts to accommodate the Veteran at his home and schedule him for a VA bedside examination for his peripheral nerves disabilities, or if not possible, at least explain why. Documentation of substantial efforts to schedule and conduct the VA examination at his home must be documented in the claims file by the AOJ. 3. After completion of steps 1 – 2 above, the AOJ should consider all of the evidence of record and readjudicate the increased rating and SMC issues remaining on appeal. If the benefit sought is not granted, the AOJ should issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his representative an opportunity to respond. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P.S. Rubin, Counsel