Citation Nr: 18146989 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 18-15 753 DATE: November 2, 2018 ORDER Entitlement to service connection for right femur fracture residuals, including as due to service-connected peripheral neuropathy of the right lower extremity, is denied. Entitlement to a disability rating greater than 30 percent for coronary artery disease is denied. Entitlement to a disability rating greater than 20 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to a disability rating greater than 20 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to a disability rating greater than 10 percent for peripheral neuropathy of the left lower extremity is denied. Entitlement to a disability rating greater than 10 percent for peripheral neuropathy of the right lower extremity is denied. Entitlement to a disability rating greater than 20 percent for diabetes mellitus is denied. Entitlement to an earlier effective date of May 11, 2016, for an award of special monthly compensation (SMC) based on aid & attendance is granted. Entitlement to an earlier effective date of September 21, 2016, for an award of a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The record evidence shows that, prior to his death, the Veteran’s right femur fracture residuals are not related to active service or any incident of service, including as due to service-connected peripheral neuropathy of the right lower extremity. 2. The record evidence shows that, prior to his death, the Veteran’s service-connected coronary artery disease is manifested by, at worst, a left ventricular ejection fraction of 65 percent. 3. The record evidence shows that, prior to his death, the Veteran’s service-connected peripheral neuropathy of the left upper extremity and his service-connected peripheral neuropathy of the right upper extremity are not manifested by any compensable disability. 4. The record evidence shows that, prior to his death, the Veteran’s service-connected peripheral neuropathy of the left lower extremity and his service-connected peripheral neuropathy of the right lower extremity are both asymptomatic. 5. The record evidence shows that, prior to his death, the Veteran’s service-connected diabetes mellitus requires, at most, insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. 6. Service connection is in effect for dementia, evaluated as 100 percent disabling effective October 20, 2017, neurogenic bladder, evaluated as 40 percent disabling effective February 29, 2008, coronary artery disease, evaluated as 30 percent disabling effective September 29, 2008, diabetes mellitus, evaluated as 20 percent disabling effective May 8, 2001, peripheral neuropathy of the left upper extremity, evaluated as 20 percent disabling effective May 8, 2001, peripheral neuropathy of the right upper extremity, evaluated as 20 percent disabling effective May 8, 2001, hearing loss, evaluated as 20 percent disabling effective June 9, 2016, peripheral neuropathy of the right lower extremity, evaluated as 10 percent disabling effective May 8, 2001, peripheral neuropathy of the left lower extremity, evaluated as 10 percent disabling effective May 8, 2001, tinnitus, evaluated as 10 percent disabling effective June 26, 2008, cerebrovascular accident, evaluated as 100 percent disabling effective July 12, 2017, and as 10 percent disabling effective February 1, 2018, and for hemorrhoids and recurrent genital herpes, each evaluated as zero percent disabling effective April 1, 1973. 7. The record evidence shows that, prior to his death, the Veteran was rendered so helpless as to require the regular aid & attendance of another person effective May 11, 2016; this is the earliest factually ascertainable date that entitlement to SMC based on aid & attendance was met. 8. The record evidence shows that, prior to his death, the Veteran’s service-connected diabetes mellitus, alone or in combination with his other service-connected disabilities, prevented him from securing or following a substantially gainful occupation effective September 21, 2016. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right femur fracture residuals, including as due to service-connected peripheral neuropathy of the right lower extremity, have not been met. 38 U.S.C. §§ 1110, 1131, 1154, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2017). 2. The criteria for entitlement to a disability rating greater than 30 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code (DC) 7005 (2017). 3. The criteria for entitlement to a disability rating greater than 20 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, DC 8699-8612 (2017). 4. The criteria for entitlement to a disability rating greater than 20 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, DC 8699-8612 (2017). 5. The criteria for entitlement to a disability rating greater than 10 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, DC 8699-8621 (2017). 6. The criteria for entitlement to a disability rating greater than 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, DC 8699-8621 (2017). 7. The criteria for entitlement to a disability rating greater than 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.119, DC 7913 (2017). 8. The criteria for entitlement to an earlier effective date of May 11, 2016, for an award of SMC based on aid & attendance have been met. 38 U.S.C. §§ 1114(l), 5107(b), 5110 (West 2012); 38 C.F.R. §§ 3.350(b), 3.352, 3.400, 3.401 (2017). 9. The criteria for entitlement to an earlier effective date of September 21, 2016, for an award of TDIU have been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.400, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1950 to January 1966 in the U.S. Coast Guard and from January 1966 to March 1973 in the U.S. Army, including in combat in the Republic of Vietnam. He died in February 2018. In March 2018, the Agency of Original Jurisdiction (AOJ) found that the Appellant, the Veteran’s surviving spouse, was an appropriate substitute claimant for the Veteran. See 38 U.S.C. § 5121A (West 2012). The Board notes that, in a November 2017 rating decision, the AOJ granted, in pertinent part, claims of service connection for dementia, assigning a 100 percent rating effective October 20, 2017, and for a cerebrovascular accident, assigning a 100 percent rating effective July 12, 2017, and a 10 percent rating effective February 1, 2018, based on residuals. The Board observes here that, because the grant of a 100 percent schedular rating for a service-connected cerebrovascular accident effective July 12, 2017, is the greater benefit, a TDIU claim is considered moot after this date. The Board also notes that, in a January 2018 rating decision, the AOJ granted a claim of entitlement to SMC based on aid & attendance effective July 12, 2017. The Veteran, during his lifetime, and the Appellant, after his death, continued to disagree with the effective dates for a TDIU and for SMC based on aid & attendance. Thus, these claims are as stated above. Neither the Veteran, during his lifetime, nor the Appellant, after his death, nor the service representative in this appeal has raised any other issues. Nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that Board not required to address issues unless specifically raised by claimant or reasonably raised by record evidence). 1. Entitlement to service connection for right femur fracture residuals, including as due to service-connected peripheral neuropathy of the right lower extremity The Board finds that the preponderance of the evidence is against granting the Appellant’s claim of service connection for right femur fracture residuals, including as due to service-connected peripheral neuropathy of the right lower extremity. The Veteran, during his lifetime, and the Appellant, after his death, essentially contends that he incurred right femur fracture residuals during active service or, alternatively, his service-connected peripheral neuropathy of the right lower extremity caused or aggravated (permanently worsened) his right femur fracture residuals. The record evidence does not support finding an etiological link between the Veteran’s right femur fracture residuals and active service, including as due to service-connected peripheral neuropathy of the right lower extremity. It shows instead that, although the Veteran was diagnosed as having and treated for right femur fracture residuals prior to his death, this disability is not related to active service. For example, the Veteran’s available service treatment records show no complaints of or treatment for right femur fracture residuals at any time during his active service. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The post-service evidence also does not support granting the Veteran’s claim of service connection for right femur fracture residuals, including as due to service-connected peripheral neuropathy of the right lower extremity. Contrary to the lay assertions of record, the evidence shows instead that this disability is not related to active service or any incident of service. The Board notes initially that the Veteran had right hip surgery (open reduction internal fixation (ORIF)) on his right hip in May 2016 following a fall in which he fractured his right femur. The pre-operative and post-operative diagnosis was right hip intertrochanteric proximal femur fracture. There were no surgical complications. On VA hip and thigh conditions Disability Benefits Questionnaire (DBQ) in October 2016, the Veteran complained that his status-post right femur fracture residuals had worsened since he broke his right hip and had surgery to repair it in May 2016. The VA examiner reviewed the Veteran’s electronic claims file, including his service treatment records and post-service VA treatment records. “The flare-ups of the right hip can be described as still in [the] healing process.” The Veteran stated that he was unable to walk due to constant right hip pain. Physical examination of the right hip showed evidence of pain on weight-bearing, no objective evidence of crepitus, pain not resulting in or causing functional loss, 5/5 muscle strength, no muscle atrophy, no ankylosis, and his right leg was shorter than his left leg “likely due to femur fracture and knee fracture and compensation in weight bearing.” The VA examiner stated that the Veteran was “still in [the] acute healing phase of hip fracture.” This examiner also stated that the Veteran was “still walking with walker” and had pain when bearing all of his weight on the right side “but [he] also recently had [a] right kneecap fracture.” The Veteran constantly used a walker for ambulation. X-rays did not show any traumatic arthritis. The Veteran was unable to “do anything now” because he was “limited to walker” and unable to get to the bathroom in time. He paid someone “to sit with him and help him to [the] bathroom.” He also was limited in his ability to walk. The diagnosis was status-post right femur fracture and ORIF. Following this examination, the VA examiner opined in October 2016 that it was less likely than not that the Veteran’s right femur fracture residuals were related to active service or any incident of service, including as due to service-connected peripheral neuropathy of the right lower extremity. The rationale for this opinion was based on a review of the Veteran’s claims file. The rationale also was that the Veteran himself reported that his peripheral neuropathy was asymptomatic and denied any problems with sensation in his lower extremities (legs/feet). The rational further was that, due to the Veteran’s age “and multitude of co-morbidities,” the causes of his hip fracture residuals were “more likely than not multifactorial, to include age and generalized weakness,” his history of transient ischemic attacks, coronary artery disease, “fluctuating blood sugars from diabetes, [and] recent knee fracture and surgeries (post-operative). Hip fracture is one of the most common morbid factors at this age and very common and expected for anyone in the age category” of the Veteran. The Veteran, during his lifetime, and the Appellant, after Veteran’s death, contend that his right femur fracture residuals are related to active service or, alternatively, his service-connected peripheral neuropathy of the right lower extremity caused or aggravated (permanently worsened) his right femur fracture residuals. The record evidence does not support these assertions. The Board acknowledges that the Veteran fractured his right hip in May 2016 and experienced constant right hip pain following surgery to repair the fracture. The Board also acknowledges that service connection is in effect for peripheral neuropathy of the right lower extremity. The October 2016 VA examiner specifically opined, however, that the Veteran’s right femur fracture residuals are not related to active service, including as due to service-connected peripheral neuropathy of the right lower extremity. This opinion was fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Neither the Veteran, during his lifetime, nor the Appellant, after his death, has identified or submitted any evidence demonstrating entitlement to service connection for right femur fracture residuals. In summary, the Board finds that service connection for right femur fracture residuals, including as due to service-connected peripheral neuropathy of the right lower extremity, is not warranted. Increased Rating 2. Entitlement to a disability rating greater than 30 percent for coronary artery disease The Board finds that the preponderance of the evidence is against granting the Veteran’s claim of entitlement to a disability rating greater than 30 percent for coronary artery disease. Despite the lay assertions to the contrary, the record evidence shows that, prior to his death, the Veteran’s service-connected coronary artery disease is manifested by, at worst, a left ventricular ejection fraction of 65 percent. For example, on VA heart conditions DBQ in October 2016, no relevant complaints were noted. The VA examiner reviewed the Veteran’s electronic claims file, including his service treatment records and post-service VA treatment records. This examiner stated that the Veteran’s heart condition did not qualify within the generally accepted medical definition of ischemic heart disease. “There is narrowing of coronary vessels due to plaque but [this] has not caused ischemia in the heart at this time.” Continuous medication was required for control of the Veteran’s heart condition. The Veteran had not had a myocardial infarction, congestive heart failure, cardiac arrhythmia, a heart valve condition, infectious cardiac condition, or pericardial adhesions. A history of angioplasty in 2008 to treat coronary artery disease was noted. Physical examination showed a heartbeat of 52, a regular heart rate and rhythm with point of maximal impact at the fourth intercostal space, normal heart sounds, no jugular venous distention, clear lungs to auscultation, normal peripheral pulses, no peripheral edema, and blood pressure of 150/78, 154/68, and 152/70. There was no evidence of cardiac hypertrophy or cardiac dilatation. An EKG showed bifascicular block. A chest x-ray was normal. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 65 percent with abnormal relaxation of wall motion and normal wall thickness. On an interview-based METs test, the Veteran denied “experiencing any symptoms attributable to a cardiac condition with any level of physical activity.” The diagnosis was coronary artery disease. An echocardiogram in January 2017 showed an LVEF of 60-65 percent. Despite the lay assertions of record made by the Veteran during his lifetime and the Appellant after his death, the medical evidence does not support assigning a disability rating greater than 30 percent for service-connected coronary artery disease. It shows instead that, prior to the Veteran’s death, this disability is manifested by, at worst, an LVEF of 60-65 percent. The Board finds it highly significant that, on VA heart conditions DBQ in October 2016, the Veteran specifically denied “experiencing any symptoms attributable to a cardiac condition with any level of physical activity.” This suggests that the Veteran believed that he still could participate in physical activity without experiencing any symptoms attributable to his service-connected coronary artery disease at the time of this examination. The October 2016 VA examination also did not disclose evidence of acute congestive heart failure or an ejection fraction of 30-50 percent or chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent as is required for a 60 or 100 percent rating for service-connected coronary artery disease under DC 7005, respectively. See 38 C.F.R. § 4.104, DC 7005 (2017). Neither the Veteran, during his lifetime, nor the Appellant, after his death, has identified or submitted any evidence demonstrating entitlement to a disability rating greater than 30 percent for service-connected coronary artery disease. In summary, the Board finds that the criteria for a disability rating greater than 30 percent for coronary artery disease have not been met. 3. Entitlement to disability ratings greater than 20 percent for peripheral neuropathy of the left upper extremity and for peripheral neuropathy of the right upper extremity The Board next finds that the preponderance of the evidence is against granting the claims of entitlement to disability ratings greater than 20 percent for peripheral neuropathy of the left upper extremity and for peripheral neuropathy of the right upper extremity. Both the Veteran, prior to his death, and the Appellant, after his death, contend that his service-connected peripheral neuropathy of the left upper extremity and peripheral neuropathy of the right upper extremity are more disabling than currently evaluated. The record evidence does not support these assertions. It shows instead that, prior to the Veteran’s death, these service-connected disabilities are not manifested by any compensable disability. For example, on VA diabetic-sensory peripheral neuropathy DBQ in October 2016, no relevant complaints were noted. The Veteran was right-hand dominant. Physical examination of the bilateral upper extremities showed normal strength, deep tendon reflexes, and sensation, and no muscle atrophy. The VA examiner concluded that the Veteran had no upper extremity diabetic peripheral neuropathy. This examiner also stated, “when I do monofilament testing, and vibratory testing, [the Veteran] states he feels everything normal and perfectly and denies this is a problem.” The Veteran, during his lifetime, and the Appellant, after his death, essentially contend that his service-connected peripheral neuropathy of the left upper extremity and service-connected peripheral neuropathy of the right upper extremity are both more disabling than currently evaluated. The record evidence does not support these assertions. It shows instead that, prior to his death, the Veteran experienced no compensable disability due to his service-connected peripheral neuropathy of the left upper extremity or his service-connected peripheral neuropathy of the right upper extremity. The VA examiner specifically found in October 2016 that the Veteran had no upper extremity diabetic peripheral neuropathy. The Veteran himself denied that peripheral neuropathy was a problem at this examination although the Appellant subsequently asserted that her husband’s answers at this examination were unreliable because he already was experiencing dementia. Nevertheless, even assuming for the sake of argument only that the Veteran’s dementia was too advanced for his lay statements made during this examination to reflect his actual physical condition, the physical examination findings obtained in October 2016 supported the VA examiner’s conclusion that peripheral neuropathy was not present in either of the Veteran’s upper extremities. And the evidence does not suggest that, prior to his death, the Veteran experienced at least moderate incomplete paralysis of the lower radicular group (whether on the major or minor side) as is required for a 30 or 40 percent rating for the minor (left) side or major (right) side under DC 8612, respectively. See 38 C.F.R. § 4.124a, DC 8699-8612 (2017). Neither the Veteran, during his lifetime, nor the Appellant, after his death, has identified or submitted any evidence demonstrating entitlement to disability ratings greater than 20 percent for service-connected peripheral neuropathy of the left upper extremity or for service-connected peripheral neuropathy of the right upper extremity. In summary, the Board finds that the criteria for disability ratings greater than 20 percent for peripheral neuropathy of the left upper extremity and for peripheral neuropathy of the right upper extremity have not been met. 4. Entitlement to disability ratings greater than 10 percent for peripheral neuropathy of the left lower extremity and for peripheral neuropathy of the right lower extremity The Board next finds that the preponderance of the evidence is against granting the Veteran’s claims of entitlement to disability ratings greater than 10 percent for peripheral neuropathy of the left lower extremity and for peripheral neuropathy of the right lower extremity. Both the Veteran, prior to his death, and the Appellant, after his death, contend that his service-connected peripheral neuropathy of the left lower extremity and peripheral neuropathy of the right lower extremity are more disabling than currently evaluated. The record evidence does not support these assertions. It shows instead that, prior to the Veteran’s death, both of these service-connected disabilities are asymptomatic. For example, on VA diabetic-sensory peripheral neuropathy DBQ in October 2016, the Veteran complained of worsening peripheral neuropathy of the bilateral lower extremities. He was right-hand dominant. He reported experiencing “pain running up and down [his] right leg” due to patella and femur fractures. Physical examination of the bilateral lower extremities showed severe constant pain, severe paresthesias and/or dysesthesias of the right lower extremity but no paresthesias and/or dysesthesias of the left lower extremity, 5/5 muscle strength, normal deep tendon reflexes and sensation, and no muscle atrophy. The VA examiner concluded that the Veteran had no lower extremity diabetic peripheral neuropathy. This examiner also concluded that the Veteran’s peripheral neuropathy of the bilateral lower extremities was asymptomatic. The diagnosis was bilateral lower extremity neuropathy. The Veteran, during his lifetime, and the Appellant, after his death, essentially contend that his service-connected peripheral neuropathy of the left lower extremity and peripheral neuropathy of the right lower extremity are both more disabling than currently evaluated. The record evidence does not support these assertions. It shows instead that, prior to his death, the Veteran’s peripheral neuropathy of the bilateral lower extremities was asymptomatic. The Board again acknowledges the Appellant’s assertion that, because of cognitive decline due to dementia, any statements made by the Veteran at his VA examination in October 2016 should be discounted. Nevertheless, the physical examination findings obtained at this examination do not support assigning disability ratings greater than 10 percent for the Veteran’s service-connected peripheral neuropathy of the left lower extremity or for his service-connected peripheral neuropathy of the right lower extremity. See 38 C.F.R. § 4.124a, DC 8699-8621 (2017). There is no indication at this examination the Veteran experienced at least moderate incomplete paralysis of the external popliteal nerve (common peroneal) as is required for a 20 percent rating under DC 8621. Id. The October 2016 VA examiner instead found that the Veteran had no lower extremity diabetic peripheral neuropathy at this examination. Neither the Veteran, during his lifetime, nor the Appellant, after his death, has identified or submitted any evidence demonstrating entitlement to disability ratings greater than 10 percent for service-connected peripheral neuropathy of the left lower extremity or for service-connected peripheral neuropathy of the right lower extremity. In summary, the Board finds that the criteria for disability ratings greater than 10 percent for peripheral neuropathy of the left lower extremity and for peripheral neuropathy of the right lower extremity have not been met. 5. Entitlement to a disability rating greater than 20 percent for diabetes mellitus The Board next finds that the preponderance of the evidence is against granting the claim of entitlement to a disability rating greater than 20 percent for diabetes mellitus. As noted, both the Veteran, during his lifetime, and the Appellant, after his death, contend that his service-connected diabetes mellitus is more disabling than currently evaluated. The record evidence does not support these assertions. It shows instead that, prior to the Veteran’s death, his service-connected diabetes mellitus requires, at most, insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. For example, on private outpatient treatment in October 2015, it was noted that the Veteran’s service-connected diabetes mellitus was “managed with diet.” The diagnoses included diabetes mellitus. The Veteran was advised to follow his “prescribed diet plan” and increase his level of physical activity. In October 2015, the Veteran reported “high blood sugars throughout the day, but also has some hypoglycemic reactions as well in the mornings and late afternoon. He appears to be on too high a dose of short acting insulin relative to long-acting especially at his age.” His insulin dosages were changed. The assessment included diabetes mellitus. In March 2016, the Veteran’s treating physician stated, “Since his insulin doses were reduced two weeks ago, he has had more hypoglycemia.” The Veteran’s insulin dosages were changed again. “No serious hypoglycemia.” On VA diabetes mellitus DBQ in October 2016, no relevant complaints were noted. The VA examiner reviewed the Veteran’s electronic claims file, including his service treatment records and post-service VA treatment records. The Veteran’s diabetes mellitus required more than 1 injection of insulin per day but did not require regulation of activities. He visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than 2 times per month. He had not been hospitalized for treatment of either ketoacidosis or hypoglycemia at any time in the previous 12 months. He had not had unintentional weight loss or loss of strength due to diabetes mellitus. He experienced diabetic peripheral neuropathy, erectile dysfunction, and cardiac conditions as a result of his diabetes mellitus. Physical examination showed no signs of malaise, both eyes within normal limits, no evidence of rashes or lesions, chest and lungs normal, no tenderness to palpation, symmetric breath sounds, no evidence of abdominal tenderness, liver and spleen not palpable, normal bowel sounds, no evidence of bruits or ascites, no edema in either of the bilateral lower extremities, motor and sensory examination within normal limits, and no urinary or bowel incontinence. The diagnosis was diabetes mellitus type II. Despite the lay assertions to the contrary, the record evidence does not support assigning a disability rating greater than 20 percent for the Veteran’s service-connected diabetes mellitus at any time during the appeal period. It shows instead that this disability requires, at most, insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. The Board acknowledges that the Veteran’s private outpatient treatment records dated prior to his death indicated that his service-connected diabetes mellitus was managed with a restricted diet and he was advised by his diabetic care provider to increase his level of physical activity. These records do not suggest that the Veteran’s service-connected diabetes mellitus required regulation of activities. Similarly, the Veteran’s VA diabetes mellitus DBQ in October 2016 showed that his service-connected diabetes mellitus only required more than 1 injection of insulin per day but did not require regulation of activities as part of the treatment plan for managing this disability. The Board notes in this regard that regulation of activities is required for the assignment of a 40 percent rating for diabetes mellitus under DC 7913. See 38 C.F.R. § 4.119, DC 7913 (2017). The October 2016 examination also did not find that the Veteran experienced episodes of ketoacidosis or hypoglycemia or was hospitalized for either of these complications of diabetes mellitus or required more than 1 daily injection of insulin alongside progressive loss of weight and strength as is required for a 60 or 100 percent rating under DC 7913, respectively. Id. Neither the Veteran, during his lifetime, nor the Appellant, after his death, has identified or submitted any evidence demonstrating entitlement to a disability rating greater than 20 percent for service-connected diabetes mellitus. In summary, the Board finds that the criteria for a disability rating greater than 20 percent for diabetes mellitus have not been met. 6. Entitlement to an earlier effective date than July 12, 2017, for an award of SMC based on aid & attendance The Board next finds that evidence supports granting an earlier effective date of May 11, 2016, for the Veteran’s award of SMC based on aid & attendance. The Veteran, during his lifetime, and the Appellant, after his death, essentially contend that he required the regular aid and attendance of another person well before he was awarded service connection for a cerebrovascular accident, evaluated as 100 percent disabling effective July 12, 2017, which supported the award of SMC based on aid & attendance as of that date. The Board notes initially that SMC is payable at the aid & attendance rate when a Veteran is in need of the regular aid & attendance of another person. See 38 U.S.C. § 1114(l) (West 2012) and 38 C.F.R. §§ 3.350(b) (2017). The basic criteria for entitlement to SMC are found in 38 C.F.R. § 3.352. See 38 C.F.R. § 3.352 (2017). The effective date for an award of aid & attendance is the date of receipt of claim or date entitlement arose, whichever is later, unless it is factually ascertainable that an increase in disability occurred earlier and a claim is filed within 1 year from such date. See 38 C.F.R. §§ 3.400(o)(2), 3.401(a)(1) (2017). The record evidence shows that the Veteran required the regular aid & attendance of another person effective May 11, 2016. For example, a review of a VA Form 21-0779, “Request For Nursing Home Information In Connection With Claim For Aid And Attendance,” date-stamped as electronically received by the AOJ on July 22, 2016, shows that the Veteran was admitted to a nursing home on May 11, 2016, because of mental or physical disability and was receiving skilled nursing care. The Board finds that this form constituted the Veteran’s informal claim of entitlement to SMC based on aid & attendance. On VA aid & attendance examination on May 25, 2016, it was noted that the Veteran was not hospitalized but had been diagnosed as having a femur fracture, cardiomyopathy, and diabetes. The Veteran was able to feed himself although he could not prepare his own meals. He needed assistance in bathing and tending to other hygiene needs. He was not legally blind. He required nursing home care because his wife “cannot physically do transfers for him” and could not help him with ambulation. The Veteran also required medication management and was unable to manage his financial affairs due to his cognitive impairment. He was unable to stand upright and walk independently due to his status-post right femur fracture. He needed help with all of his activities of daily living. “He will not be able to drive due to his short-term memory deficits and cognitive impairment. Physically, he is frail.” The Veteran was able to leave his home during the day “with extensive/total assistance in transfers for a short period of time.” The Veteran subsequently was admitted to the U.S. Naval Hospital, Camp Lejeune, North Carolina, on July 13, 2017, following a suspected cerebrovascular accident on July 12, 2017. On admission on July 13, 2017, the Veteran’s wife reported that she had found the Veteran on July 9, 2017, “being more sleepy, unrecognizing people including his wife, no speaking effort, unable to feed himself, and no desire or effect to walk using walker. The [Veteran] usually asks to smoke a cigarette multiple times daily but did not” after July 9, 2017. “This persisted without change” until the Veteran’s family was advised to take him to the hospital. On arrival to the hospital on July 13, 2017, the Veteran “became acutely more aware of his surroundings…He was able to answer simple questions and helped with walking…using his walker. This new improvement continued until the evening of hospitalization. His mental status has again declined.” The Veteran had been walking with a walker during the day following his admission to the hospital and spoke without difficulties although his speech was poor. He also needed help with his activities of daily living, including dressing himself. A history of a cerebrovascular accident and advanced dementia was noted. Physical examination showed that the Veteran was non-verbal with very limited interaction during the examination “but with eye tracking, ability to stick out tongue, and reaching out to grip a hand, and an ability to reach and grab objects “with slight occasional intentional tremor.” An MRI scan of the Veteran’s brain showed a small acute lacunar infarct in the left medial thalamus with no acute hemorrhage and an old lacunar infarct in the left pons. The treating clinician stated that he suspected vascular dementia with acute change due to a new cerebrovascular accident and a change in the Veteran’s baseline. This clinician also stated that the Veteran “will require 24/7 assistance” due to his “profoundly demented [status] with very limited ability to adapt to any stressor.” This clinician stated further that the “mildest infection or fluctuation” in any of the Veteran’s levels (glucose, electrolytes) “will likely result in decompensation and delirium.” The assessment was unspecified cerebral infarction. The Veteran, during his lifetime, and the Appellant, after his death, essentially contend that he required the regular aid & attendance of another person well before July 12, 2017, the effective date of his award of SMC based on aid & attendance. The record evidence supports these assertions, at least effective May 11, 2016, the date that the Veteran was admitted to a nursing home for skilled nursing care. VA aid & attendance examination on May 25, 2016, clearly showed that the Veteran’s service-connected disabilities rendered him so helpless as to require the regular aid & attendance of another person. See 38 C.F.R. §§ 3.350(b), 3.352(a) (2017). He needed assistance in bathing and tending to other hygiene needs and required nursing home care because his wife could not help him physically with transfers or with ambulation. The findings obtained on aid & attendance examination are contemporaneous to the date when the Veteran was admitted to a nursing home for skilled nursing care. The regulation governing effective dates for SMC based on aid & attendance is clear – the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later, unless it is factually ascertainable that an increase in disability occurred earlier and a claim is filed within 1 year from such date. See 38 C.F.R. §§ 3.400(o)(2), 3.401(a) (2017). It is undisputed that the Veteran’s informal claim of entitlement to SMC based on aid & attendance was received by the AOJ on July 22, 2016, within 1 year of the date of medical evidence showing that he required the regular aid & attendance of another person when he was admitted to a nursing home for skilled nursing care on May 11, 2016. VA examination on May 25, 2016, documented the Veteran’s need for the regular aid & attendance of another person contemporaneous to the date when he was admitted to a nursing home for skilled nursing care. In other words, although an informal claim of entitlement to SMC based on aid & attendance was not received by the AOJ until July 22, 2016, it is factually ascertainable that the Veteran met the criteria for SMC based on aid & attendance on May 11, 2016, when he was admitted to a nursing home for skilled nursing care and within 1 year of the date of receipt of this claim. Id. Thus, the Board finds that the criteria for an earlier effective date of May 11, 2016, for an award of SMC based on aid & attendance have been met. 7. Entitlement to an earlier effective date than July 12, 2017, for an award of a TDIU The Board finally finds that the evidence supports granting an earlier effective date of September 21, 2016, for an award of a TDIU. The Veteran, during his lifetime, and the Appellant, after his death, essentially contend that his service-connected disabilities, alone or in combination, precluded his employability well before he was assigned a 100 percent rating effective July 12, 2017, for a service-connected cerebrovascular accident, which rendered consideration of a TDIU moot after that date because the 100 percent schedular rating is the greater benefit. The Board notes initially that effective dates for TDIU ratings are governed by the regulations governing effective dates for increased ratings. See 38 C.F.R. § 3.400(o). The Board also notes initially that service connection is in effect for dementia, evaluated as 100 percent disabling effective October 20, 2017, neurogenic bladder, evaluated as 40 percent disabling effective February 29, 2008, coronary artery disease, evaluated as 30 percent disabling effective September 29, 2008, diabetes mellitus, evaluated as 20 percent disabling effective May 8, 2001, peripheral neuropathy of the left upper extremity, evaluated as 20 percent disabling effective May 8, 2001, peripheral neuropathy of the right upper extremity, evaluated as 20 percent disabling effective May 8, 2001, hearing loss, evaluated as 20 percent disabling effective June 9, 2016, peripheral neuropathy of the right lower extremity, evaluated as 10 percent disabling effective May 8, 2001, peripheral neuropathy of the left lower extremity, evaluated as 10 percent disabling effective May 8, 2001, tinnitus, evaluated as 10 percent disabling effective June 26, 2008, cerebrovascular accident, evaluated as 100 percent disabling effective July 12, 2017, and as 10 percent disabling effective February 1, 2018, and for hemorrhoids and recurrent genital herpes, each evaluated as zero percent disabling effective April 1, 1973. The Veteran’s combined disability evaluation for compensation is 70 percent effective May 8, 2001, 80 percent effective February 29, 2008, 90 percent effective September 29, 2008, and 100 percent effective July 12, 2017. Thus, the Veteran met the schedular criteria for a TDIU effective May 8, 2001. See 38 C.F.R. § 4.16(a) (2017). The Board finds that the record evidence supports the lay assertions of record that the Veteran’s service-connected disabilities precluded him from securing or following a substantially gainful occupation effective September 21, 2016. For example, in statements on a VA Form 21-8940 (formal TDIU claim) date-stamped as electronically received by the AOJ on July 22, 2016, the Veteran asserted that his service-connected diabetes mellitus and coronary artery disease prevented him from securing or following a substantially gainful occupation. These disabilities affected his full-time employment on January 1, 1979, when he last had worked full-time and became too disabled to work. Following VA diabetes mellitus DBQ on September 21, 2016, the VA examiner stated, “The Veteran’s diabetes mellitus affects his ability to function in the occupational environment by causing him to tire quickly and easily if he works with his arms overhead more than 5 minutes.” In contrast, following VA heart conditions DBQ on September 21, 2016, the VA examiner concluded that the Veteran’s service-connected coronary artery disease “does not affect his ability to function in the occupational environment.” The regulation governing effective dates for TDIU is clear – the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400(o). In this case, it is undisputed that the Veteran’s formal TDIU claim (VA Form 21-8940) was date-stamped as electronically received by the AOJ on July 22, 2016. The Board has reviewed the record evidence and finds that entitlement to a TDIU arose is September 21, 2016, the date when the record evidence shows that the Veteran’s service-connected diabetes mellitus, alone or in combination with his other service-connected disabilities, rendered him unemployable. See also 38 C.F.R. § 4.16(a). In other words, although the Veteran’s TDIU claim was received by the AOJ on July 22, 2016, entitlement to a TDIU arose only on September 21, 2016, when VA examination showed that his servcie-connected diabetes mellitus, alone or in combination with his other service-connected disabilities, precluded his employability. The record evidence otherwise does not demonstrate that entitlement to a TDIU arose prior to September 21, 2016. In summary, the Board finds that the criteria for an earlier effective date of September 21, 2016, for a TDIU have been met. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel